Ask Dr. Z

Our vascular surgeon informed us on this new endovascular treatment (Helix-FX EndoAnchor System), and we were wondering if it is able to be billed, along with the other codes he has always used. He gave us some information on it and it is saying to use unlisted procedure code 37799 and use it comparable to 34825. What is your opinion on this?? In one case, he billed 34825 already for an extension cuff. Is this new system something that is separately billed? 

Can you please tell me what the difference is between an iFR and an FFR done during a heart cath? And is the same code 93571 utilized when billing either procedure?

Please provide the CPT codes with an explanation. "12 month old with large dominant macrocyst. Sclerotherapy of the left neck lymphatic malformation. In supine position, using ultrasound guidance, a 20 gauge angiocath needle was initially directed into the lobular posterolateral collection. Only a small amount of fluid could be aspirated, likely due to collapse of this smaller cavity. The catheter was removed. Using direct ultrasound guidance, a 20 gauge Angiocath needle was then used to access the large anechoic cyst more anteriorly. The needle was removed and a total of 10 ml of amber colored fluid was aspirated. The pocket of fluid again collapsed around the Angiocath, and access to the cyst was lost. After aspiration, on ultrasound, the large cyst was noted to be significantly smaller in size. No additional fluid was aspirated. The needle was removed from the sheath. Through the Angiocath, 100 mg of doxycycline (10 mg/mL) was injected under fluoroscopic guidance. Even filling of numerous adjacent microcysts. Sheath was removed."

"Left heart catheterization with intraprocedural Nitroglycerin administration with hemodynamic monitoring. A 6 French JL4 catheter was advanced into the ascending aorta. Aortic blood pressure was measured. It was markedly elevated at 220/110. The patient was administered 0.4 mg sublingual Nitro. Hemodynamic monitoring was performed. Repeat blood pressure was obtained a few minutes after Nitro administration, and blood pressure had dropped to 160/100." Can code 93463 be billed for this part of the heart cath procedure? My physician needs clarification regarding the criteria for use of this CPT code.

This is a two part question, but involving the same situation. Part 1: If two radiologists from the same practice each perform one element of an S&I code (Dr. A performs the supervision; later Dr. B performs the interpretation), would the modifier -52 rule apply? I interpret CMS Pub. 100-04 Chapter 13 Section 80 to indicate that the separation of the two components can be billed separately with modifier -52 when two practices/specialties are involved; not physicians from the same group. Is this correct? Part 2: In either case, is the -26 modifier appropriate? If the radiologist performs BOTH the supervision and the interpretation, is the -26 modifier necessary (i.e., cholangiogram performed in a hospital setting where the radiologists are employed by another entity, not the hospital)? Your guidance is much appreciated. I have searched all regulatory guidelines and reliable sources I can find, but have found no direct answer to my question thus far.

I'm not sure how to code this procedure. "The patient who suffered an out of hospital cardiac arrest came into the ER. Patient previously had a PFO closure and a history of LBBB. A left heart catheterization and coronary angiogram were performed and were completely normal. At the intensivist request, a Cool Guard Cooling catheter was placed via the right femoral vein." I am not really sure how I would bill for the cooling catheter. 37799 maybe? I was wondering if you could give me some input on which code should be used.

I am at a loss as to what code to use for the procedure listed below. It appears that an ICE procedure was performed, but code 93662 is an add-on code, and no other procedure was performed. "Procedure: Time-out was observed with full agreement of all participants. Thereafter, an intracardiac echocardiographic (ICE) catheter was placed from the right femoral vein to the right atrium. A full scope of the right heart chambers was visualized from where the leads entered the atrium from superior vena cava to their termini. No vegetations were observed on leads or adjacent structures. The ICE catheter was removed, and the sheath secured in place pending subsequent percutaneous pacing system extraction. Summary: Clean pacing leads without large vegetation; she is suitable for an attempt at percutaneous lead extraction."

I am very confused with this procedure. "The patient has a 1 year old radiocephalic AV fistula (left arm). Suspected steal syndrome versus compounding PVD. Under ultrasound guidance (no documentation of image storage), access was gained into the left brachial artery in the antecubital fossa. The sheath was then advanced over a microwire into the ulnar artery, and an ulnar arteriogram was performed of the forearm and hand. Next, an antegrade fistulogram was performed after contrast was injected in the ulnar artery. The sheath was retracted into the brachial artery, and a left brachial arteriogram was done. Then the sheath was directed into the left radial artery, and a radial arteriogram was done." Do I report a fistulogram and extremity angio? And what about catheter placements?

We have a case wherein the doctor started with a PVI ablation (93656), did an additional (93657), and an SVT additional (93655). Along with these ablations, mapping (93613), LV pacing (93622), ICE (93662), and ICD reprogramming (93287) were performed. At the end the doctor did an AV node ablation (93650). Our question is what can be charged here? The AV node ablation edits to most everything.

I code cases for a hospital, and we are needing clarification regarding epidural steroid injections. Your 2015 Interventional Radiology Coding Reference, page 511, #1, states, "Per CMS, do not use code 77003 with codes 62310-62319." What is the specific CMS guideline/regulation stating not to report code 77003 with 62310-62311?

"A surgeon performed an embolization to a large middle cerebral artery arteriovenous malformation by accessing the left internal carotid artery and infusing DMSO and ONYX 18 into the nidus feeder, which was coming off of the MCA branch. The surgeon then accessed the right internal jugular vein and placed 6 coils into the distal segment of the draining vein." Since the AVM was accessed by two separate points, one venous and one arterial, can we code for both? Or is it still considered one code because the AVM is consider one surgical field? Also, if one AVM is accessed and treated by two different arterial access points, would we be able to code for both? Or is this only one code based on the surgical treatment field?

If a surgical level is billed for angioplasty (35476), should the supervision and interpretation be billed separately (75978)?

Following a PVI ablation for atrial fibrillation, I will occasionally see documentation of a coumadin ridge/ligament of marshall ablation. The report reads, "Post ablation of the pulmonary veins, left atrial appendage as well as the coumadin ridge/Ligament of Marshall region were ablated with slowing and organization of the atrial fibrillation to atrial tachycardia at 180ms cycle length." I know that a roofline ablation is considered inherent to a PVI procedure, but I'm not familiar with the coumadin ridge/ligament of Marshall. Would this be coded as a second atrial fibrillation ablation, 93657?

When using code 33530, should both approaches be sternotomies? Meaning, if the first CABG or valve procedure was performed via sternotomy approach and a year later the redo CABG or valve was performed via port access or thoracotomy, may I bill code 33530? I think code 33530 is for sternotomies only, but I need your advice.

How do I code diagnostic lumbar puncture and intrachecal CNS chemotherapy injection - CSF removed?

My physician states "rhythm ECG monitoring with interpretation performed" within his OP note. He also states that "because of patient's medical status, EKG monitoring was used during this procedure." Ive been told during an audit of our OP notes that I can code for the EKG monitoring if a monitoring strip is saved in the patient's chart, but I thought EKG monitoring is now bundled with code 36147. Can you please let me know what your thoughts are on coding both codes 36147 and 93040?

Prior to TIPS, a fiducial marker is placed into the liver. "Under real-time CT fluoroscopic guidance, a 3 cm x 3 mm coil was placed to mark the portal vein bifurcation. FINDINGS: Archived images demonstrate excellent positioning of the fiducial marker at the portal vein bifurcation. IMPRESSION: Successful marker placement." Following, TIPS was attempted. "Access the right internal jugular vein using US guidance. A multipurpose angiographic catheter was used to select right hepatic vein, accessory right hepatic vein, and left hepatic vein. Hepatic venography was performed in each vessel. I tried several times to pass a working sheath into the occluded left hepatic system, and was unsuccessful each time. Due to hepatic venoocclusive disease, no invasive pressure measurements were obtained. IMPRESSION: Hepatic venoocclusive disease." I am unsure of how to code the coil. It's not being used for radiation, so I don't believe code 49411 is correct. It is not an embolization either. Also, would the hepatic venography be reported with codes 75891 and 36011 x 2?

I have a physician who extracted both the atrial and ventricular leads of an ICD. The physician thinks he should report codes 33217 and 33244. I feel it should be reported with code 33215 x 2 (repositioning PPM/ICD lead). What are your thoughts? "Indication: Mechanical complication. The ICD was placed several weeks ago. He then accessed the axillary vein (x2) and used the same leads placing them in different positions, the right atrial appendage and right ventricular apical septum."

I have a question. My physician parks the catheter in the distal aorta and does an aortogram of the distal aorta and bilateral iliacs. He then moves the catheter to the contralateral limb and does another angiogram followed by an intervention. Can I bill code 75625 and the intervention?

Indications: Significant stenosis of posterior tibial artery (by duplex sonography) Procedure Report: The skin overlying the graft was infiltrated with 1% Lidocaine without epinephrine, and the graft punctured with a micropuncture needle. An .035 glide wire was inserted into the graft and the needle exchanged for a 4F sheath. Multiple AP and oblique views of the distal femoral to posterior tibial artery, and tibial artery were obtained. A diffuse stenosis was seen distal to the graft. In fact, approximately 15 cm of vessel was very narrowed. A 014 Choice PT wire was passed across the anastomosis followed by a 2x120 Fox SV balloon. The vessel was angioplastied, stent placed. This case is a sample of a phyisian that uses Duplex sonography on graft patients in office then brings them in for an angiogram of the portion of interest. This is not a full extremity angio. Can you still code a diagnostic angio. Prior to intervention. We are reluctant due to the limited area being studied and prior duplex sonography. In this case we coded Stent placement.

Are there any physician supervision requirements (direct vs. general) for billing the contrast code 93352 with a stress echo? Code Correct indicates that the physician gives the patient the contrast, but our locations have general supervision, and the tech usually gives the contrast.

At our facility we have started a new CTO program. These cases are, as expected, more complex. The technique that has been adapted here is bilateral access with dual injections of both the LMCA and RCA to assess the collateral flow for a potential retrograde approach. The physician who has been doing these procedures feels that we should be able to charge something in addition to code 92943 or C9607. I have been expressing my disagreement with him. I feel that the CTO charge already encompasses the additional access and greater procedure involvement. Please advise.

Left upper extremity bypass with reverse great saphenous vein from the radial artery to the proximal brachiocephalic arteriovenous fistula with ligation of arteriovenous fistula at the level of the arteriovenous anastomosis. What are all codes associated with this procedure?

Is there a HCPCS code specifically for Onyx/embospheres for the hospital charge related to embolization procedure for nosebleed?

Please help me code the following: "Reason - asymmetric arm blood pressures, abnormal stress test, leg pain, abnormal lower ext arterial Doppler. Performed: Left heart cath coronary angio selective right brachiocephalic angiogram selective left subclavian angiogram infrarenal and aortoiliac angiogram with runoff selective right external iliac angiogram selective left external iliac angiogram unsuccessful pci attempted of occluded left common iliac Accessed both left and right groins, due to left iliac total occlusion. Results: Patent subclavian and brachiocephalic Distal aortoiliac disease." Please help me code the above procedures and include what dx code could be used for the asymmetric arm blood pressures.

Patient has single ICD at end-of-life and RV lead. Plan is to upgrade generator to biventricular ICD and place LV lead. Multiple attempts made to place LV lead are unsuccessful, so in the end only a single ICD is replaced. How would you code this scenario?

Could you please clarify the uses of code 0234T. The CPT description states "transluminal peripheral atherectomy". Since there is a separate code for the brachiocephalic trunk and branches (0237T) on the right side of the body, does this mean that code 0234T may be used for atherectomies in the left arm, as well as renal atherectomies?

We have physicians who have been given the direction, by company reps, to use code 37197 when snaring a wire advanced from an access site in the foot and exteriorizing it though a sheath placed in the common femoral artery. Is that an appropriate use of code 37197? I code for the facility and have never reported code 37197 in that scenario. I don't believe it is an appropriate use for code 37197, and I am being questioned by the physicians. If you could clear that up for me, I sure would appreciate it!

"Right common femoral artery was accessed, and a 5 French sheath was placed. Omni flush catheter was advanced to the abdominal aorta using the support of a Glidewire. A flush catheter was placed in the abdominal aorta, and angiogram was performed. Next, the Glidewire was advanced to the common femoral artery on the left. Next, Omni flush catheter was exchanged for straight flush, which was advanced to the proximal left common iliac artery. Next, run-off was performed. Next, the catheter was removed and right groin sheath was used to perform right lower extremity angiogram." I reported codes 36245-LT, 75625, and 75716. Are those the correct codes for this scenario? Glidewire was up to left common femoral artery, but catheter was placed at left common iliac artery.

The patient had an external cardioversion for atrial fibrillation. Case end was called and patient was transferred to "holding". An EKG was performed at this point. Is this EKG (93005) considered included/during the procedure and not separately chargeable? Or is this chargeable, as it was performed after procedure ended and patient was transferred to a different area?

Would code 33418 be appropriate for repair of regurgitation of an existing mitral valve prosthesis? The physician used an Amplatzer device.

What is the best CPT code to use for an ultrasound of the abdomen/lower extremity for ingunal hernia? 76705 or 78881/78882?

I would like to know if the physician does a fem-pop bypass with reversed transposed gsv, iliofemoral thromboendarterectomy, and profundoplasty, can I bill codes 35556, 35572, and 35355?

Patient had existing dual AICD on left side with erosion. Generator was moved to right side; RV and RA leads were replaced, and a new LV lead was inserted to existing generator. I'm coming up with codes 33244, 33217, 33223, and 33224, but I'm getting an edit on 33223. Is this the correct code assignment for this scenario? Should we not report code 33223?

I was wondering if you have ever seen this before? And what you would code to? An IVC filter, stent? "Utilizing the gooseneck snare and sheath, the hook of the filter was engaged with the snare. Gentle traction was then placed on the gooseneck snare and sheath to allow the hook to be disengaged from the filter and removed in its entirety under fluoroscopy onto the table. A fluoroscopic image was taken, demonstrating that the struts of the inner portion of the filter did not fully deploy. A 5 French Sos catheter was advanced over the wire into the inferior vena cava under fluoroscopy. Several passes were made with the catheter in order to remove any fibrous bands. Repeat images demonstrated that several of the struts were not fully deployed. Further maneuvers were performed with a Rim and Cobra catheter. Despite these additional maneuvers with these catheters, there were two struts that were not fully deployed. At this time, a balloon was used to assist deployment of the struts fully. Following the use of a balloon, the structures were fully deployed."

For purposes of coding, can we retain both codes 36147 and 36148 when arterial anastomosis is angioplastied, or are we required to drop the catheter (either 36148 if two cannulations, or 36147 and gain 75791) since a lower extremity intervention is being performed?

When billing code 34803, would I also report code 34812 if that is done? In our Encoder pro software it says that code 34812 is included in code 34803. "34803 - INCLUDES: Balloon angioplasty/stent deployment within the target treatment zone; introduction, manipulation, placement, and deployment of the device; open exposure of femoral or iliac artery/subsequent closure (34812)." Not sure if I should be billing code 34812 with a -59 (-XS) modifier or just not using it at all.

Can you please explain the difference between codes 36818, 36819, 36820, 36821, and 36825? Perhaps with examples of each? I've been reading through my new book, Dr. Z's Vascular & Endovascular Surgery Coding Reference, but I am still as confused as ever.

If an angio is done during an intervention that is NOT a diagnostic study, would you code and bill the catheter placement? For example, embolization of a liver tumor. "The physician selectively catheterizes the cystic artery, right hepatic artery, and branch of right hepatic artery. Findings: Location of cystic artery confirmed, both the main right hepatic artery and branch of right hepatic artery were confirmed to supply the tumor. Intervention: The catheter was advanced into the right hepatic branch, and embolization was done." The codes I am using are 37243 and 36247. Would you also report code 36248 for the cystic artery cath placement?

I have a dictation under the heading "Paracentesis with Imaging Guidance", and the hospital has billed for a paracentesis with imaging guidance. I am billing for the provider, and I am not so certain that this should be coded as a paracentesis. My concern is that report states this: "The most accessible fluid pocket in the right lower quadrant was localized under ultrasound guidance, and the overlying skin was marked. The patient was prepped and draped in the standard sterile fashion. Approximately 5 mL of 1% lidocaine was injected into the skin and subcutaneous tissue for local anesthesia. With the patient supine, a micropuncture needle was used to access the identified pocket of fluid. Approximately 2 mL of serous fluid was aspirated to confirm placement. 4 mCi of technetium-99m MMA was injected into the ascites fluid." Can you please give some input for this?

Can you bill fluoroscopic guidance with the placement of a loop recorder for hospital based billing? I can't find anything that states you can't bill it, but yet I can't find anything that states that you can bill it.

My patient had a splenic embolization done, and the sheath was left in place for possible use in the following splenectomy. The following day the patient was brought back into IR for subsequent removal of the sheath. "DESCRIPTION OF PROCEDURE: The right groin was cleaned and prepped in the usual sterile fashion. Local anesthesia was then injected into the skin and subcutaneous tissues. An angiogram of the right common femoral artery was performed through the existing 5 French sheath. The 5 French vascular sheath was seen within the midportion of the right common femoral artery. The sheath was then removed, and hemostasis was achieved using 6 French Angio-Seal device. The patient tolerated the procedure without difficulty or immediate complications. IMPRESSION: Successful Angio-Seal device deployment in the right common femoral artery." How would you code the pro fee for this, if at all? I was considering reporting code 75710. Is there anything else you would suggest?

Our physician performed a redo open thrombectomy, right limb of aorto-bi-femoral bypass graft. Then a stent placement, right limb of proximal aorto-bi-femoral bypass graft, followed by another stent. Those were successful. There was then brisk flow through the right limb of the graft. Because of the patient's small, poor outflow, it was felt best to perform a fem-pop bypass with vein, as the SFA was occluded. The physician wants to bill all services performed. Can we bill everything or just the bypass?

IFR is now being performed regularly in the cath lab. The difference between it and FFR is that there is no pharmacological agent being given (adenosine). As the CPT for FFR (93571) specifically states “including pharmacologically induced stress”, is there another code that can be used for IFR, or can it perhaps be modified? It is performed using the exact same wire and control module. Any suggestions?

I have a patient in whom we are treating bilateral iliac aneursyms with an AAA endograft. The graft we are using has one docking limb. We placed the endograft with the docking limb on the right side, and then extended both sides with extensions. Would you suggest codes 34900-62, 34900-62-59, and 34825-62 along with the S&I and catheter placements?

Our physician recently attended a conference where he was told that you can now bill all of the following: 4-vessel diagnostic angio done (36226-50 & 36224-50), emergent crani done for aneurysm clipping (61697), and follow-up angio done in internal carotid (36224) to make sure the clipping was complete. This is done all in one operative session. MUEs previously had 36224 as one, so we have only been billing code 36224-50 in these cases. But I see the MUE table for April 1, 2015 now is showing three per day for code 36224. (Looking at the January 1, 2015 MUE table on your site the MUE for code 36224 is still at 1.) So with that in mind, is it acceptable after April 1, 2015 to then bill codes 36226-50, 36224-50, 61697, and an additional 36224?

"Initial placement of the microcatheter (by IR) into the right hepatic artery resulted in decreased antegrade flow and reflux into the small, patent gastroduodenal artery. The decision was made to embolize the GDA prior to the Y-90 treatment by the AU." In this case, can the IR bill for the GDA embolization since the AU is billing the Y-90? If so, would that be reported with code 37242?

Our physician performed a kyphoplasty of the T12 level and the L1 level. The 2015 guidelines are confusing, and reading the instructions #5 and #6 from the Dr. Z Interventional Radiology Coding Reference, it appears that we would report code 22513 for initial level and 22515 for the additional level. Is this correct? The example given #2 shows 22513 and 22514 for T10 and L2 levels, but there is an NCCI edit that does not allow the use of two initials together.

"Patient had a previous ICD that was infected and removed. Several days later we created a new pocket on opposite side. We attempted to access veins, and venogram with contrast was done, which showed everything to be occluded. Procedure was aborted and the new pocket was closed." Is there a code for just the creation/closure of the new pocket?

For the following case, are the angioplasties performed in the iliofemoral billable, or would they be considered bundled into the carotid stent with filter procedure (37215)? "The patient has extensive lower extremity vascular disease. The right femoral artery cannot be accessed percutaneously, and left side is therefore accessed. Severe occlusive disease is present in the iliofemoral segment. Angioplasty was required with a 6 mm balloon of the external iliac and common femoral on the left, allowing placement of 6 French sheath. A 6 mm balloon was dilated to 12 atmosphere pressure of the left external iliac and proximal-mid common femoral. Stenting was not performed. The physician went on to selectively catheterize bilateral common carotids, and left subclavian retrograde for grams, and eventually placed a right carotid artery stent with filter."