Ask Dr. Z

Patient with common femoral thromboendarterectomy with patch graft performed above the fem-pop bypass. The artery was severely degraded and fell apart during patch angioplasty necessitating the need to go higher in the iliac requiring conversion to ilio-fem bypass. An 8 mm Gore-Tex graft was brought to the table. It was beveled and attached to the iliac with the distal end extending into the bypass graft and sliding nicely together. Would I code for both the endarterectomy and, say, a revision of the graft? Codes 35371 and 35883? Or 35876 alone?

Our physicians have placed stents in the celiac artery and lower abdominal aorta due to high grade stenosis. Is 37236 the correct code for the stent placement? The LCD for our area does not include coverage information for the celiac artery or abdominal aorta like it does, for example, the renal and mesenteric arteries. Since it is not included in the policy, does that mean it would be considered investigational for the celiac and aorta or just not covered? Is there any way to be reimbursed for these procedures?

We report code 95940 for IOM monitoring in the operating room. In our system the techs are reporting the total number of minutes of monitoring. I think this should be converted to 15 minutes = 1 unit for reporting on the UB04. Since it is status indicator N, Medicare is not going to pay. Is the correct way to report this in units or minutes? I see in your book that it is important to be reported accurately. Can you explain so that I can explain it to them?

We are in disagreement with the pulmonary angiogram codes and the number of coil closures that can be billed for this case. The procedures were right and retro left heart cath for CHD, selective right and left pulmonary angiograms, and multiple subsegmental pulmonary angiograms. The embolizations performed were: 1) Inferior lateral basilar right lower pulmonary artery, 2) posterior segmental lateral basilar right lower pulmonary artery, 3) posterior-superior subsegmental accessory right upper pulmonary artery, 4) antero-inferior subsegmental accessory right upper pulmonary artery, 5) apical segmental right upper pulmonary artery, 6) medial and lateral subsegmental anterior right upper pulmonary arteries.

Code suggestions have been:

1. 93531, 93568, 37242 x 2 (right upper and right lower as two separate surgical fields)
2. 93531, 93568 multiple times for the pulmonary and subsegmental angiograms, and 37242 x 6
3. 93531, 93463, 93568, 36015/75741 multiple times for the subsegmental pulmonary angiograms, and 37242 x 6

I've got a case in which the patient has multiple intracranial aneurysms: aneurysm in the distal left vertebral artery, a separate aneurysm in the mid basilar artery, as well as a separate aneurysm in the distal basilar artery. This totals three separate aneurysms. The physician performs coiling of each of these aneurysms. Would it be permissable to report code 61624 for each of embolizations of the prior addressed aneurysms? In your 2014 Vascular & Endovascular Surgery Coding Reference on page 259, it's indicated that intracranial aneurysm are coded per surgical field. Three surgical fields: right and left cerebral hemishperes and cerebellum. It's instruced to code per surgical field. However, in the CPT Assistant November 2006, Volume 16, Issue 11, it states (when reference 61624): "This code can be reported more than once for additional aneurysm treated at the same setting." Basically, I'm wanting your thoughts on this situation and to query where the information on page 259 of the ZHealth Publishing Vascular & Endovascular Surgery Coding Reference was obtained.

I'm confused as to what modifier would be appropriate for a diagnostic coronary angiogram that leads to the decision to do an intervention. It doesn't seem like any of the new modifiers fit the bill. Would you suggest still using a -59 modifier or using -XU (as that seems closest)?

I'm not sure what I can bill here. I know thrombectomy isn't separately billable, and the dottering was done with a wire, so I'm thinking that isn't either. It seems to me the physician should be able to bill something for the work. Acute MI is documented in report. Interventions: "Given bolus and started on infusion of angiomax. Prowater wire advanced beyond PLB occlusion, but distal vessel very small and tortuous. Two aspirations with Pronto thrombectomy catheter, restoring TIMI-1 to TIMI-2 flow. Wire then pulled back and advanced to distal PDA occlusion. Vessel very tortuous and occlusion very distal, so no thrombectomy. Floppy wire then used to dotter the PLB occlusion again, restoring TIMI-2 flow. Elected not to do PTCA or stenting, given how distal both occlusions were and how small the vessels were at that point. Considered integrilin, but small hematoma at right groin (patient practically jumped off table with lidocaine at beginning of case) and concerns about bleeding risk (with effient on board as well). Angio-seal deployed right FA."

Is code 0236T correct for aortogram, iliac angiography with closure device, PTA? We are getting claim denials even with records sent.

Are codes 36595/75901 correct for PTA of a fibrin sheath through the same access site (via the CVC) as the CVC during a replacement of the existing CVC without port? Or is this included in the replacement procedure (36581)?

Could you help to clarify the use of modifier -Q0 in certain circumstances? Let’s assume the patient had the original acid placed for primary prevention and is coming in because the acid is at the end of life and the dx v53.32 is coded on chart. If patient comes in to have only the generator replaced, do you add modifier -Q0 to codes 33262-33264? If patient comes in to have a lead replaced to the existing generator, is modifier -Q0 added to code 33224? If the total system is replaced or upgraded, do you add modifier -Q0 to the CPT codes? Or are the above examples considered secondary intervention and modifier -Q0 not assigned because you have a qualifying dx on the claim (V53.32)?

When ordering an aortic study and an ABI study, is it acceptable to use dx code 440.0 for both studies?

"TEE for possible ASD. Scheduled for possible ASD closure, however, unable to cross the defect using the Coournand catheter. Then RHC performed to measure right sided pressures, and we were able to wedge the catheter and obtain wedge pressure. Then pulmonary angiogram was performed for possible AVMS. ICE catheter also used. Also perfomed SVC, which showed no persistent left SVC." We coded 93451/93568/75827 and 93799 for ICE. Please advise. Thanks

Follow-Up Inquiry: If it is ASD closure/diagnosis, then only RHC performed, do you suggest coding 93530 or 93451? According to the CPT Codebook for PFO use non-congenital heart caths? Sometimes they find ASD but not able to cross the defect and RHC/pulmonary angiogram/ICE/SVC performed. In both cases we charge 93799 for ICE, but not sure of 93530 versus 93451? Please advise.

We had a patient come for X-rays. The patient had an X-ray of the skull 70250 and an X-ray of the orbit. Per coding guidelines it states to use cot code 70250 when less than four views are taken of the orbit. This patient's orbit X-ray was less than four views. Please advise me of how to code this since both an X-ray of skull and orbit were done on the same day. Please advise me of the appropriate CPT code usage along with the correct modifier. If a modifier is necessary please provide me to which procedure code the modifier should be attached to.

With the new modifiers that go into effect starting on January 1, 2015, could you clarify which modifier we would use in a case where the physician performs a bilateral lower extremity angiogram (75716-26) and then crosses over the bifurcation and performs a POP angioplasty (37224)? Would we still use the -59 modifier on code 75716-26, or would we need to use one of the new modifiers? If so, which one would be appropriate?

Are codes 33946 and 33947 for physician use only? Should codes 33951-33954 be used for facility billing of placement of cannula in the cath lab setting even on first day, or are they only for subsequent cannulas (after day 1)?

Please let me know if I can code venography and PICC line together on this type of case. "Clinical History: Needs improved central venous access, poor peripheral access. A small amount of contrast was injected, confirming chronic occlusion of the right upper extremity central venous system. Therefore, right internal jugular central venous catheter placement was pursued. Access to the right internal jugular vein was gained by sonographically-guided puncture. A permanent sonographic image was obtained. The vein was confirmed to be patent. Under fluoroscopic guidance, a dual lumen peripherally-introduced central venous catheter was placed with the tip at the junction of the superior vena cava and right atrium at completion. A permanent radiographic image was obtained. Fluoroscopy time was 3.1 minutes. Successful placement of right internal jugular central venous catheter." Please let me know if I can report codes 75820 (not sure), 77001, 76937, and 36556 for this case.

Physician performed percutaneous left atrial appendage exclusion using epicardial and femoral access via the Lariat Suture delivery device (33999). A different physician performed a transesophageal echocardiogram, which demonstrated no evidence of a left atrial appendage thrombus. This physician performed TTE throughout the entire procedure. Is this TEE separately billable, or is it included in code 33999?

For the following example, would the wedge pressure be reportable with codes 36012 and 75889? "Patient has a right heart cath with hemodynamic measurements via right internal jugular (93451). Through a separate femoral vein approach, catheter is advanced through the vena cava to the hepatic vein, and a hepatic wedge pressure is taken. No contrast was used for procedure."

For the following scenario, can I report code 36244 along with codes 61624, 36217, and 75894? "Cavernous carotid artery aneurysm was found on CTA. Therefore, selective catheter was placed in right internal carotid artery, and cerebral angiogram 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."

Is code 37241 or 37243 appropriate in the following scenario? "Patient with advanced gallbladder cancer presenting for right portal vein embolization prior to possible future right hepatectomy. 1) Contrast enhanced C-arm CT on injection of the main portal vein. 2) Portal venogram. 3) Right portal vein posterior division venogram. 4) Glue embolization of the posterior division of the right portal vein. 5) Right portal vein anterior division venogram. 6) Glue embolization of the anterior division of the right portal vein. 7) Completion fluoroscopic image. Successful embolization of the right portal vein ANTERIOR AND POSTERIOR DIVISIONS with histoacryl and lipiodol."

How would I code the NM study performed in conjunction with a pre-Yttrium MAA injection? We coded the following report as 78201. "NM liver imaging static hepatic shunt study. 3mCi of 99mTc MAA was administered into the hepatic artery by the staff. Subsequent images of the liver and lungs were performed with calculation of a lung to liver shunt fraction. It was calculated that 2.25% of the administered activity into the hepatic artery appeared in the lungs. The remainder of the activity visualized appears to reflect elution of pertechnetate judging from its biodistribution. Impression: Negative intrahepatic shunt study, shunt fraction calculated at 2.25%."

If while performing a diagnostic or interventional heart cath the patient requires emergent CPR, do we code for the CPR separately in addition to the heart cath procedure? Or is it considered part of the procedure?

We have a patient who was brought to the IR department and had an ultrasound scan performed of the left chest to evaluate pleural effusion. The patient was then positioned in right decubitus and had the drain attached to suction to remove fluid. Would you recommend billing for a limited ultrasound, unlisted procedure, or a clinic visit for this service? The order was for a pleural drain evaluation, possible removal versus tPA of loculated collection.

Patient had temporary pacemaker placed a week ago. He came in today and had it removed, and a permanent pacemaker was placed. Would you just charge a pacemaker lead removal and the insertion of the new device?

What CPT code can we use (if any) to bill for sizing of an ASD?

We explanted a left ventricular lead and replaced it while attaching it to an existing biventricular generator. The best code I can find is 33224, yet the code definition doesn't seem to capture the explant of the lead, only the implant.

Could you please indicate how to code this case? A stent was placed in an AV graft venous outflow while an angioplasty was performed on arterial anastomosis.

When a patient is seen for biopsy and "core biopsies" were not possible due to nearby vessels, would it be appropriate to bill biopsy if report calls it such? In this example, the title of report is "Image-Guided Biopsy of 1 cm Left Common Iliac Lymph Node Lesion".

"Using a lateral approach under CT guidance, an 18 gauge needle was advanced down to the lesion of interest. A 22 gauge needle was used to obtain samples for cytologic assessment. The lesion is not amenable to core biopsy because of the close proximity of the arterial vessels and ureter."

Would this be billed as an abdominal biopsy (49180), a lymph node biopsy (38505), or an FNA (10022)? It is titled "Biopsy", yet the report states "core" not collected, rather a needle "biopsy" was. Is this a needle biopsy or an FNA? If it is a biopsy, would "common iliac lymph node" be reported with code 49180 or 38505? It would seem that the work of accessing an area that is deep (such as abdominal or visceral) would be more involved than just an FNA. I would really appreciate your input!

I'm looking at using an unlisted code for this procedure (37799): renal vein reimplant to the IVC/renal vein transposition (being done for nutcracker syndrome on one case, and renal vein entrapment with pelvic congestion syndrome on another). I wasn't sure if you were aware of something better to use.

Can I bill surgical cutdown codes 34812 and 34834 along with fenestrated aortic stent graft with three visceral artery endoprostheses?

Total excision of an infected left upper extremity AV graft was performed. Afterwards they harvested the distal brachial vein for a vein patch. The vein patch was sewn onto the brachial artery to repair the artery after the graft had been removed. I reported code 35903 for removal of the infected graft. Should a code also be assigned for the vein patch repair of the brachial artery?

Per Ask Dr. Z question ID #6250, Dr. Dunn advised coding based on the type of generator replaced. For the case below, will we use code 33228 (dual chamber pacemaker generator) for what was placed, or should we use code 33227 (single chamber) for what it is pacing?

"Patient came in for replacement of dual chamber pacemaker battery, which was carried out. Right ventricular lead was left in place and capped. Right atrial lead was left in the right atrial appendage. Guidant Model 1298 generator was removed from the chronic leads. Leads were inserted into the header of the new generator, Boston Scientific Ingenio Mode 390813 (C1785), tightened in place with immediate pacing,  sensing noted, and pocket closed." Later the same day, an addendum was added to supplement the operative note: "Severe scar tissue over leads and generator. When checked, ventricular lead was not capturing, but atrial was working. We were unable to advance wire into proximal subclavian. When given contrast, vein appeared occluded. Instead of going to right side, we assessed the AV, and it was conducting 1:1 even at rate of 140. We implanted generator on this side and put patient on AAI mode." 

In 2014 we used code 37236 for subclavian, etc. stenting. In reading new code 37218 for 2015, is this code taking the place of 37236? If not, what is your interpretation of this new code, and what is it to be used for?

We have had a few patients with tricuspid valve issues that require our MDs to put the ventricular lead in the CS (using a CS lead), rather than the RV, for a dual chamber pacemaker. How do we code this?

I am having issues with insurance companies (multiple) denying 34812-50-62-59-51, 36200-50-59-51 with code 36245 on the AAA procedures. The CPT codes that I am charging are: 34802-62, 34825-62, 34812-50-62-59-51, 36200-50-59-51, 36245, 37250, 37251, 37251-76, 75952-26, 75953-26, 75945-26, 75946-26, and 75946-26-76. I am at a loss because I have always charged this and have had no problem before.

When a cerebral angiogram (36224) is done, and a 3D reconstruction is done on an independent workstation (76377), as well as a cone CT to check for a bleed, can the CT scan be billed? if yes, would billing it as a limited (76380) or (70450) be correct ? If a limited CT is done for a non-invasive spinal procedure, would the CT be bundled into the S&I code?

Does the hospital charge for the contrast material itself with a cardiac cath procedure, or is it considered included?

Our physician did an external iliac-popliteal bypass with graft. I am not seeing a CPT code for this procedure. Since the popliteal is included in the femoral family for percutaneous intervention, would it be correct to report code 35665, or should we use an unlisted code for this procedure?

Patient has a left to right femoral-femoral bypass with a PTFE graft. Using the same graft, the physician does a left femoral-popliteal bypass graft. Can I use both codes 35656 and 35661, as two bypasses were done but only one PTFE graft used?

I researched prior questions along with your cardiovascular coding book and could not locate an answer to my question. Patient has a biventricular ICD in which the left ventricular lead is repositioned in the anterior cardiac vein, the dislodged right atrial lead is repositioned, and adequate slack was added to the right ventricular coil. I want to report this with code 33215 along with 33226, but I am encountering an NCCI edit. Please advise.

Could you please assist with the correct procedure code? I am unsure of which code is most appropriate (37799 or 37220). "5 French Cobra Glidecath was advanced through the sheath into the distal aorta and advanced over a Glidewire to the contralateral left internal iliac artery. Digital subtraction arteriography was performed over the pelvis and upper thigh. Cobra catheter was exchanged over a guidewire for a 12 mm diameter by 4 cm long angioplasty balloon, which required exchange of a 5 French angiographic sheath, a 4 a 7 French Balkan cross-over sheath, into the contralateral persistent sciatic artery. The antiplastic balloon was inflated across the arteriovenous fistula in the distal persistent sciatic artery, and digital subtraction arteriography of the popliteal and lower leg region was performed to the level of the hindfoot. The balloon was deflated and exchanged over a guidewire for a 5 French Davis catheter, which was advanced into the pseudoaneurysm arising from a persistent sciatic artery, and digital subtraction arteriography was performed."

Is there a CPT code specifically for thoracic aortic angiogram?

The CPT Assistant article from November 2013 states embolization of liver tumor in two separate lobes may be reported with codes 37243 and 37243-59. Does this update your response to question ID #5157 from 10/22/13 that stated the liver is one surgical site? Our patient had radioembolization of right and left hepatic arteries for bilobar hepatic metastases, so we are using codes 37243 and 37243-59.

Which code (49406 or 10030) should be used for drainage of a gluteal seroma followed by alcohol ablation? And would code 20500 be correct for the ablation? Procedure details (partial): "Following preparation of the right gluteal region and administration of 8 mL, 2% lidocaine local anesthesia, a 12 French pigtail catheter was introduced into the collection using serial CT guidance and Seldinger technique. A total of 480 mL of turbid dark brown fluid was aspirated, and CT scan was performed to confirm coaptation of seroma capsular membrane. Next, 50 mL of absolute alcohol was introduced into the collection. The alcohol was allowed to dwell within the cavity for 5 minutes, during which time the patient was repositioned, and the cavity was compressed externally to distribute the sclerosant CT-directed, catheter drainage, alcohol ablation of pelvic, seroma..."

What is the correct coding for this case? "The urostomy site was prepped and draped in the usual sterile manner. A scout image demonstrated ureteral stents in place. A 0.035 Coons wire was advanced through the indwelling ureteral stents, which was subsequently removed. Bilateral 7 French Bander catheters were placed over wire. Impression: Fluoroscopic-guided retrograde bilateral ureteral stent exchange for 7 French Bander catheters."

Do we use code 34802 or 34203 for an Endurant 2 stent graft for AAA?

If an Amplatzer plug is placed after the removal on an internal/external biliary drain, would this be an embolization of the hepatic parenchyma? What code would we use for the embolization of parenchyma? "Removal of internal/external biliary drain and placement of metallic biliary stents in a patient with malignant distal common bile duct obstruction. Because the tube tract was not mature, and because the patient has ascites, the hepatic parenchymal tube tract was occluded with an Amplatzer plug."

The instruction under code 77003 says, "Injection of contrast during fluoroscopic guidance and localization [77003] is included in 22526,...., 62310-62319." And yet there is no NCCI edit. We have not been coding for the guidance since discovering this note. Does this note mean that we can charge code 77003 if it is for localization but not if contrast is injected? How should this note be interpreted?

I have never seen a procedure like this, so I am in need of your advice! The procedure is a left subclavian bypass and endograft covering of the original of subclavian and diverticulum with Kommerell and orgin of the left subclavian artery. A graft was deployed just at the distal margins of the origin at the right subclavian artery and completely covered the origin of left subclavian artery and diverticulum Kommerell. I am looking at codes 33880 and 35621.

Regarding Q&A #6213, in review of your diagram of the Pulmonary Arterial System, the left pulmonary artery is a first order vessel (36014, and the diagram is color coded as first order down to where there are branches off). Because documentation referred to the vessel as "descending branch of left pulmonary artery", without further specification of location of cath tip, could you please explain what indication makes this a second order vessel (36015)?