Ask Dr. Z

Would I use code 75625 for this procedure? I understand if just the distal abdominal was performed I would not use code 75630. I am not sure when to use code 75625 vs. 75630. Can you tell me how to distinguish the difference?

Right lower extremity angiography with run-off to the foot was then performed with hand injection of dye. A 5 French Omniflush catheter was advanced to the distal abdominal aorta, and abdominal aortography with iliofemoral run-off was then performed with hand injection of dye. The catheter was then advanced over a Glidewire to the left common femoral artery using standard crossover technique, and left lower extremity angiography was performed with run-off to the foot with hand injection of dye. The catheter was then advanced over a Glidewire to the left common femoral artery using standard crossover technique, and left lower extremity angiography was performed with run-off to the foot with hand injection of dye.

Which unlisted code would you use for this case: 47999 for biliary or 44799 for intestine because they went into the duodenum? Also would I skip coding the conscious sedation because the ERCP immediately  follows? "Procedure summary: 1. Informed consent. 2. Conscious sedation with continuous vital sign monitoring provided by the nursing staff with physician supervision. 3. Injection of existing PTC catheter with small volume of contrast. 4. Removal of the existing PTC catheter over a 0.035 C-wire. 5. 4 French Kumpe catheter advanced over the wire to the level of the mid common bile duct. 6. Mid/distal common bile duct stenosis crossed with the Kumpe catheter and 0.035 Glidewire. 7. Kumpe catheter advanced to the level of the third portion the duodenum. 8. Placement of a 0.035 Jag wire to the level of the ligament of Treitz. 9. Jag wire secured to the skin and patient transferred to the endoscopy unit for further intervention."

Can codes 36598 and 36597 be charged together? Here are the highlights of the report: "Spot image of tunneled CVC shows tip flipped superiorly into left brachial cephalic vein. Saline injections attempted to move catheter were unsuccessful. Access was gained into right common femoral, and catheter was advanced into SVC. Catheter used to hook the CVC catheter tubing and reposition the tip into the SVC. Contrast injection into the CVC catheter demonstrates rapid flow through CVC with tip in SVC." My thought was to report codes 36598 and 36010-59, but now I'm questioning if we should also add code 36597, as I don't see any edits for coding the repositioning and the evaluation together.

Is it CMS guidance that separate reporting of 93623 is never appropriate with EP ablation procedures? Or is it appropriate to report code 93623 if the service is performed during diagnostic programmed stimulation and pacing or after ablation is delivered?

I need help coding this report. The procedures were left heart catheterization, selective cornonary, saphenous vein and IM angiography, ventriculography, RAO view, aortography, AP view, right iliac angiogram, and primary stenting of vein graft to RCA with use of spider. Closure of access site using Mynx grip. Here is the part of the note that I don't know how to code: "Aortography was performed in the AP view, as patient was complaining of discomfort in his right leg. This shows significant stenosis of 60-70% in the right common iliac, which with the placement of the catheter was obstructing flow. Following this, selective right iliac angiogram was performed, and this iliac appeared to be diffusely diseased with 60-70% narrowing, but I felt I could get the procedure done and bring him back for elective intervention of his iliac vessel." I am new to cardiac coding, so I'm feeling very lost. The patient has Medicare.

A patient had a biventricular AICD with a right atrial lead. They brought the patient to the EP lab and did an AV node ablation. Then they added a His bundle lead and capped the right atrial lead. They replaced the generator with a biventricular pacemaker generator. I am unsure of how to code this. I was thinking of reporting codes 93650, 33207, and 33241. What are your thoughts?

I am not sure if this unsuccessful AV fistula placement should be reported with 36821-53 x 2 or some other code. What are your thoughts? 

A longitudinal incision was made to wrist between the cephalic vein and the radial artery. The cephalic vein was exposed proximally and distally along the incision, and after inspecting the vein, it appeared to be less than 2 mm and appeared inadequate for fistula placement. Because of that, this incision was closed with 2 layers of absorbable suture. A second incision was made in the upper arm, above the elbow crease, over the cephalic vein. Again, the vein was then inspected for adequacy and the vein was sclerotic and again not adequate for fistula placement. This incision was then closed in 2 layers. After discussion with the nephrologist, it was felt not to place an AV graft at this point.

We have a case where we placed a subcutaneous ICD lead and then placed the ICD generator in the retroperitoneum. What would you recommend coding for this? Code 0319T, even though the generator is in the retroperitoneum, or possibly code 33999?

I am having an issue with denials when reporting code 93580 with codes 93568 and 93567. Do you have any suggestions on how we can get this paid when billed?

For the following case, are codes 36012-50, 36005-59, 75822, and 75825 correct?

Using US guidance, a micropuncture needle access attempted into small irregular LT CFV (36005-59). Several attempts were made to pass a wire up through left iliac stents but were unsuccessful. Then access was from the right IJV down into the left SFV and right CFV with catheter placement (36012-50). We traversed entire length of existing iliac venous stents. Contrast injection digital subtraction LLE and left pelvic venogram were performed. Could not traverse beyond region of proximal left thigh due to significant venous irregularity. Catheter was pulled back and positioned in distal aspect of left iliac vein stents, and contrast injection pelvic venograms were performed to evaluate stent patency. Next, access was gained into right iliac vein with glide catheter and with resistance in expected region of right CFV. Could not advance beyond level of right femoral head. Contrast injection digital subtraction right pelvic venogram performed with catheter in right CFV (75822). Catheter was pulled up into central right common iliac vein, and then IVC venogram was performed (75825).

Technique: After informed written consent was obtained, the patient was prepped and draped in the usual sterile manner. Access was obtained using CT fluoroscopic guidance. An 8 French catheter was advanced into the distended bladder. Subsequently, as the patient drain uterine the bladder contracted. The pigtail catheter utilized was unable 2 remain within the lumen of a contracting bladder. The referring urologist was notified. The patient left the department in the same condition. Once the bladder had retracted a window through the lower pelvis was not identified for replacement. The bladder capacity was an inadequate target for a replaced catheter. The patient tolerated the procedure well. The patient left the department in the same condition. Unsuccessful attempt at placing a super pubic catheter with an 8 French pigtail drain. The catheter was placed within the lumen and the bladder was drained. As the bladder retracted the pigtail catheter sideholes were eventually excluded from the smaller capacity bladder. The referring urologist was notified.

How would you code this scenario? PTCA in the diagonal for chronic total occlusion and PTCA with drug-eluting stent to the mid LAD (no total occlusion). I want to report code 92943 for the CTO and 92929 for the drug-eluting stent; however, code 92929 states in the descriptor that it is for a branch of the major coronary artery, not the major coronary artery itself. So then it is code 92928 for the major coronary artery and 92944 for the CTO... but that is also not coding by the guidelines since it states you code by the hierarchy of services based on the intensity of the service.  Thoughts?

What do you suggest for the cardiologist who is performing the ECHO guidance during a TAVR? I see a code for 2015, but what do you suggest for 2014 and what type of documentation is needed.

I need to know when I can code both a fine needle aspiration and a core biopsy. Sometimes our physicians do not say why they go on to obtain a core after an FNA has been done. If a reason is not documented, should I just code for the core biopsy? Following is an example: "Ultrasound of the neck revealed 2.5 cm of right cervical lymph node/mass. A 25 gauge needle was advanced into the mass with ultrasound guidance, and an FNA was obtained and given to pathology. The needle was removed, and a total of six core biopsies were also obtained. Post ultrasound demonstrated no hematoma or complication."

The procedures I am auditing are performed by an interventional cardiologist (who is also dictating the reports for the procedures). The co-surgeon is the cardiovascular surgeon. Cutdowns are being performed by the vascular surgeon. Is there any coding I can do for them? I want to be sure I am looking at these procedures correctly.

If the physician just states that the RCA is totally occluded without saying "chronic total occlusion", can we report code 92943, or should we report code 92928 instead?

How would we code for contrast injection into the ileostomy with imaging? Is code 49465 appropriate, or would codes 20501 and 76080 be reported? Brief Report: "Fluoroscopic evaluation of abdominal ostomy after cannulation of bowel ileostomy openings and administration of water-soluble iodinated contrast. Left ostomy opening demonstrates opacification of distal ileum, which extends to the ileocecal valve and inferior cecum. Mild blush of contrast outside small bowel surrounding small segment prior to the ileocecal valve is seen. Right sided ostomy demonstrates slight more proximal segment of small bowel opacification overlying the left mid pelvis."

Can we use code 76775 when just an AO is being scanned or just renals without bladder (retroperitoneal limited), or do we need to use code 76705? Can we use code 76770 for renal with bladder or for retroperitoneal complete that includes everything?

A stereotactic breast biopsy was attempted but on the stereotactic localization images of the breast the lesion could not be found so the biopsy was not performed. What if anything can the physician bill for?

Scenario: ER physician orders a CT abdomen/pelvis, CT lumbar, and CT thoracic due to trauma. The patient is taken to the CT Department for scans. A “whole body” CT scan is obtained. The technologist manipulates the films, and the radiologist separately reports on each orderable. Please validate if it is appropriate to charge separately for a CT abdomen/pelvis, CT lumbar, and/or CT thoracic... or if the CT lumbar and CT thoracic would be considered “2D rendering”.

Our neurointerventionalist performed a coil embolization of the ophthalmic artery. After the coils were placed there was a protrusion of two loops that required emergent stenting which was accomplished with a neuroform EZ stent. The doctor is trying to bill for both the embolization (61624) and the stent placement (61635). It's always been my understanding that any complications that arise during the procedure that were caused by the physician are not billed when corrected. Can you point me to something to give back to the provider regarding this? Is he correct that, in this scenario, both the stenting and the embolization are billable? Any insight on this would be greatly appreciated.

Please help with coding this report. Would codes 33320, 36010, and 75827-26 be appropriate? I was also thinking about codes 36597and 76000 since they had to reposition it back in place. Do I separately code for thoracotomy? I am really lost on the coding for this one! "Fluoroscopy was used, demonstrating that the proximal port was in the SVC and the distal port was within the pleural space. Completion venogram showed distal port was now in the right atrium. Once the cath was originally determined to be in the pleural space, the patient was placed in the left lateral decubitus position, sterilely prepped, and sterilely draped. A thoracotomy incision was made. Entry was through the fifth intercostal space. Lung was retracted and cath identified. Purse-string suture in position, and cath was then pushed back into the SVC and placed into the right atrium. Suture was tied. There was no hemorrhage from suture, and the chest was closed. Chest tube in place. Fluoroscopy was brought back into position and distal tip in the RA."

For the following, would you use codes 49424 and 76080-26 for the evaluation, code 49999 for repositioning the catheter, and code 49082 for the paracentesis? "Right abdomen and pleurx site were prepped and draped. A short multiside hole seroma catheter was used to access the pleurx, followed by contrast administration to evaluate the pleurx drain. Using a combo of glide catheter and Amplatz guidewire, the pleurx catheter was slowly repositioned from the pelvis to the contralateral left lower quadrant and superiorly along the left abdomen. A repeat contrast evaluation was performed. At this point, the pleurx was accessed for a therapeutic paracentesis. The entire site was then sterilely dressed."

I would appreciate you help with this scenario. We did a drug-eluting stent procedure on the LAD (C9600-LD). Later in the day, this patient developed pain and returned to the cath lab. The diagonal was closing down, and the same physician put a drug-eluting stent in the diagonal. For the second encounter, would I report code C9600-76-LD, or would I report code C9601-LD?

After the hemodynamic data were obtained, an aortogram was performed using a 4F Pigtail catheter in the standard PA/LAT projections and the fractured coarctation stent was identified and appropriate measurements made. Using a 4F angle glide catheter a super stiff Amplatz wire was parked in the distal right subclavian artery. The catheter was removed and the sheath was exchanged over the wire for a 14F x 80-cm Check-Flo sheath. An 18 x 30-cm Gore graft was mounted onto a Palmaz 4010 stent and then the entire stent system was mounted on an 18-mm x 4-cm BiB balloon catheter. The balloon was inserted over the wire and centered within the previously placed, now fractured, coarctation stent. The BiB balloon was deployed in the usual fashion, first by inflating the inner balloon, checking position, the finally inflating the outer balloon for definitive stent deployment. The outer balloon, unfortunately, burst before reaching nominal pressure but the stent was expanded enough that it did not migrate or embolize on balloon deflation.

We have a new piece of equipment that is being used to assist in guidance. The doctors each dictate the use of it a little differently, but in essence it looks to me like it might be most accurately coded with 76377. Here is a sample of the technique description: This case was performed using the I-guide feature of the Siemens artist Q. fluoroscopy suite. Guidance was performed using rotational cone beam, the 3D reconstruction, with extensive use of a workstation 2 project and then confirm the needle trajectory." Is this description adequate to capture CPT code 76376 or 76377? Can we even code for the use of this type of guidance?

According to your reference and previously asked questions, codes 47805 and 74305 are reported for a cholecystostomy tube check. I'm coding for a "follow-up of post gallbladder drainage" in which "scans are obtained through upper abdomen without contrast and after injection of the drainage catheter. After injection there is filling of the gallbladder." The impression was "after injection of contrast through the drain there is a small amount of leakage into the pericholecystic region." So I am told by the IR coder that in this case code 74150 should be used. However, could code 47505 also be used for the injection into the catheter? Or is code 47505 only to be used for a specific check of the tube functioning?

In your "Ask Dr. Z" knowledge base forum, you previously recommended the use of unlisted code 93799 for percutaneous treatment of a paravalvular leak instead of code 37242. Would you please elaborate on why this is the case? I am assuming that since code 37241 is for venous embolization and 37242 is for arterial embolization you would not be able to use these codes, as a paravalvular leak treatment is used to treat a valve. The reps have also pointed us to the embolization codes (37241-37244), but I am reluctant to bill these out for treatment of a paravalvular leak. I am hoping you can shed some light on this relatively new procedure.

What are the correct surgical CPT codes for lateral branch blocks in the sacrum? The orthropaedic physician says he is injecting bilaterally the lateral branches S1-S4. The radiology guidance reports seeing four needles into the SI joints; however, the physician says he is not injecting the joints, rather he is performing lateral branch blocks. The physician also confirms he used four needles for the injections, and he advises the codes for this are 64493-50, 64494-50, and 64495-50. My question is, if he is using four needles, would three levels be injected bilaterally? Also, I am seeing on some pain management websites recommendations to use code 64450 for lateral branch blocks, as they are considered peripheral nerves in the sacral area. Please advise.

Should I report the following with codes 36200, 34825, and 75953? Please advise. "The flush catheter was positioned in the proximal visceral segment of aorta. Aortography was performed. This identified some suggestion of a type 1 endoleak. Pre-close technique was used to fire two perclose devices in the right femoral artery and facilitate introduction of a 14 French sheath, which was done over a stiff Lunderquist wire after administration of systemic heparin to the therapeutic level. With the 14 French sheath in position, a 40 x 10 Palmaz stent was mounted onto a Coda balloon. This was advanced up to the level of the perirenal aorta, and the balloon mounted stent was then inflated and appropriately positioned."

"11 year old male status post pacemaker for sinus node dysfunction, with a recent change to ERI mode. He presents for elective replacement of the generator. In pre-procedure discussion with the surgery team, it seems that the post-rectus device had possibly migrated upwards and centrally. We thus elected to have surgeon scrub in to the procedure to assist in removal of current generator. After removal, leads were tested and found to be stable in function. We thus proceeded to create a new pocket (33222) in the left-sided abdomen under the anterior rectus sheath above the rectus muscle. The existing leads were attached to a new device. Testing confirmed stable thresholds and impedences. The new device was placed in the new pre-rectus pocket (33228) on the left and closed in three layers. The old pocket was also closed in three layers. Patient tolerated procedure well." NCCI edits do not allow codes 33228 and 33222 to be reported together, no modifier allowed. Do you have any suggestions on an appropriate code combination that would allow reporting of pocket relocation?

Question: Is the cephalic arch considered separate central venous zone for coding 37238? If so would this case be coded 37238 and 37239? 1. Multifocal short segment cephalic arch stenoses treated with angioplasty and telescoping stents. 2. Intra-stent venous limb restenosis treated initially with angioplasty and restenting with markedly improved luminal flow and post intervention venogram.

Is it okay to report code 93580 (fenestration closure) and 93568 (pulmonary angiography) when the angiography is done after the fenestration closure when documentation states that "angiography revealed complete occlusion of fenestration in right atrium"? It is my understanding that codes 93580 and 93568 are bundled and should not be billed separately.

Is there a CPT code for tissue Doppler imaging, or would this be inclusive to the echocardiogram?

Pt had a positive finding for traumatic retro bleed found on CTA. Selective cath plmnts 2nd & 3rd lumbars, contralat. common, internal & ext iliacs w/embo of 3rd lumbar. dr also comments that in order to "locate" the lumbar artery's he also selected splenic, lt gatric, lt renal, and IMA. I feel those would be considered roadmapping or guiding shots so I did not code them. I've coded the following-37244,36245x2 for lumbars, 36246 for ext common iliac and 36248 for internal. No S&I's since CTA. Would this be correct or should I code what I think to be the guiding selective catheter plmnts also? Thanks in advance for your help!

Will code 36833 cover the following procedure? Or are codes 36147 and 36148 also needed? Please advise. "Patient with aneurysmal left brachiocephalic AV fistula with aneurysmal stick site, skin ulceration over upper stick zone. Micropuncture needle was inserted into proximal portion of fistula with wire advanced under fluoroscopy into upper fistula beyond aneurysmal stick zones. Sheath inserted up into subclavian vein and parked there with fistulogram done. Long segment of high grade stenosis (80%) began just beyond aneurysmal upper stick zone. Stenoses were balloon-dilated with good result and puncture site sutured. Attention turned to aneurysmal site in upper stick zone. Ulcer was excised with elliptical incision back to healthy skin on both sides, down to fistula. Inflow portion of fistula into stick zone was dissected and clamped. Patient was heparinized. Part of aneuyrsmal fistula was excised, revealing ulcer had penetrated into fistula with layer of thrombus between scabbed area and fistula. This was excised including excessive thrombus. Opening was oversewn in two layers, clamps were released, and suture line was hemostatic. Subcu and skin sutured."

We have 49180 for deep lymph node biopsy for all peritoneal/retroperitoneal lymph nodes. What about deep axillary or intramammary lymph nodes? If unlisted, would you use 38999 even if a clip was placed at the biopsy site?

What is the recommended CPT code for placement of a leadless pacemaker? "A pigtail catheter was then advanced into the right ventricle and a hand injected RV gram showed normal RV function and the RV apex was nicely visualized. Subsequently with serial dilation over an amplatz super-stiff wire, the 8F sheath was upsized to an 18F delivery sheath.The Leadless pacemaker delivery apparatus was then assembled with appropriate flushes and was then advanced under flouroscopic guidance carefully into the RV. A suitable spot in the mid RV septum was chosen to deliberately avoid the apex, given a very small heart. A contrast injection showed good septal wall apposition on both LAO and RAO projections. The pacemaker helix was then torqued in 1.25 turns. The sheath was then released and a vigorous tug test showed no lead dislodgement."

Patient with jaundice presents for biliary evaluation. Physician performed: percutaneous transhepatic cholangiography (47500-59, 74320-59), cholangioplasty with stent placement (47556, 74363), and internal/external drainage catheter placement at the initial presentation. Would you please give us your insight on why the drainage catheter (47511, 75982) is not coded in addition to ductal dilation with or without stenting when the procedure was not staged?

Our doctors have started using stereotactic technology to perform certain EP ablation procedures. Is there a CPT code for this?

My doctor is checking the activated clotting time and post stent placement, and sometimes does this two or three times. Is this something that would be included with the stent placement procedure, or is it something that we should be billing for? I am confused as to what code to use, if indeed we can bill.

"Patient was brought into the electrophysiology laboratory in the fasting, non-sedated state. The patient was prepped and draped in the usual sterile fashion. 1 percent lidocaine was used for local anesthetic. An incision was made in the left infraclavicular region. The tissues were dissected down to the level of the ICD pocket. A redundant lead was extending just beyond the device with stretched skin and impending erosion. That lead was dissected free and turned into the pocket. The lead was sewn to the pocket floor with 0 silk. The pocket was irrigated with a combination antibiotic solution." We know this was not a pocket revision or move. How would this be coded?

Would you mind telling us how you would code the following? "Initial scout imaging demonstrated a peroneal dialysis catheter coiled within the right lower quadrant. Gentle contrast administration demonstrates patency of the catheter and positioning in the peritoneum. Under fluoroscopic guidance, a 0.035-inch stiff glide wire was advanced to manipulate the catheter. A tip deflecting wire was also used. These were unsuccessful. Then, a 5.5 French Fogarty balloon catheter was advanced into the distal end of the peroneal dialysis catheter, and attempts to reposition the catheter were unsuccessful. The stiff guidewire was used to push the tip of the PD catheter into the right upper quadrant. A 5 mm x 2 cm Mustang balloon was advanced over the wire into the distal end of the PD catheter, and manipulation was attempted. This was followed by the Fogarty balloon. All of the attempts to reposition the PD catheter into the pelvis were unsuccessful."

Can you please help with the correct diagnosis code for the following scenario? The patient has CRF and is coming in for creation of an AV fistula (36821). In my opinion the primary diagnosis would be for the CRF. Per our in-house auditor, the primary diagnosis should be V56.1. What are your thoughts?

Follow Up to Question ID #5966, it states: ‘A caveat would be if two physicians are in same group and use same billing number then code as usual, as add-on code 93571 would be okay with the heart cath.’ Can you further clarify what is meant by ‘code as usual’? Do you mean first physician can code and bill add-on code since second physician is in the same group even though first physician didn’t perform add-on procedure? CPT manual, p. xiv outlines: “The add-on code concept in CPT 2014 applies only to add-on procedures or services performed by the same physician. Add-on codes describe additional intra-service work associated with the primary procedure…Add-on codes are always performed in addition to the primary procedure and must never be reported as stand-alone code.” CMS 1/1/14 policy outlines the same principal. Also, if FFR/IVUS is performed on same day as heart cath but by two physicians in different groups then do you recommend each physician code their part with second physician utilizing unlisted code 93799 to capture the stand alone px of FFR/IVUS.

I'm only adding the procedures and not the actual description. I know the codes for the thoracic and lumbar etc., but I'm not sure what to use for the superselective injections. "Questionable spinal vascular pathology. POSTPROCEDURE: No vascular pathology identified. OPERATION/PROCEDURE: 1) Diagnostic cerebral angiogram 2) Right common femoral artery selective 3) Complete aortic survey 4) Left intercostal selective injection 5) Right bronchial superselective injection 6) Left bronchial superselective injection 7) Left T8 selective injection 8) Left T9, left T10, left T11, left T12, left L1, left L2, left L3, right T8, right T9, right T10, right T11, right L1, right L2, right L3, right vertebral artery, right subclavian, left vertebral artery, left thyrocervical, superselective injections 9) Personal review and interpretation of angiogram."

Is it appropriate to assign EP codes 93620, 93653, and 93656 when it is not necessary to induce an arrhythmia? In some cases, the patient presents for the procedure with an arrhythmia, such as atrial flutter, already present.

We need clarification on the catheter access that is performed for a TAVR procedure. Our vascular surgeons are providing the access for the cardiovascular physicians for their TAVR procedures. We have been billing the access through our vascular physicians. We listened to a webinar that states we should not be billing the access separately even though the physicians involved are of different specialties. What is your opinion on this?

Can code 20500 be utilized when, at time of abscess catheter placement or exchange, the cavity is debrided of necrotic material using normal saline (500 ml, in this case)? This is time-consuming and goes above and beyond just placing or exchanging the catheter.

I need your perspective on this one. At conclusion of study the provider mentions that the patient will need an aorto-bi-femoral bypass. "Operative Synopsis: Pigtail catheter placed first at renal artery and then pushed down to distal abdominal aorta. Then after completing peripheral angiogram, cardiac catheterization was decided." The provider mentions findings for abdominal aorta, common/internal/external iliacs, and bilateral SFAs. Report states that they were "unable to visualize clearly the below-knee vessels due to slow flow". I'm thinking this needs to be reported code 75625 only. My rationale is that the statement of slow flow to see below-knee vessels is not acceptable to also capture code 75716. I did not go with code 75630, as the catheter is not in one spot. With conclusion of statement that patient needs bypass, is this study then considered screening (G0278)?