Ask Dr. Z

There has been lots of back and forth over the years on whether or not congenital heart transplant patients should continue to be reported as congenital for heart cath coding purposes. Physicians state that once congenital always congenital, but I've understood from consultant recommendations that unless the new heart has a congenital defect or complex re-routing of vessels due to congenital cardiac anatomy, then all heart caths for transplant patients are coded as non-congenital. Can you please clarify?

"During the procedure the physician harvested the GSV and attempted to create a proper hepatic to right renal artery end-to-end bypass. The anastomosis was completed, but failed once, and following a revision and re-attempt was found to be too diminutive on arteriography and was removed and abandoned. A 6 mm PTFE bypass graft was then used as the conduit." My question is, with PFTE graft vs. 35535, should I report code 35535 alone with a -22 modifier (assuming documentation states as such) and/or another code for the PTFE graft that was ultimately left in place? (It appears that code 35535 only covers vein, and I cannot find a synthetic.) I would also like to code the arteriography (75726). What are your thoughts?

Can you elaborate on what constitutes a "basic" exam of the pulmonary arteries? Can a basic exam be performed non-selectively at the main artery (75746) first, and then performed selectively? Would you still then report code 75746 (non-selective artery from the main pulmonary) if a selective placement of one or more of the other pulmonary arteries are selected? Or is the non-selective artery bundled once a selective arteriogram is done? For example, say a non-selective was done at the main, and then just one side is done selectively at the left pulmonary artery. Could you give some examples? I'm looking in your book, and I'm not quite understanding the scenario of what constitutes a basic exam. Your book says the basic exam is a "bilateral pulmonary angiogram", but the vessels can be viewed selectively and non-selectively, so I guess that's what is tripping me up.

When the report states that the anastomosis was treated with PTA, are we to assume that this graft is a direct anastomosis between vein and artery (which is reported with code 35475)?

"The patient had stenosis of a previous fem-pop bypass. Access with cutdown due to previous placed kissing iliac stents. Angiography was performed, which showed the stenosis at the proximal anastomosis, which was angioplastied. A stent was deployed from the anastomosis down into the proximal graft. Sheath was removed and suture placed to close access site." What's the appropriate code here?

I get an NCCI edit for code 93976. When a female patient comes in for pelvic pain, we do a pelvic ultrasound (76856). If nothing is found, we check for arterial and/or venous flow through the ovaries. Can I add modifier -XU if done on the same encounter?

For the following example, would you report codes 19287 and 19288? Or just code 19287? "Pre-operative MRI-guided bracket 2-wire localization of the right breast, with the target R1 (a 4.1 cm linear clumped non-mass enhancement at the 8:00 position in the anterior to middle depth, 7.4 cm from the nipple) located between the two wire tips and their distal segments."

When performing chemoembolization, do you use V58.11 (encounter for antineoplastic chemotherapy) as your primary dx? These encounters are not your typical “chemotherapy”, but I believe they would qualify as antineoplastic chemotherapy. If that is true, then would you also use V58.0 (radiotherapy) when performing a radiofrequency ablation?

Patient has AV fistula, and physician documents medical rationale for advancing the fistula beyond the anastomosis (i.e., steal/embolus). I am comfortable in the concept that code 36147 includes imaging of the adjacent fistula. However, the question came up that if the physician evaluates only one other artery, is that sufficient for code 75710? Or does it have to be multiple arteries? It's a weird question, but the physician has it in his head that to qualify for 75710 beyond 36147 there should be at least three vessels visualized, but that seems to imply that there is a minimum to use the code. Thanks for any insight.

I'm not quite sure what codes should be used for this. The radiologist is stating that this is a conversion of an existing nephrostomy tube to a nephroureteral stent. "A scout image demonstrated the existing catheter in place. Contrast was injected into the tube, which demonstrated filling of the renal collecting system. Contrast flowed into an irregularly opacified bladder. A suprapubic catheter was in place. A wire was passed through the catheter, and the catheter was removed. A new 10 French nephroureteral stent was advanced over the wire, and its distal loop formed in the bladder, with the proximal loop in the renal pelvis. The catheter was sutured to the skin, and a sterile dressing was applied. The tube was capped. A drainage bag was provided to the patient in case the tube becomes obstructed."

How do I code left heart catheterization, left ventriculogram with LVEDP measurement, selective coronary angiography, and non-selective LIMA angiography?

Our physicians have begun using a research device called Sentinel for embolic protection, placed in the right brachiocephalic and left carotid arteries during TAVR procedures. The use of embolic protection is not separately reportable with various other coronary and revascularization procedures, but would an additional code (93799) for the placement of the device be allowed when it is performed as part of a TAVR?

I am leaning towards code 50395 for this example, but I have read conflicting opinions that code 74485 should/should not be reported. Could you provide your guidance and opinion? "Indications: Pre-op access for lithotripsy; nephrolithiasis. After injection of 1% subcutaneous lidocaine, an 18 gauge x 15 cm Hawkins needle was used to access a right posterior, inferior calyx under fluoroscopic guidance (after inflation of a proximal ureteral balloon and injection of approximately 5 cc contrast). The stylet was removed, and reflux of urine was confirmed. A 0.035" stiff Glidewire, with the aid of a 5 French Berenstein catheter, was placed in the urinary bladder to maintain access. The Berenstein catheter was then exchanged for an 8.5 French nephroureteral stent. A small amount of contrast was injected to confirm placement. The wire and stylette were then removed. Final sonographic image was obtained to confirm placement. The catheter was sutured into place using a 2-0 silk suture,and it was then capped. Sterile dressings were applied."

Which is the appropriate code for needle biopsy of T9 transverse process? 20220 or 20225?

"Cavernous carotid artery aneurysm was found on CTA. Therefore, selective catheter was placed on right internal carotid artery, and cerebral angiogram was confirmed aneurysm. Catheter was then navigated into the right middle cerebral artery, and Pipeline embolization device was placed across the neck of the aneurysm. Angiogram showed endoleak. So the second pipeline embolization device was placed." Can I report code 36224 along with 61624, 36217, and 75894? Or, should I use codes 36224 and 61624 only?

A 6-week-old girl with HLHS, interrupted aortic arch type B, and moderate VSD who is status post Norwood, modified BT shunt and DKS presents with concerns for RV dysfunction with moderate tricuspid regurgitation and LPA stenosis on last echo. She presents for diagnostic cath to rull out causes of RV dysfunction and/or possible intervention. A right and left heart cath via existing atrial septal opening (93533-26) was done. Contrast injection of the innominate artery shows a right-sided BT, which is widely patent. The RPA appears to be of good caliber. There is severe long segment stenosis of the LPA with severe hypoplasia distally with normal pulmonary venous return of the left atrium." Is the statement 'rule out causes of RV dysfunction' sufficient documentation to support medical necessity for billing the S&I for the BT shunt (75710-26)? Also, can we bill for the catheter placement in the innominate artery (36215), or would that be bundled in the pulmonary angiography code 93568?

Can we report both codes 93655 and 93656 for FIRM (focal impulse & rotor modulation) and pulmonary vein isolation catheter ablation to treat atrial fibrillation? Usually these rotor ablations are done in both the right and left atrium prior to PVI. If reportable, should we assign code 93655 twice for left and right no matter how many rotors/lesions were ablated? Or do we code based on the number of lesions ablated? Here's an example: "The 60 mm basket catheter was deployed in the left atrium and Epoch 3 created, which appeared to show rotors on the mitral annulus just anteroinferior and posteroinferior to the left lower vein. These rotors were ablated and ablation lesions connected. Epoch 4 showed a posterior wall rotor, which was over the esophagus and was difficult to ablate extensively due to heating. Epoch 5 and epoch 6 were created after adjusting the basket to better contact the posterior wall. These revealed rotors in similar areas as the prior rotors. Ablation lesions were delivered extending the prior lesions along the mitral isthmus and on the posterior wall. During ablation, atrial fibrillation terminated."

Patient had an implantation of patient-activated cardiac event recorder on Sept. 12, 2014 (33282, 90 day global-period). In November 17, 2014, patient returned to the OR for the removal of the implantable event recorder and permanent dual pacemaker implantation (33208, 90-day global as well). Since the patient is on the 90-day global period I was considering appending a -78 modifier to the pacemaker code (33208). This claim was denied by the insurance carrier already because of the 90-day global period. Is it possible to use a -78 modifier and resubmit this claim or not?

We have a patient coming to us after having a biventricular ICD implanted at another facility. The left ventricular lead was not attached, nor was the screw tightened. What would you code for opening the pocket and tightening the set screw?

Can we code a TEE during TAVR? Your 2015 Diagnostic & Interventional Cardiovascular Coding Reference, page 146, #3, says do code for TEE if utilized during percutaneous valve replacement; however, your online member newsletter dated December 17, 2014 states under Chapter 5 that "TEE is also NOT separately reportable with TAVR". Which is correct?

I have patient with CTO of the LAD and left circumflex. To bill out to Medicare Advantage plan, would I use codes 92943-LD and 92943-59LC? Or should I bill codes 92943-LD and 92944-LC?

Do the same rules apply for a congenital echo that apply for congenital heart caths for patients with a diagnosis of coronary anomalies, PFO, etc.? In other words, for patients with PFO/coronary anomalies, would I code the echo as congenital or non-congenital?

For the following example, is it appropriate to report codes 62273 and 0232T? "Patient with suspected CSF leak. L1-2 level was localized with fluoroscopy. Needle was then placed in the posterior epidural space under fluoroscopic guidance. Contrast was injected to confirm epidural position. 60 mL of peripheral blood was withdrawn from the IV catheter, which was then centrifuged to obtain 7 mL of platelet rich plasma that was slowly injected into the spinal needle. The patient maintained normal motor function in both feet and denied significant radicular symptoms throughout the injection."

I hope you can help with this unique request. The patient’s condition warranted a bedside esophagram. Fluoroscopy was NOT used. Instead, the tech used a digital portable x-ray machine with cassette placed behind and on the side of the patient to take 11 or so images in the AP and lateral projections in the chest area. This was done before, during, and after ingestion of contrast material, which was injected via GI tube at the level of mid esophagus by the patient’s physician (not the radiologist). What is the appropriate way to code this? Scout film demonstrates evidence of pneumomediastinum and soft tissue emphysema in the neck and supraclavicular regions. No pneumothorax is evident. Extensive bilateral pulmonary parenchymal disease is noted with diffuse infiltrates. Administration of contrast opacifies the mid to distal esophagus, which demonstrates no evidence of obstruction or extravasation of contrast. We are concerned if we need to report this as a chest x-ray or as an esophagram.

I have cases in which two separate procedures were done on the same day by the same physician. For example, a GI tube was placed, and a port-a-cath was done. I have codes 49440, 36561, 77001, and 76937. The documentation is appropriate to what was done. Now I have an edit of code 77001 needing a modifier due to code 49440. With the new 2015 modifiers (-XE, -XS, -XP, and -XU), which one would I use instead of modifier -59?

What is the correct for midline (peripheral) catheter placement? I keep hearing either that codes don't exist or they haven't been clarified. I'm having trouble getting clarification from anyone.

Please help with the following case: "Patient had right subclavian artery occlusion. Upon incision and exposure of the distal common carotid artery, it was found to be amenable for use as an inflow vessel for a bypass. Then the axillary artery was exposed and good for use as target vessel. A tunnel was created between the common carotid and infraclavicular incision to allow for passage of the bypass graft. A plane was created underneath the clavicle connecting the two incisions, and an 8 mm ring PTFE graft was selected for the conduit. The conduit was passed through the tunnel, and the PTFE graft was passed through the tunnel. Arteriotomy was created over the common carotid artery and anastomosis created in an end-to-side fashion. Flow was restored through the graft to the right carotid artery. Arteriotomy was then created over the axillary artery. The vascular graft was then cut for a wide spatulated anastomosis. The anastomosis was then created in an end-to-side fashion between the graft and the axillary artery. A strong brachial artery was noted upon completion of the bypass."

"A 22 gauge spinal needle was inserted into spinal canal using fluoroscopy. Omnipaque was injected into the thecal sac. Multiple radiographs were performed. Subsequently, because a 'block' to the cephalad flow of contrast material was encountered from the lumbar region at the T12 level, a C1-C2 puncture was accomplished under fluoroscopy. Clear, colorless cerebral spinal fluid was obtained. Approximately 8 cc of Isovue-M 300 was injected into the cervical subarachnoid space. Because the procedure was performed in Special Procedures, the dynamics of the table would not allow sufficient elevation of the head for the contrast material to flow caudally to the thoracic spine. Afterwards the patient underwent a CT, which will be dictated separately." Would it be correct to report code 62305, or should we use code 61055?

Patient goes to X-ray department for fluoro-guided injection for myelogram, then to CT for spinal exam. Code 62284 bundles 77003 per hospital NCCI edits. Should X-ray only report code 62284 and not 77003?

My IR group wants to bill for the CT acquisition along with 3D reconstruction code 76377 when performing TACE or Y-90 procedures. I can't locate any documentation to state they can or cannot do this. The physicians are telling me permanent CT images are being obtained by this machine and stored in the patient's chart. If they can code for this in addition to the TACE or Y-90 procedures, what additional documentation should they include in their reports?

One of our surgeons placed a stent at the origin of the left common carotid artery by open cutdown along with aortic arch angiogram. Pre and post angioplasties were performed of the common carotid origin as well. A filter was not used for this case, and the patient has Medicare. The question is, do we consider the procedure of the left common carotid artery origin to be a carotid stent code or unlisted code? Not sure how to properly code this one.

A previous question answered to use unlisted code 37799 for renal vein transposition; however, my physician did a renal vein bypass to the IVC using cryrovein. Does this fall under code 37799, or could you use code 35281 intra-abdominal repair with other than vein (for nutcracker syndrome)? "Procedure: I was able to expose the renal vein back towards the left kidney. Meticulous dissection was performed with blunt sharp dissection, and I was able to expose the renal vein to level of both gonadal vein and adrenal vein. I placed Satinsky clamp on the inferior vena cava where renal vein joined. Also placed Satinsky clamp on the left renal vein at level of adrenal vein . The renal vein was divided at its junction with IVC. The IVC was oversewn with 5-0 prolene. We then did end of renal vein to end of cryopreserved vein anastomosis, as we did not have enough mobility in renal vein itself. We brought this down more distally on the IVC and placed a second clamp. We performed longitudinal venotomy, beveled the cryovein, and performed end to cryovein to side of vena cava anastomosis."

Could you please review this example and help with the coding of 92928 and 92921 or just 92928? "A wire was advanced into the distal portion of the left anterior descending. A wire was advanced into the distal portion of a medial branch of the first diagonal branch. The diagonal was dilated at its ostium and mid portion with a 2.0 x 15 mm Mini TREK balloon. The ostium was then dilated using a 2.25 x 8 mm NC TREK. Subsequently, a 2.25 x 8 mm Xience Alpine drug-eluting stent was deployed at the ostium of the diagonal. Post-dilation was performed using a 2.5 x 6 mm NC TREK balloon at the ostium of the diagonal and a 3.25 x 12 mm NC TREK balloon within the left anterior descending. Successful stenting of ostial diagonal lesion using drug-eluting stent. The initial stenosis of 90% was reduced to final residual stenosis of 0% with an excellent angiographic result. Successful balloon angioplasty of lesion in a medial branch of the diagonal branch of the left anterior descending."

Patient has severe coronary artery disease to left main, LAD, and circumflex. Stents were placed in each vessel during myocardial infarction. Patient expired. Can code C9606 be reported three times?

A patient had a CABG, and during that procedure an LV lead was placed for future use. Previously the patient had an infected pocket and the ICD generator was removed along with the lead. Now the patient is back in the OR to implant an ICD with leads and also to attach the LV lead that was previously placed. Would you report code 33249? DFT was done, so we'd use code 93641-26. Code 33249 states single or dual chamber, but patient did have three leads attached.

We would sure appreciate your advice. We have a physician who performs paracentesis with an angiocatheter. She does not feel that is necessary to document that the catheter was removed at the end of the procedure because she states that "it is common sense that an angiocatheter cannot be left in the belly". Can we report this to as a paracentesis with code 49083, or do we need to use code 49406 because the documentation doesn't reflect that the catheter was removed? We also have a similar situation with a thoracentesis. She doesn't document removing the catheter (angiocatheter), and she is tellling us that "if she doesn't state it was sutured to the skin then she removed it". Please advise.

Do you have any guidance for using new TEE code 93355 with the TAVR procedures? If I am understanding the code correctly it is for use with these procedures, but when I run through the coding edit it appears to bundle under NCCI.

I have a two-fold question: 1) What CPT codes would you recommend for a diagnostic percutaneous nephrostogram, nephroureterostomy placement, and nephrostomy placement in one kidney in preparation for a nephrolithotomy the next day by a urologist? Would you use 50393, 50392, and 50390? The notes do not mention dilation. 2) If yes, would the -XU modifier be used instead of -59 in 2015?

I am hoping you can help with the following case. I don't believe that code 35879 should be billed at the same time as code 35566, but I am considering the use of a -22 modifier. "Once femoroperoneal bypass was completed, ultrasound Doppler was used to evaluate graft, and the graft was found to have relatively low velocities of 15cm/sec in the thigh. There was a significant flow difference noted with velocities of 80 cm/sec in comparison to adjacent velocities of 15cm/sec. Incision was made over the graft, graft was mobilized, and it was decided to proceed with patch angioplasty since abnormality was likely a frozen valve. A segment of residual GSV was harvested and opened longitudinally for patch purposes. Arteriotomy was made through the valve and fibrotic tissue debrided away from the wall. Standard onlay vein patch angioplasty was then performed. Repair was complete, flow restored, and duplex showed no abnormalities with significantly improved velocities. Total procedure time was 7 hours."

At our children’s hospital we have a procedure where they did an esophageal recording/pacing (93616) along with a programmed stimulation and pacing after drug infusion (isoproterenol or epinephrine). Normally for EP procedures we charge for the drug stimulation/pacing (93623), but code 93616 is not a parent code to 93626. We do this to determine if they need a full invasive EP procedure or if continuation of antiarrhythmic medication is still needed until they are large enough (weight or age depending on the child’s size) to have the EP procedure. What would you suggest to code in addition to 93616? Is there an appropriate code to charge for the pharmacologic portion of these procedures?

If a surgeon performs a stereotactic (or mammographic) guided breast biopsy, and the radiologist then does a post-procedure mammogram, can the radiologist bill for the post-procedure mammogram? What if the surgeon performs an ultrasound-guided breast biopsy, and the radiologist then does a post-procedure mammogram; can the radiologist bill for the post-procedure mammogram?

If a hospital department is performing breast mammograms with tomosynthesis, would you say across the board that the CAD codes should not be coded additionally? The mammogram coded with the tomography code would become the base code for the CAD add-on code. We have checked, and some of the coding pairs (77062 & 77052 and 77063 & 77052) are on the NCCI edit list preventing their use together, but others (for e.g., 77061 paired with 77051) appear to be allowable. I have not been able to find any further guidance to help clarify. I would appreciate your help and expertise.

Patient had drug-eluting stent to RCA and then was taken back to cath lab on same day because of re-occlusion to RCA stent. Patient had second procedure with more drug-eluting stent to RCA. Can we bill C9600 x2?

With the implementation of the new modifiers -XE, -XS, -XP, and -XU, which would be used to report when no previous diagnostic imaging was recently performed? Would modifier -59 still be used in this instance?

Below is a portion of dictation from a cardiac catheterization; just the portion related to the aortogram is included; a full catheterization and coronary angiogram were performed. Can you please help settle a dispute between the cath lab and the coders? Would the correct code for the aortogram be 75625 or 93567? "PROCEDURE LIST: 1) Left heart catheterization. 2) Coronary angiogram. 3) Left ventriculogram. 4) Abdominal aortic angiogram with flow through angiogram of both renal arteries and right iliofemoral artery. TECHNIQUE OF PROCEDURE: The catheter was then pulled to the abdominal aorta. Abdominal aortic angiogram with flow through angiogram of the right iliofemoral artery and both renal arteries was performed. ANALYSIS OF DATA: 1) No abdominal aortic aneurysm is noted. 2) No renovascular stenosis is noted. 3) The right common iliac artery has no significant stenosis."

I would like some coding advice on coding the aortic root aortogram and peripheral angiography in the following example. "PROCEDURES: Coronary angiography, right heart cath, aortic root aortogram, peripheral angiography. PERIPHERAL ANGIOGRAPHY: Peripheral angiography of the renals was done. Abdominal aortogram: Technique - RBA access, DSA, with pigtail in abdominal aorta. Findings: Right and left renal arteries are patent; severe calcification of aortic bifurcation; right common iliac moderate focal stenosis; right external iliac moderate diffuse narrowing; right common and external iliac linear defect; right internal iliac is patent; left common iliac mild stenosis; left external iliac occlusion; left internal iliac is patent. AORTIC ROOT AORTOGRAM: A selective aortogram was performed. The size of the ascending aorta is in the upper limits of normal. Maximum aortic diameter: 3 cm. There is no aortic valve regurgitation."

With patients who have possible symptoms of stroke, we perform an MRI and MRA to rule out a stroke. If the MRI comes back negative, we then do an MRA. Can we charge for both or only one? If yes, what modifier would we use?

Our physician states he selectively catheterized the left subclavian artery and then advanced into the left vertebral artery where an angiogram was done. We want to report code 36227, but he did not state that an angiogram was done in a previous artery. In order to bill code 36227 you need to have either 36222, 36223, or 36224. What do we bill without angiograms being done in these areas?

I have a question on coding the interventions for the following example. Would this all be captured with codes 37221 and 37223? "Right CFA accessed. Contrast injection revealed high-grade stenosis of the right common and external iliac arteries. The stenosis was secondary to eccentric 90% plaque. Decision was made to intervene with right-sided stent placements. The right iliac system was stented from just below the bifurcation down to the inquinal ligament. A series of Nitinol stents were placed. Upon placement of the last stent, patient began to bleed profusely. Pressure was applied. A second puncture was made in the lower right common femoral artery and a sheath placed. A Viabahn graft was placed to line the entire bare metal stents. Final angiogram showed excellent flow and palpable pulses in both feet."

The cardiologists in our practice have recently become employed by the hospital, and we need to start billing the nuclear stress test as a global procedure. The hospital was billing codes 93017 and 78452, as well as the radiopharmaceuticals and other drugs used. What codes should we be billing now to cover both the physician charges and the hospital charges? Also, are the injection and infusion codes billable from the hospital side? The place of service is hospital outpatient.