Ask Dr. Z

"Patient continues to have episodes of VT storm resulting in multiple ICD therapies, and he is therefore now being referred for selective septal coronary alcohol ablation during which EP testing and RV stimulation protocol along with 3D mapping and ICE are being utilized. Conclusion: Successful alcohol ablation of basal septal branch for the treatment of medically refractory and catheter ablation refractory septal VT."  (A heart catheterization was also done.) I don't think I can use code 93583, as the patient does not have HOCM. How do I code this? Unlisted? And are all the add-ons a loss?

If non-selective catheter placements (36200 and 36005) are done to perform diagnostic angiography, and then the decision is made to perform embolization, would the non-selective catheter placements be coded in that situation or not? I understand only selective catheter placements would be coded with the embolization typically, but I wasn't sure if needing diagnostic angio first would make a difference.

We performed a patch angioplasty of the proximal portion of the left fem-pop vein bypass graft with a Vascu-Guard patch. We wanted to use code 35883, which fits; however, that code is for a synthetic arterial bypass graft and we are revising the femoral anastomosis of a vein graft. What code would you use for this scenario?

How would you code catheter placement in a dialysis fistula, when doing venous angioplasty, if the patient only had ultrasound-guided PTA, without injection of contrast? At your conference, I thought I heard you state that code 36147 requires contrast injection. Code 36005 is for venography, and code 36010 does not work (neither does 36011). Am I limited to unlisted code 37799?

I received your February 2015 Q&A answer regarding coding a patient non-congenital once they've had a heart transplant. I have your Diagnostic & Interventional Cardiovascular Coding Reference, and it states that once a patient is diagnosed as having congenital heart disease he/she should always be coded as such, even if the patient receives a heart transplant. My book version is a couple of years old, so I was not sure if your new version has the opposite of what this version has.

I have a question on using a -52 modifier. Patient comes in for a nuclear medicine stress test (78542). The rest portion is performed with images, and for various reasons the stress portion is not completed. Should this be reported with code 78452-52 or 78451 for what was actually performed? The interpreting physician does not want the code to be changed, but to code what was originally ordered. Documentation is there to describe that the test was not completed. I have some advice that says to code the original order with a -52 modifiier, with the example that the patient could not cooperate for the complete study. My thought is if there is a code for what was performed that is what should be coded. Any help would be appreciated.

A critically ill neonate with coarctation of the aorta with multiple ventricular septal defects s/p CoA repair, patch closures of membranous and mid-muscular VSD, and PAB placement, who is in complete heart block with temporary pacemaker. A plan is in place by a cardiothoracic surgeon to place permanent pacemaker when patient stabilizes. In the meantime, our EP doctors do temporary device interrogations. Can we bill for temporary device interrogations? If so what codes can we use?

My physician performed a right and left heart catheterization on a patient. The physician states in the findings/impression of his dictation that a congenital saturation study was done with no evidence of significant intracardiac shunt. Is there a code that I could bill for that, or would that be inclusive with the right and left heart catheterization?

How do I code this report? "Technique: The internal/external biliary drain was prepped and draped. Contrast was injected, and a cholangiogram performed. This revealed a malignant obstruction of the distal CBD. No contrast enters the duodenum. Guidewire was advanced through the drain and into the duodenum. Sheath was placed at the insertion site. Under fluoroscopic guidance, a biliary covered stent was deployed at the level of the malignancy. It was then dilated with a balloon. Excellent result with brisk flow into the duodenum. No safety catheter was left. Impression: Successful internal biliary stent placement. No safety catheter was left."

Can you code a cephalic vein transposition if the documentation doesn't specifically state that a tunnel was created or that two incisions were created? Documentation states, "The cephalic vein was identified and mobilized with ligation of collateral vessels. It was then "swung over" to the brachial artery and anastomosed end to side." I am debating between codes 36818 and 36821 when the documentation does not specifically state that "tunneling was performed". If the vein is anatomically superficial and did not require a tunnel could this still be a transposition?

Patient comes in for EP study in arrhythmia. Physician administers isuprel. Is it appropriate to bill code 93623 if the patient is already in an arrhythmia BEFORE drug infusion?

"We have a patient who presented to IR for an attempted transvenous esophageal varices sclerotherapy. The portal vein, splenic vein, and superior mesenteric veins are known to be occluded. The access site was the right femoral vein. A draining vein for a splenorenal shunt was selected without success in accessing the varices. Catheter was moved superiorly into the inferior phrenic vein (36012) and venogram performed with no access. Catheter withdrawn to find second vein from the femoral vein without success. Venocavogram was then performed at the level of the kidneys and catheters removed." We have findings for the selective vessels, vena cava, and kidneys. What would we use for our imaging codes? I don't think medical necessity was met for the vena cava imaging, but I also cannot find a code for the visceral venous imaging.

Patient had a temporary catheter that was converted to a permcath, and using the same entry site a triple lumen central venous line was placed. Would these both be coded as replacements, or what would you suggest?

Does code 36147 include selective venography of a collateral vein to assess for surgical turndown option? Or should I use codes 75791, 36011? "Patient has left upper brachial artery to cephalic vein fistula. Lower fistula is punctured and contrast injected, demonstrating decent flow through the fistula which is well-dilated peripherally. There is one focal area of mild narrowing in the mid fistula which is not felt to be flow limiting. There is diffuse stenosis of the cephalic arch with collateral vessels draining to the axillosubclavian veins. Left-sided central veins are widely patent, as is SVC. Next a glidewire is advanced centrally and a sheath placed. A glide catheter was used to selectively catheterize the left arm basilic vein. Diagnostic venogram was performed at the same time that the fistula imaging was performed to assess the feasibility of surgical turndown option. This showed the basilic vein to be a large caliber vessel comparable in diameter to the fistula. It was widely patent through its transition to the axillosubclavian vein."

"In 2012, patient had left mini-thoracotomy and placement of epicardial pacing system; however, the place where these leads were attached to the pacemaker generator was infected. In view of this, in October 2014, the leads were truncated at the point where they were entering the pericardial space, removing the remaining part of the leads towards the pacemaker generator as well as the generator itself. This admission, patient was temporized with a transvenous pacemaker system from the neck and was sent to Cardiothoracic Surgery for placement of epicardial leads. Upon performing median sternotomy, we noted significant adhesions inside of the pericardial space from the previous opening of the pericardium. These adhesions were carefully taken down to the point where I was able to identify 3 epicardial leads that were placed before and were truncated at the level of the entry into the pericardial space. These were carefully released and removed and sent to the pathology." The only code I am coming up with is 33999 (in addition to 33202/33221-51, implant report not attached).

"The 8 French sheath was exchanged for a 9 French curved Flexor sheath over the Amplatz wire. The 2.5 mm Turbo-Elite laser was advanced coaxially (calibrated per protocol) and activity to perform laser thrombectomy within the iliac stents. A Lunderquist wire was advanced through the laser catheter until tip to tip. This was then shaped within the laser catheter to allow for better torque-ability, control, and improved thrombectomy." The above info is for a common/external iliac veins. There were two distict catheters involved, one from the RIJ the other from the LFV, for the tip to tip. In the 2015 book, code 37187 can be reported twice if two vascular distributions are involved with two separate treatment caths. Would the above scenario constitute coding 37187 twice?

"BRTO was performed with coil embolization of varices. Balloon left inflated overnight. Patient was brought back to IR department the following day for evaluation." What, if anything, can be charged for the release and removal of the occlusion balloon and subsequent imaging?

When billing code 93286 or 93287 twice, for before and after another procedure (such as an ablation), Encoder Pro states we should bill the code x 2, but I have seen it also billed on two lines with either a -76 or -59 modifier. Which way is correct?

Does your previous answer to a question from years ago regarding code 36818 still apply - must this procedure still require two incisions to code for it? "Procedure: We made incision a fingerbreadth above the elbow crease where the vein and artery had been mapped. We dissected first the cephalic vein circumferntially and exposed at least a segment of around 5-6 cm both proximal and distal to our incision so that we could swing it over. We divided a little part of the biceps muscle to allow for no compression with the transposition of the vein towards the brachial artery medially. The brachial artery was exposed proximally and distally. She had some scarred valves in the vein walls which were trimmed at the level of the anastomosis to allow no problem with the venous anastomosis for the future. We then clamped the artery distally and proximally and made an incision with 11 blade and dissected with micro Potts in oblique fashion. The vein was then anastomosed using 6-0 prolene in a running fashion." What code would you use if not 36818? Unlisted?

I would appreciate your guidance on documentation. It has been proposed that the CPT guidelines before a section are technical requirements that need to be performed, but are not necessary to be documented in the professional report unless they are “clinically relevant”. For instance, for a complete echocardiogram (93306), the guidelines state the structures that need to be evaluated or the reason that they can’t be visualized needs to be stated. If, for instance, the right atrium was not referenced in the report because it was not deemed to be clinically relevant, could a complete echocardiogram be billed if all of the other elements were on the professional report? In your opinion, have we met the requirements for documenting a full echo (without including all the elements in the professional report) because we have the supporting tape to show that the service was rendered completely? Secondly, would a statement indicating that “the structures were visualized” suffice? In other words, must it be an interpretation of what is seen?

For the following example, I'm not sure what to code for this because it is not muscle or bone.  What are your thoughts?  "Physician performed a venogram of the right common femoral vein, that had been previously stented. The venogram showed limited flow from a mass pressing on the stent. With percutaneous access, a biopsy guide for 16 gauge core biopsies were then placed through the stent into the mass. Three good core biopsies of the mass were obtained and placed in formalin."

My cardiologist did a cardioversion and a stent on the same day. Do I use modifier -59 on both the stent and cardioversion since they are in the same CPT code set?

I’m not sure what to do with this one. Patient came to cath lab to have an angioplasty of his AVF. While ballooning the subclavian and innominate vein, the balloon ruptured. Due to aspiration of blood from the inflation port of the balloon, the surgeon decides to take the patient to the OR for emergent surgery. In the OR he opens the arm, creates a venotomy in the fistula, and removes the balloon. It is noticed that there is some thrombus, so he removes the small amount of clot present and closes the venotomy. I don’t like code 37197 since this is open instead of percutaneous. I was thinking of reporting the exploration with code 35761 (which includes foreign body removal) (or possibly 35860 since there was bleeding) with modifier -XU or -59, as well as the open thrombectomy with code 36831 since they shouldn’t have had to do a thrombectomy as well. My other thought was unlisted code 37799. What are your thoughts?

What is going on with the delay on the use of the -KX modifier on pacemaker procedures? I know the ruling to use it was delayed in July 2014. Has there been any further development on whether or not it should be applied?

I know fluoroscopic guidance is included with code 62311, but our IR people almost always use CT guidance for this procedure. Would you use code 77012 with this procedure, or are all types of guidance included?

I have a case where the physician did a primary percutaneous mechanical thrombectomy of the following areas (right common femoral approach): left common iliac, left external iliac, left common femoral, left superficial femoral, left popliteal, left anterior tibial, and the left posterior tibial/tibioperoneal trunk. How many times should codes 37184 and 37185 be submitted in order to cover all these areas?

I took a webinar for the CIRCC exam by Dr. Z, and I think Dr. Z mentioned that we no longer would apply modifier -50 if -LT and -RT breast lesions are biopsied. Instead we would use add-on code. Could you let me know where I can find the AMA article about it. I was just reviewing 3M Encoder Pro, and they still recommend using modifier -50 for a bilateral procedure. Could you clarify?

If we do a right or left ax-bi-femoral bypass graft surveillance, which code is appropriate, 93931 or 93926? Or is it appropriate to use both?

Would you consider this documentation sufficient for billing a lumbar myelogram (72265-59) with LS spine CT (72132)? The physician orders a CT spine and lumbar myelogram. Documentation for the myelogram in the first example states: "Myelogram without significant compression on the thecal sac or exiting nerve roots, osseous structures are unremarkable." In a second example the documentation states: "Conus/Cauda: Tip of the conus is typical at L1. Individual nerves of the cauda equina are unremarkable. There is no evidence of arachnoiditis or other pathology." All elements of the LS CT are well documented in both instances. In either instance, can the lumbar myelogram be separately coded?

When a patient with a biventricular defibrillator comes in for an EPS study (93620, 93621, 93623), and his/her defibrillator is turned off before the EPS procedure, then turned back on and reprogrammed after the procedure, we have been placing a -59 modifier on the second instance of 93287. Will that still be the most specific/appropriate modifier in this scenario, or will modifier -XU or -XS be more appropriate?

Looking for clarification on what findings need to be documented in order to bill code 36221 in conjuction with a congenital heart catheterization. If the physician report does not describe any findings of the great vessels, ONLY findings of the arch, can code 36211 be billed?

In the 2015 Vascular & Endovascular Surgery Coding Reference, page 384, example #2, you included code 36010. Can you explain why? I didn't know you could bill a catheter placement during open procedures.

One of our cardiologists was assisting another surgeon, and our cardiologist performed an angioplasty in the external iliac to stop bleeding below the iliac so the surgeon could perform repairs. Since the angioplasty was done for bleeding and not disease, I don't think code 37220 would apply. I'm thinking of using code 37799 (unlisted procedure, vascular surgery), but I would appreciate your opinion on this one.

I was brought into an organization due to concerns regarding loss revenue, lack of clinical documentation, and poor procedure charging. I am new to this facility. I have used your resources for a long time now in my role roles of a radiological technologist in cath lab, IR, and EP. In my new role I am required to become more aware of Medicare reimbursement. My main issue I have had in the short time I have been at this new facility is that when reviewing cases there are many small coding mistakes that are taking place. Examples being 77001, 76937, 75625, 75630, 75716. In the last year, no CVC cases had code 77001 attached to procedure when they were all done with fluoroscopic guidance. Code 76937 is charged with no documentation of recorded image, and codes 75625 and 75716 are being charged without documentation of catheter placement, which should have been coded as 75630. When asked about these practices I am told we have almost 100 percent Medicare patients and we get reimbursed the same no matter how we code it. How do you overcome this mentality? I'm so frustrated.

I have case where the physician opened up a PPI pocket and cauterized a bleeding vessel. No mention of a hematoma. Any ideas if there is a code that might apply here?

Patient has 403.90 and 585.9. Patient comes in for AV shunt. The MD plans to create the AV shunt at the wrist area. He makes his incision and explores the area and decides the vein is too small. He closes here and then moves to the upper arm and creates the AV shunt there. I did refer to your Q&A # 6128, but this was for two unsuccessful attempts.

In addition to performing a left heart cath and coronary angiography, the report reads: "A gradient assessment across the aortic valve was performed using manual pullback technique. Due to the patient's ongoing chest discomfort we elected to perform an aortogram in the LAO position using 15 cc/second for a total of 30 cc of contrast. Findings: Aortography- Ascending, transverse, and descending thoracic aorta appear to be normal." The provider selected code 93567 for supravalvular aortography; however, the AMA CPT Codebook notes in parentheses: "For non-supravalvular thoracic aortography or abdominal aortography performed at the time of cardiac catheterization, use the appropriate radiological S&I codes (36221,75600-75630)." In the above scenario, is code 93567 appropriate, or would 75600 (without serialography) or 75605 (by serialography)/aortography, thoracic radiological S&I be appropriate? Also how do you determine if aortography is performed with or without serialography? In addition a 12 lead EKG was performed. Is this billable or bundled in 93458?

Would a TAVR px via left common carotid artery cutdown for placement of CoreValve be reported with code 33363?

How would you code a VSD stent with LV and RV angiograms with no heart cath performed?

What code do you suggest for repositioning of a peritoneal drainage catheter? CT abdomen shows drainage malpositioned catheter. Using a stiff guidewire, it is brought to position.

We attempted to upgrade a dual ICD to a biventricular ICD; however, the physician was unable to implant the CS lead after multiple attempts. He implanted the biventricular ICD and plugged the CS port. Can we still report code 33264 since the biventricular ICD generator was implanted even though it's only with the existing atrial and ventricular leads? Would we use a -52 or -74 modifier on code 33225 for the facility bill?

Would you report the following example with code 36140? "Access from the right groin with multiple attempts and radiological guidance was unsuccessful, and the left side was also unsuccessful. The patient is extremely corpulent, and access was not possible. The patient had the radial artery used during surgery, so we are going to need to go from the left arm brachial or radial in order to access her arteries, and this will be rescheduled."

Patient is status of femoropopliteal bypass for his critical limb ischemia, resulting in the setting of a thrombosed popliteal artery aneurysm. He has had some increased claudication symptoms of difficult-to-heal wounds that appear to be primarily of venous nature in the right leg. So, the physician performed an angioplasty of the proximal vein graft stenosis. My question is, should I use the code for venous angioplasty of the fem-pop bypass graft for lower extremity? Or the arterial angioplasty code?

I have a physician who wants to limit radiation dose in patients with frequent dialysis interventions, therefore he is considering limiting the shunt study to the region of concern. The physician is wondering if he does not discuss findings of ENTIRE outflow, will this be a reduced service? Does code 36147 require discussion of findings of entire outflow to the vena cava to substantiate billing the charge?

If the patient has two separate pseudoaneurysms in the CFA, and the physician does two separate punctures to treat each, can we bill codes 36002/76942 twice?

A cardiologist recently asked for echocardiography to assist with a temporary pacemaker insertion. My understanding is that transthoracic echo guidance was utilized for intracardiac RV lead placement. How would you suggest this be reported? Is a UPC the most appropriate? Thank you for your expertise.

For the following example, we assigned codes 36216-LT, 75894, and 75898.  However, I'm questioning if this should be 61626 or 61624. Please advise.  "Previous recent angiogram showed sluggish flow within distal left vertebral artery concerning for thromboembolism. Via right CFA, a 5 French straight guide cath over a guidewire selectively catheterized proximal left subclavian artery. DSA showed proximal LVA occluded approximately 15-20 mm from its origin. Microcath over microwire through guide cath was advanced into left subclavian, then LVA just proximal to the occlusion. I then advanced a TruFill DCS Orbit Complex Fill 5 mm x 15 cm coil into the LVA just proximal to the occlusion. After confirming stability with fluoroscopy, coil was successfully detached. Embolization continued with additional coils, and stability was confirmed prior to successful detachment. DSA showed occlusion of LVA approximately 10 mm distal to its origin with no filling of the more distal LVA and no filling defect in left subclavian to suggest thromboembolism. Cath withdrawn and closed with a Mynx."

For the following example, is code 36247 billable for the selection of the right SFA because it was more distal than where the intervention was performed? Also, is it acceptable to bill for the retraction of the catheter into the left CFA with subsequent run-off (36140)?  "Access via left groin, catheter placed into aorta for dx aortogram (75625). Catheter advanced to the right SFA for selective RLE run-off and catheter retracted to ipsilateral left common femoral artery for LLE run-off (75716). Access then warranted on the right side for kissing angioplasty and stenting of the common iliacs (37221-RT & -LT)."

For the following example, would you charge as a lymph node biopsy or breast biopsy? If lymph node biopsy, is it appropriate to charge for post procedure mammogram?

"52 year-old with newly diagnosed right breast malignancy and prominent right axillary lymph node. The procedure and risks of ultrasound-guided core biopsy and ultrasound-guided metallic localizer clip placement for a right axillary lymph node were discussed in full with the patient. Both oral and written consents were obtained. With ultrasound guidance, aseptic technique, and 1% lidocaine and lidocaine with epinephrine as the local anesthetic, the mass of concern was sampled 3 times with a 14 gauge Achieve biopsy needle. Immediately thereafter, a metallic localizer clip was placed within the mass. Direct pressure was applied to the site immediately post procedure, and hemostasis was achieved. The site was bandaged with antibiotic ointment. POST PROCEDURE MAMMOGRAM was performed in a separate room: The localizer clip is in the expected location of the axillary lymph node."

Physician is doing a transcaval aneurysm sac embolization for an endoleak after an abdominal aortic aneurysm endovascular repair. He is accessing the vena cava, placing a TIPS needle, and gaining access into the aortic aneurysm. How should I report catheter placement? Should I just report code 36200 since that is where the catheter ultimately landed? Or do I report both codes 36200 and 36010?