Ask Dr. Z

Patient has a draining sinus tract from a non healing abdominal wound. Patient taken to the operating room where the sinus tract was then probed with forceps. It went about 4-5 cm deep and was narrow. An incision was made with a scalpel through the old midline suture surgical scar spanning the mouth of the sinus tract. Essentially this sinus tract was split all the way down to it's base. Halfway down we encountered the first piece of ethibond suture which was barely incorporated and easily removed. Then using electrocautery, the scalpel and Kocher clamp the subcutaneous scar was cored out and circumferentially around the sinus tract saw more fibrous material at the base and pulled on this and removed another piece of unincorporated ethibon suture. Palpating the wound we could not feel anymore scar. It was healthy tissue thoughout the entire wound bed now. The wound was irrigated, no further bleeding identified and no foriegn bodies were seen. All the tissue was healthy. Sutured deep cavity and skin. Excision and repair?

The radiologist states in the dictation that contrast was infused after catherization by gravity (following placement of a tube)Does that satisfy the requirements to bill 51600 CPT? Does the infusion "by gravity" change anything in regards to the coding the injection CPT 51600?

I have an exam that the physician selects the left renal vein for a venography and then advances the cath to the left gonadal vein. I know the selection will be a 36012, but what code whould I use for the interpretation of the gonadal vein?

Would it be appropriate to code 35371, 35372, 35741 for this case? Incision left groin, exposing the distal external iliac artery, entire common femoral artery, several centimeters of superficial femoral artery and well down into the profunda femoral artery as well- extensive endarterectomy of the entire common femoral artery extending well down into the profunda femoral artery. The superficial femoral was totally occluded - We divided that beyond its origin, the SFA, about 6cm distally and divided it, over sewed the distal SFA. The proximal and then the 6 cm stump was opened on its inferior surface, endarterectomized and this was used as the patch for the profunda endarterectomy. We then opened up the profunda femoral artery for several centimeters, did extensive endarterectomy of the profunda. The vessel of course was opened here and we did an extensive endarterectomy of the common femoral artery through this same access. He also did an exploration of the popliteal artery for possible by-pass but found that it was a non-bypassable vessel

I have a question regarding -51 modifiers. I am billing out a 37229, 37233, 37224 for charges. Is it neccesary to add a -51 modifier to the 37224? If so, why? We are having some debate in our office.

95% of the patients my practice sees have chronic total occlusions. This is shown through CTAs prior to the patient being presented for the operation. The doctors thus pre-plan thrombectomies for the occluded vessels. After performing an aortagram, sometimes transluminal angioplasty, stent placement, and atherectomy are required in the femoral artery. We use 37227 for this. My question is this: Can we perform 37184 and 37185 in addition to 37227 if the thrombectomies are pre-planned? The most common vessels they perform thrombectomies on are the CFA, SFA, Popliteal, and Peroneal.

Common femoral with advancement of diagnostic catheter. Selective catheter placements second order RT common carotid artery, third order RT internal carotid artery, third order RT external carotid artery, superselective greater than third order RT ascending pharyngeal artery. We use cpt code 36224. Please help!

Hi! One outpatient department performs this procedure. The patient comes in with a previously placed pleural catheter. The catheter is attached to a drainage system to drain fluid. Since the catheter was already in place, it does not seem appropriate to report CPT code 32556. Should the hospital report a low level E/M code or 32556 with a 52 modifier? Thanks in advance!

"Patient presents for ablation of atrial flutter. They are post MAZE/MV replacement procedure for a-fib at another facility and has since had continued issues with a-flutter. EP and ablation today show patient to have reconnection of one pulmonary vein with LA, which is causing the a-flutter. Another a-flutter mechanism is also identified in the RA." Should this situation be reported using codes 93656/93655 or using codes 93653/93655?

I just recieved a referral on code 20600 small joint/bursa. The Doctor injected the navicular cunieform joint space of the foot with Kenolog and they would like me to chance the coding to intermediate joint/bursa injection. I was always taught that only the ankle joint was concidered an intermediate joint so the only intermediate joint on the foot would be the Calcaneus bone I'm I correct in my thinking?

When using bilateral procedure codes and separate S&I codes, ie. 50394/74425, 50398/75984 or 50390/74470 etc, how would you report the S&I? Would it be: 1)50394-50 and 74425 and 74425-59 2)50394-50 and 74425 x2 3)50394-50 and 74425 x1 ??? I seem to remember reading somewhere that you would code the 2nd one with a 59 but I can’t find it now...

Bilateral groin cutdowns (34812-50) were made. Rt CFA accessed and catheter advanced to the ascending aorta, Lt CFA accessed and positioned at L1 (36200-50) Main body deployed (34803, 75952-26). Angiogram done which showed 90% stenosis of rt renal artery. Using lt groin access angiogram obtained and contralateral limb deployed proximal to the bifurcation of CIA. Rt docking limb deployed above bifurcation and limbs were dilated. Post dilation angiogram revealed good flow in stent but proximal aspect was found to have migrated more distal than what was the initial placement. There was concern so Dr elects to proceed with placing a cuff to obtain a more proximal seal. Aortic cuff placed and post dilated (34825, 75953-26). Angiogram shows significant stenosis of Rt CIA. Stent placement done in rt CIA (37221) post dilation angiogram revealed excellent results, but there was impingement of the lt CIA, so Dr placed stent in the lt CIA (37221-59). Post stenting angiogram revealed good results. Does this look correct? The common iliac artery stents have me confused.

How would you code additional venography if MUEs for 75820/75822 is one? Do we code additionals with 75820/75822 with 59 modifiers, or use 76496? Venography below performed with heart cath. RT/LT arm venograms: Injections via peripheral IVs revealed patent axillary veins, with complete occlusion of RT/LT subclavians. SVC: complete occlusion of SVC. RIJ peripheral: Injection reveals complete occlusion at clavicle, with a network of collaterals. LT cephalic: Selective injection via left brachial sheath. Left cephalic vein enters collateral network that drains to left paravertebral plexus. There is complete occlusion of communication into subclavian vein. LT subclavian vein: With catheter in LT subclavian vein shows complete occlusion of LT subclavian vein as it passes between first rib and clavicle. Lt innom vein: Catheter advanced to LT innom vein, it is diminutive and completely occluded at SVC connection. RT innom vein: With catheter in RT innom vein it is found to be diminutive from caudal aspect of the RIJ into SVC.

I have a question about coding using modifier -59. Scenario is patient receives SIJ injection with fluoroscopic guidance (27096) and at the same session has TP injections at a separate body area under fluoroscopic guidance (20552/77002). Would it be appropriate to add a -59 modifier to code 77002 since the guidance was provided at a separate body area from the SIJ?

"Patient had a CTA with run-off showing AV fistula at the fem-pop bypass graft and came to IR. Bilateral run-off was done, catheter was placed in the graft, and embolization occurred with many coils. PTA was done in the popliteal artery at the anastomosis." I believe I should report code 37242 for the embolization and code 37224 for the PTA of the popliteal. The vascular surgeon wants to code the bilateral run-off plus catheter placements. Would you verify for me please?

A question has come up from a Radiology bill. The radiologist coded 76870 and 93976, the hospital coded just 76870. My question is what documentation is needed to be able to code the 93976? An example of the documentation, "Color and duplex doppler interrogation of both testicles confirms normal testicular vascular flow bilaterally" or "Color Doppler and spectral waveform analysis demonstrates normal arterial waveforms within both testicles". My understanding was that "inflow and outflow" needs to be included or "Arterial/Venous flow" must be documented. I want to code correctly but not to over code.

One of our doctors marked his rounding with VT ablation (93654) and another arrhythmia (93655) for the second PVC that he treated. The doctor describes these as two entirely discrete PVCs but he was aware of them from a prior outpatient study. When code 93655 was introduced we were taught that the doctor could not be aware of the arrhythmia prior to the procedure..that the other arrhythmia had to emerge during the procedure in order to get credit for the 93655. Is that correct? Should we give him the 93654 only for treating both PVC's or should he get the 93654 and 93655? The doctor also states that the source of the PVCs would be the mid LV and that PVC1 was spontaneous and that PVC2 was triggered and that Isoproterenol was infused to facilitate increased frequency of PVCs.

Would a balloon occlusion of the distal thoracic aorta just above the diaphram for the purpose of temporizing be coded when a stent graft is placed in the SMA for a hemorraging pseudoaneurysm d/t pancreatic carcinoma. The balloon in the aorta was deflated just before the stent was placed in the SMA. I've coded 37236 for the stent but am not sure if the balloon is included in this case since.

I thought I had this figured out but I need to clarify. I always coded a fistula anastomosis plasty to an arterial. But then reading up in your book, you state that there are both venous anastomosis and arterial anastomsis in a graft. You also state we should code arterial anastomosis or perianastomotic region angioplasty to an arterial 35475/75962. If the physician states that the angioplasty is of the anastomosis,how do you know if it was arterial or venous anastomosis? Does it matter? Do all anastomotic strictures of the fistula automatically get an arterial angioplasty code assigment?

We have an ESRD patient who ran out of dialysis access options. Two surgeons worked on her. Physician #1 (thoracic surgeon) did an incision of RT anterior chest wall, entered pleural space, excised pericardial fat pad, incised pericardium and dissected the RT atrial appendage free from aorta & SVC. Physician #2 (vascular surgeon) created a tunnel across anterior chest wall, brachial artery was fragile & injured requiring a bovine patch. He then made an arteriotomy on the patch & anastamosed a Goretex graft to the ptach and tunneled the graft across the anterior chest wall. Next the other end of the graft was anastamosed to atrial appendage by Physician #1. Chest tube was place in the RT pleural space and attached to Pleur-Evac suction. There are three billers involved in the coding. One biller states it can't be an AV dialysis graft, as no vein is involved. However, the RT atrium is acting as the venous anastomosis, according to the vascular surgeon. How would you code this case? We are considering codes 36830-22 and 32551, but we really are out of our comfort zones.

CT Physician created open drainage via a thoracic window. Starting posteriorly the 7-8th rib space was identified and using cautery the intercostal muscle was removed from the top of the rib. Dissection of pleural space, encountered extremly thick rind, frozen section of pleural was sent to check for malignancy. Resected through the 7th rib to gain more access to the chest cavity. A rongeur was used to removed 5cm segment of rib. Rind was entered and was almost 3 cm thick and was removed to the size of the incision. Debris was sent for cultures. Removed calcified purulent debris. Performed open drainage via a thoracic window. The 8th rib was resected in a similar fashion. Skin edges around the rib resection were marsupialized, muscle was closed and then deep dermis and skin stapled around the window. I think this would be a 32036 except for the fact that this is Thoracotomy. Would it be more descriptive to bill unlisted procedure?

We are a group of cardiologists, we have one interventionalist. we have situations were our cardiologists consult on a patient and then on occassion call in our intervention cardiologists and 2 consults are done the same day. Is there a way we can get paid for both the interventionalist and the managing cardiologists the same day when they are trying to determine need for surgery AND surgery is not needed.

Please provide the correct catheter selection code for this procedure: Left groin prepped & draped & a 4 French sheath placed. Flush catheter introduced in the proximal abdominal aorta. An aortogram revealed normal aortoiliac system. Bilateral patent renal arteries and the SMA well visualized with the catheter selected into the distal right external iliac artery. Right femoral angiography revealed patent common femoral, deep femoral, and superficial femoral artery with the superficial femoral artery selected. The distal superficial femoral artery was widely patent. All 3 tibial vessels were patent with direct runoff into the foot. The catheter was removed.

The pt had Bentall procedure 2mo ago with Magna valve and Valsalva graft.Now has returned due to pseudoaneurysm of the ascending aorta.CP bypass was initiated. His previous median sternotomy incision was opened.I crossclamped ascending aorta.We entered the rt coronary button and a thrombus around the graft.Thrombus was removed.There seemed to be bleeding coming up from underneath the right side coronary button,coronary sinus and rt/lt commissure area. We then performed a transverse incision thru the previously placed Dacron graft, above the sinus of Valsalva section of the graft. There was no evidence of injury of the valve.I then cut alongside the rt coronary button down thru the Valsalva segment of the graft.It was difficult to find hole where the bleeding was coming from. I then decided to reinforce the whole area with sutures. These were placed thru the prior sinus segment, LVOT, and back up thru the sewing ring of the valve and the rt coronary sinus segment. I then repaired the sinus of Valsalva graft segment with Prolene. Then graft incision was closed.

Our hospital/neurosurgeons use fluoro in all their spinal cases. What is the instruction for charging/billing for fluoro done in the OR for these cases? It seems that cpt codes for open procedures 63001 and on, do not include fluoro. The minimally invasive/percutaneous procedures 0274T and 0275T seem like they do include the fluoro charge. If we do charge for the fluoro, would we use 77003 or 76000. Thank you very much.

The physician initially attempts a right radial approach and documents that he has difficulty and brings the catheter up to the aortic arch and into the ostia right subclavian and documents that the patient has an anomolous takeoff of the right subclavian off the aortic arch. The doctor then takes a femoral approach and performs a standard left heart cath. No vertebrals were mentioned. I'm thinking 36215-59 (separate takeoff of the right would make this a 1st order, correct?) and a 75710-RT-59 as well as the 93458 for the garden variety LHC and a 93567 as he does discuss the aortic arch but that was after with the LHC approach. I considered 36225 but no vertebrals were mentioned and it didn't seem like this was really the intent of the angiography. I'd really appreciate your thoughts on this. Thank you.

What is the correct coding for a femoral acetabular impingement (FAI) exam? In our protocol, we perform a CT through the bony pelvis and proximal femurs, 3D reconstructions are created of both hips. In addition we obtain axial CT imaging through the knees to evaluate for femoral anteversion. Since this exam is primarily focused on the hips it seems most appropriate to code this as a Bilateral CT Lower Extremities (which covers the hips and knees) and include a 3D post processing component (76377). We also considered billing it as a CT Pelvis with 3D post processing component however that seems to ignore the added imaging through the knees?

All of the following is through one SVG: Physician stents the body of the SVG to RCA and also a spot in the RCA - one charge 92937. In the same setting he also stents the PDA branch of that RCA, still through that same SVG. Can I use 92921 with the 92937?

If you were to approach this physician on his documentation of the below generator changeout, what would be your exact verbiage? There is no documentation of work done, nor info on implanted device (only intraprocedural measurements). "PROCEDURE PERFORMED: Generator replacement of a dual chamber biventricular cardiac defibrillators, fluoroscopy of device and lead, and capsulectomy pocket revision. Explanted device is a Guidant CRT-D model D224TRK. Existing leads: Atrial lead is Medtronic model 5076, length 45 cm in the right atrial appendage. The ICD lead is a Medtronic model 6947, length 58 cm in the right ventricular apex, and the CS lead is Medtronic 4196, 78 cm long in the lateral branch. Tachy detection at 300 millisecond. Tachy interval for ventricular fibrillation, first therapy 35 joules then 35 joules x 5. Bed rest for 4 hours. Antibiotics used."

What CPT code or codes would you use if we are performing an IR prostate artery embolization?

If a CHD patient receives a heart transplant, are heart cath and echos coded as congenital or non-congenital? Physicians insist on congenital, but problem then is what congenital diagnosis can we use if it no longer exists? Also, see the following example of patient with post transplant complex anatomy. Should this patient be coded as congenital? Patient's native IVC and SVC were left-sided; complex re-routing of the systemic veins was performed at the time of his transplant. A flap of atrial tissue was used to redirect the IVC to the right atrium, while the donor innominate vein was anastomosed to the recipient left-sided SVC to the right atrium. Instead of using a congenital code, should we be adding a modifier -22 for this patient?

How do we code for saphenous vein transposition as thigh AV fistula?

We have a case were the vascular surgeon placed a TAA and AAA graft with iliac coil embolization and also placed a renal stent. Are we allowed to bill an open femoral exposure (34812) and/or a brachial exposure (34834)? Or are they considered bundled due to the other procedures done during the case?

Documentation shows both a diagnostic extremity venogram and venacavagram, as well as IVUS of the external iliac, common iliac, and vena cava. Can both be coded together? Also, he states a stent is placed across the external iliac, common iliac, and vena cava. The vena cava is normal, so I am thinking it's a bridging stent and to code only the stent for one common iliac vessel; although, he says he starts to see narrowing in the external iliac. "Duplex US to puncture the greater saphenous vein at the knee antegrade to place 10 French sheath. Catheter into the femoral vein, venogram with digitlal subtract tech fluoro contrast showed normal anatomy. Vena cava looked patent. IVUS up the femoral vein into the external iliac vein and started to notice some narrowing then in common iliac vein narrowing going down to 4 mm. Vena cava normal at 18 mm. Wall stent placed 12 x 90 into vena cava across common iliac vein into external iliac vein. IVUS shows resolution of narrowing."

Do you have guidance when it comes to disruption of a fibrin sheath with a CVC diaylsis catheter exchange (not a Tessio catheter)? If a fibrin sheath was disrupted in the SVC and another fibrin sheath in the innominate vein, would codes 36595-52/75901 be assigned twice (once for each vessel) or just once (similar to guidelines of coding only one central PTA)?

How would you report a percutaneous ultrasound-guided fine needle aspiration biopsy right axilla with post-biopsy metal marker placement? "Six aspiration passes were made with a 21 gauge needle. A cytopathology technologist was present to confirm adequacy of the samples. A spring-shaped Hydromark MRI compatible stainless steel marker was deployed through an incision under direct ultrasound visualization into the biopsied area." We have billed codes 10022 and 76942. Do you agree? Would we code for post biopsy metal marker placement? If yes, what code we could use?

We billed unlisted code 17999 for this. Can you suggest a valid CPT code that would most closely describe the following procedure? "A Kopan needle was advanced with intermittent CT guidance into the left flank tumor. Position was confirmed, and Kopan wire was positioned and needle partially withdrawn. CT confirmed needle and Kopan wire position. The needle was then completely removed over the Kopan wire. Kopan wire was secured to the skin."

"Patient with metastatic gallbladder cancer to the right lobe of the liver and segment 4. This procedure is being performed to increase the size of the future liver remnant in preparation for extended right hepatectomy. Patient presents today for right portal venous embolization for future extensive hepatic resection. Puncture of a branch of the right portal vein via intercostal approach. Catheter was then reformed and positioned in the main portal vein (36481) with portography and evaluating suitable portal veins for embolization (75887-59). Catheter was manipulated into the left portal vein, subsegment 4A and 4B branches of the left portal vein, and selective portogram was performed followed by embolization with plug and coils." We are hoping to get your thoughts on selected codes please. Should we report code code 37241 or 37243 for embolization in this case?

In light of the July 2014 NCCI edit update, we (hospital staff) have been debating whether or not it is appropriate to append a -59 modifier to existing myelography codes when a CT scan of the same area is performed on the same date of service. We routinely perform a full and complete conventional myelogram with a separate report amd then send the patient to CT. Bottom line - can we bill separately for the conventional myelogram, or is it now considered bundled with the CT study performed in the same patient encounter?

Would you agree with the following joint injection assigments?
Subtalar joint injection: Intermediate
Talonavicular joint injection: Intermediate
1st or 2nd Tarsometatarsal joint injection: Small

"Patient with history of congenital aortic stenosis who had valvuloplasty done at 3 days old followed by Ross procedure with bioprosthetic valve in 2009. Now comes in with severe stenosis of the bioprosthetic valve. Doctor performed a balloon angioplasty with bare metal stent placement in the bioprosthetic valve (Palmaz 3110 XL stent inflated to 20mm) and a transcatheter placement of a Melody valve on a 20 mm Bib balloon within the stent complex." I am thinking of using code 37236 for the stent placement, but I'm not sure about the placement of the Melody valve within the stent.

We had a patient who was referred over to us for an MRI of the right clavicle. The right clavicle was imaged. Which modifier should I addend to code 71550? Should I use -RT, or should I use -52? What is the correct coding with modifier usage if modifier(s) are applicable?

I have a case in which they had a GJ, and they repositioned it and now it is a G-tube. I have code 49465 for the injection, but I am not sure about the repositioning. "Dysphagia displacement - gastrojejunostomy tube injection, gastrostomy tube repositioning. Person with need for long-term enteral nutrition. Tube was pulled back and then readvanced. Please evaluate positioning. Impression: 1) Contrast material was injected into the indwelling 14 French Shetty gastrojejunostomy feeding tube, confirming appropriate positioning of the distal tip in the proximal jejunum. The catheter is patent and amenable to immediate use. 2) Contrast material was injected into the indwelling pigtail gastrostomy. The gastrostomy tube had migrated into the proximal small bowel. For this reason, the catheter was slightly retracted and repositioned into the gastric lumen."

Would there ever be a circumstance in which suction thrombectomy and atherectomy could be performed together? Physician insisting that suction thrombectomy of CFA, SFA, popliteal, and anterior tibial was performed after atherectomy "with removal of debris" after an SFA atherectomy. My understanding is if thrombectomy is performed (even with different device) it is part of the atherectomy itself unless there is a distal thrombus being treated in an entirely different vessel. Is there some source documentation I can supply to the physician to indicate we cannot bill a separate thrombectomy?

I received this new code in an October 2014 OPPS new service update from Med Assets. Will this new C-code (C9741) go with the existing right heart CPT codes (93530, 93460, etc.), or will it have one of its own (primary or add-on)? Or is this a stand-alone code? I thought that C-codes were only on supplies and sometimes needed in conjunction with a CPT code. I am personally very confused about this new code. Any clarification that you can offer in regards to this would be much appreciated.

Can you clarify something for me? This relates to question 5222 where you said if injections were done of the L2, L3, and L3 facets that you would only code two injections (L2-3 and L3-4). If my physician dictates that he did facet injections of the L2-3, L3-4, and L4-5, would you then code three injections because he is giving the levels?

I can't find a code(s) for percutaneous transcatheter stenting of the atrial septum in a three-month old born with discrete coarctation of aorta, small left-sided structures, and pulmonary hypertension.  Here's an example dictation: "TEE probe was placed. ABG was performed and was reassuring. Swan catheter removed from pre-existing 5 French sheath. 5 French sheath in left femoral vein was exchanged for new, sterile 5 French sheath. JR 2.5 catheter was inserted in femoral venous sheath and advanced to the right atrium, and pressures were recorded. Baylis system was set up. Microcatheter followed by RF wire were advanced through JR catheter to tip of catheter. Guidance confirmed catheter in central location on the atrial septum, away from aorta and LA free wall. Wire was advanced and contact with atrial septum. Single application of energy was performed (10W for 2 sec), and bubbles were seen in the left atrium. Wire was advanced into left atrium, followed byt microcatheter and then JR catheter. Wire and microcatheter were removed and left atrium pressure recorded. Terumo Glide wire was placed through JR catheter 7 and advanced into LLPV. Catheter was advanced into PV, and wire was removed. 0.014" AllStar wire was advanced through catheter and catheter removed. Pre-mounted 3.5 mm x 12 mm stent was advanced over wire, and TEE was used to center stent in atrial septum. Stent was expanded under 5 ATM of pressure. Balloon was deflated and removed with wire."

Are codes 36011, 36590, and 77001 correct for the following case? If not, what do you advise? "Known thrombus associated with the central line of port. RUE prepped amd draped. With ultrasound guidance, a small caliber needle was directed into the right basilic vein. Guidewire was directed centrally, needle was removed, and dilators were passed until a 5 French cath could be directed into right subclavian vein. Contrast was injected under fluoroscopy with digital images recorded. Cath was then directed into upper aspect of SVC and advanced into the left innominate vein. Repeat injections of contrast agent performed. Cath was removed and hemostasis achieved. The right anterior chest wall was prepped and draped and anesthetized with local anesthesia. A transverse incision was made over the port and was then removed in its entirety with the attached central line. Pocket was closed, as was skin. Findings: Superior vena cava is chronically occluded with reversal of flow into the azygous system, which is now capacious. A port, which is no longer functional, was removed."

If order states ultrasound pelvis, and the radiologist does only TV, but does all the elements of the pelvic ultrasound (and documents), are there any concerns on passing that as a valid order? I have asked that they also document why they did the TV approach.

"Patient has paracentesis. Then, right common femoral vein is accessed and catheter advanced to thoracic aorta. Pressure bad with continuous saline flush started. Then, right jugular is accessed and catheter is advanced to IVC where a pressure bag with continuous saline flush is also started." Are the selective catheter placements and the "flushes" considered part of the paracentesis?