Ask Dr. Z

Ask Dr. Z Knowledge Base houses over 7,500 coding questions and answers dating back to 2013.

Ask Dr. Z Disclaimer

Duration Requirements 37211

What is the correct duration of an infusion in order to bill code 37211? Must it be more than 15, 30, or 60 minutes?

93655 Billed Twice

I understand that code 93655 can be billed more than once when both arrhythmias are "discrete mechanisms". My question is, what exactly does it mean by discrete mechanisms? I do know that if one is A-flutter and another is another sort of SVT that would make them each distinct. But how about when both arrhythmias are the same kind (A-flutter) oroginating from different locations, for example, one LEFT mitral annular flutter and one RIGHT atrial flutter? Would these be considered "separate mechanisms?"

Intra-Aortic Balloon Pump via Axillary

My physician is a vascular physician who inserts an IABP by transaxillary vein cuff approach. Is this reported with code 33973, even though he is not directly approaching the aorta? Or would it be an unlisted procedure? Also, four days later the IABP has migrated retrograde into the aorta and out into the subclavian artery, so the physician takes the patient back into surgery and reopens the previous incision and repositions the IABP further into the aorta and resutures. Is there coding for this, as I don't see a repositioning code for IAB's, only VADs?

Endarterectomy with Open Bypass Surgery

The physician performed left common femoral endarterectomy (35371), left axillary artery to common femoral artery extra-anatomic bypass (35621), and left femoral to below-knee popliteal artery bypass (35656). I run the NCCI edits, and all codes can be billed together. However, my confusion comes with your coding tips that when a new bypass is performed the inflow/outflow includes thrombectomy and endarterectomy related to the bypass. So, can I bill these three codes together?

Left Heart Catheterization, 93451-93461

I'm new to cardiology coding. If a physician performs a left heart catheterization and bilateral coronary angiography, is it acceptable to report codes 93458 and 93454? I know the left coronary angiography is inclusive with code 93458, but can we report code 93454 for the right coronary angiography?

Hybrid Revascularization

Can you help clarify this vascular case? "An open endarterectomy is performed of the iliac and then the superficial femoral. There is residual stenosis, and iliac and popliteal stents are placed. They were unable to clean out the SFA, so the decision is made to do a PTFE fem-pop." If inflow and outflow are included by whatever means necessary, the endarterectomies are dropped, but do I still report codes 37221 and 37226? I have been having more and more hybrid cases and have been charging the stents. But when you read the "all inflow and outflow by whatever procedures necessary", I am questioning the correct coding. I would really appreciate your expertise.

Left Heart Catheterization with Acute MI

When a patient has a left heart catheterization, followed by percutaneous intervention, both are considered necessary and can be billed. I'm not sure how to bill services provided when the patient emergently arrives to the hospital and requires this sequence: coronary angiography, percutaneous intervention, and left heart catheterization last. Is the catheterization still billable even though it was done second since there wasn't time to do it prior to the intervention? Or is it not supposed to be billed since it was not done to determine if the intervention should be put in? If not, can I bill for the coronary angiography since that was done prior to the intervention?

Intraoperative ICD Testing

Can code 93641 be billed for intraoperative ICD testing, or is this only for defibrillation threshold testing?

Balloon Maceration of Thrombus

Day One - Patient has a percutaneous thrombectomy, common and external iliac stents, and starts thrombolysis. Patient has a left iliofemoral thrombosis (37187, 37212-59, 37238, 37239). Day Two - Follow-up venogram shows residual thrombus in the left external iliac vein. The residual thrombus in the iliac vein was macerated using a pigtail catheter and 10 x 4mm balloon. Thrombolysis was completed (37214). Would you code the venoplasty (35476, 75978) for maceration of the residual clot?

Iliac Aneurysm Treatment with EVAR and Two Extensions

Our surgeon treated an iliac aneurysm using a unibody bifurcated endograft that was deployed on the aortic bifurcation and two Iliac extension grafts (same side). Can code 34804 be used in this type of situation, even though the patient does not have an aortic aneurysm? Code 34900 is only for tube endografts. But can we use it anyway, because of the extensions? Or should we use an unlisted code? If yes, what code should we use for the extensions?

Venography with Intervention, 75820

How would you code the following? Is the venography included in the new stent codes? 

1) Ultrasound-guided left femoral vein access. 2) Iliocaval venography. 3) Intravascular ultrasound: Left common femoral, external iliac, common iliac, and inferior vena cava. 4) Left 20 x 80, 20 x 40, and 20 x 80 Wall stent post-dilated to 20 mm in the common iliac vein and 18 mm in the external iliac vein.

Sinogram with Alcohol Sclerotherapy

Would codes 49424, 20500, and 76080 be supported for this procedure? "Contrast was instilled into the patient's indwelling right groin catheter/fluid collection under direct fluoroscopic guidance. Overall, the fluid pocket appeared similar in size compared to previous exam with no external communication. Contrast was aspirated and replaced with ethanol solution. Patient was repositioned into right and left decub positions. Alcohol was left in place for 30 minutes and then removed. Impression: Stable appearing fluid collection in the right groin with successful alcohol sclerotherapy of patient's lymphocele."

FFR in Non-Coronary Vessels

Would there be anything separately reportable on FFR performed on a renal artery, or would that be part and parcel of "including pressure gradient measurements when performed" in the description of CPT procedure codes 36251-36254?

RF Neurolysis Sacral, Pulsed vs. Non-Pulsed

How can we tell if this procedure is performed as a "pulsed" radiofrequency procedure? The term "pulsed" is never used in the report. Report states the target point at the ipsilateral, lateral, inferior border of the sacrum, just lateral to the S4 sacral foramen was identified. "The probe was advanced over the sacral periosteal surface to the level of the sacral such that its active contact points overlapped the exit points of the S1-S4 sensory nerve fibers. RF lesioning performed with pre-programmed protocol at 80 degrees centigrade for 60 seconds per segment and/or contact point (total duration 5 minutes). RF probe was then removed, and hemostasis was promptly obtained using hang compression. Then the L5 primary dorsal ramus RF lesioning was performed. The curved RF needle was advanced under fluoroscopic guidance. RF lesioning was performed at 80 degrees centigrade for 60 seconds. Successful R sacral RF neurolysis at S1, S2, S3, S4, and L5."

Balloon Tamponade of Perforated Inferior Epigastric Artery

"Complications: After completion of left heart catheterization, a right iliac angiogram was done for closure device deployment. A small perforation was noted from needle stick in the inferior epigastric artery, which was successfully sealed off/tamponade by 7.0 x 20 Mustang over the wire balloon, with two inflations of 10 min at nominal pressures. Angiogram was repeated, which showed normal inferior epigastric artery with extravasation of contrast." This was recently performed in the heart cath lab. My question is how would you code this to reflect the procedure performed? The first iliac angio was done for closure device evaluation. The second was done to evaluate the perforation. A balloon was used to seal the perforation until hemostasis was achieved. I spoke with the cardiologist, and the balloon was inflated in the femoral/iliac artery area, and at no time did he enter the epigastric artery. Are codes 36245, 75710, and 37244 appropriate?

Repositioning LV Lead on Same Day as Biventricular Generator and Lead Placement

"Patient in for an implantable biventricular ICD and left ventricular lead placement, which was successfully carried out (33249, 33225). Left ventricular lead was steadily withdrawn with patient experiencing phrenic nerve stimulation and only intermittent left ventricular capture. Returned to cath lab, removed retention sutures, recannulated the coronary sinus and advanced the left ventricular lead into proximal portion, and withdrew left ventricular lead from its initial position and repositioned it into the posterolateral branch with good lead stability. Suture sleeve of left ventricular lead was attached to chest wall in two locations, pocket was flushed with antibiotic solution, and left ventricular lead was reattached to the biventricular generator." Can repositioning code 33226 be reported on the same date of service as the generator and left ventricular lead placement codes 33249 and 33225? When code 33226 is reported, we get an NCCI edit with 33249 saying that 33249 is code two of a code pair with 33226 that is not allowed even with an appropriate NCCI modifier. How should this be reported?

Chest Tube

Could you clarify when it is correct to code for open chest tube placement (32551) vs. pleural drainage (32556)? Also, what do you code when a chest tube is placed by thorascopy? I have gotten two different answers.

TAVR

Coding Clinic states that a diagnostic left heart cath may be reported with the TAVR (ICD-9), but states that sampling or monitoring of heart pressures is included in the TAVR procedure. What would indicate that a left cardiac cath is done for a diagnostic purpose? Is the physician's statement that it is a "diagnostic left heart cath" enough? He gave indications (acute on chronic dias heart failure from aortic stenosis) and only provided the LEDVP. It seems to me that all patients who require a TAVR probably have some degree of acute or chronic heart failure. Would this scenario be sufficient to code the CPT for the diagnostic left heart cath in addition to the TAVR? I am hoping this will provide some insight into my ICD-9 coding.

ICD Replacement

I would appreciate some help with this AICD scenario. The patients come in for a replacement atrial or ventricular lead due to malfunction of the lead (not a recall). The physician replaces the lead and also the generator. It is not dictated that the generator is at end-of-life. I believe the replacement is so that the patient does not have to have another surgery anytime soon when the generator is actually at end-of-life. I used CPT code 33249. Can codes 996.04 and V53.32 be used for secondary prevention in this scenario, even though the generator may not be at end-of-life? Or, can the lead issue be ignored and the -Q0 modifier used? These patients were originally primary prevention.

Vasospasm Treatment, Iatrogenic

The provider performed a diagnostic angiography of the right lower extremity accessed through the ipsilateral CFA and stopping in the SFA (billing 36245-59, 75710-26-59). Then tried to cross the SFA to treat occlusion and was unable to. Closed this access up. Accessed the posterior tibial artery and advanced catheter to the SFA occlusion and did an atherectomy through this access (billing 37225). There was spasm in the posterior tibial artery, and the provider proceeded to balloon angioplasty the posterior tibial artery spasm (provider would like to bill code 37228). Can we bill code 37228 for treating the vasospasm?

36247-50 for UFE Procedure

I'm hoping you might clarify something for me. With the new UFE procedure code, code 36247-50 is being recommended when performed bilaterally. I can understand the contralateral uterine artery being a third order, but the ipsilateral uterine artery appears to be second order (common femoral puncture - 36140, internal iliac - 36245, uterine artery - 36246). Am I thinking completely wrong?

Cardiac Device Checks

We are receiving denials for CPT codes 93293, 93294, 93295, and 93296 when they are performed more than once per 90-day period. However, these are being performed because the patient has received an alert or the programing information being reviewed by the provider indicates a potential problem. We are coding these with the ICD-9 code(s) 996.01/996.04 and V45.01 or V45.02 at the recommendation of the cardiac device rep. We have appealed these feeling they are medically necessary, but have been unsuccessful in getting the denials overturned. Do you have any advice or recommendations on proper coding for these instances?

Non-Contrast Intraoperative CT Lumbar Spine

Can I use regular CPT codes (CT without contrast) 72125, 72128, and 72131 to report intraoperative CT guidance with spinal procedure? Or would you recommend use of an unlisted code?

"68-year-old woman undergoing L2-S1 revision of posterior spinal fusion. Non-contrast axial images of the lumbar spine were obtained intraoperatively for surgical guidance. Coronal and sagittal reformatted images were reviewed. There has been interval placement of a clamp on the T12 spinous process. Post-surgical changes are again demonstrated with posterior fusion hardware in the lower lumbar spine, extending from the L4 level to at least the L5 level. Note that the inferior extent of the hardware is incompletely included in the field-of-view on this exam. A soft tissue defect in the posterior midline soft tissues is compatible with the intraoperative state. Curvilinear, metallic structures within the posterior soft tissue defect may represent packing material/gauze. Multi-level degenerative changes are again identified with anterior and posterior osteophyte formation, disc space narrowing, and vacuum disc phenomenon at multiple levels. Additionally, there are facet joint degenerative changes in the lower lumbar spine."

Diagnostic Venography at Time of Venoplasty

My question is regarding the S&I codes for venography (75820) with venoplasty when both venography (75820, 76011) and venoplasty (35476, 75978) are performed in an outpatient acute care facility. We are coding for the facility. I have an edit for venography code 75820 being included in 35476. Is it appropriate to report code 75820 with a -59 modifier if no prior venography has been done?

Brachial Vein Transposition

What code should we use for upper arm brachial vein transposition AV fistula? Code 36819 is for basilic, and code 36818 is for cephalic. Would you consider code 37799 or 36825?

Epigastric Vein Embolization

How would I code the following case? "Inferior epigastric vein catheterization from a right femoral vein approach with injection and imaging. Subsequently, the anterior abdominal wall in the distribution of the right lower quadrant parastomal region was interrogated. Just along the caudal margin of the stoma there was a small vein that appeared to emanate to the surface. This was slightly ectatic. With ultrasound and dressing maneuvering, brisk bleeding was initiated. This was immediately treated with compression. Subsequently the bleeding site was intubated with a 4 French dilator. 3 mL of 3 percent sodium tetradecyl sulphate was instilled. 5000 units thrombin were placed at the superficial surface of the bleeding site. Compression was performed. Subsequently the site was further treated with three 2-0 Vicryl sutures. Sterile dressing was applied. Osteoma stoma reapplied. Bleeding cessation was encountered."

Bilateral Ovarian Vein Embolization

We have a scenario that is frequently encountered in IR, and we need clarifications for coding the number of surgical fields and if diagnostic imaging is warranted. It is my understanding that billing for bilateral ovarian vein embolization is a grey zone, and we see difference in the recommendations regarding coding one time embolization (37241) or two separate surgical fields (37241, 37241-59). "Catheter was advanced into left renal and left and right ovarian veins with imaging (36012, 36011-59, 75833). Selective catheterization of ovarian veins and coil embolization with post imaging. Left ovarian venography showed reflux of contrast into the deep pelvic venous plexus with multiple para-uterine varicosities. Varicosity also extends into the vulvar region. Initial hand injection into the right gonadal vein demonstrated no reflux of contrast towards the pelvis. The patient was therefore placed in 15 deg of reverse. Injection revealed reflux of contrast into the deep ovarian vein with opacification of small para-uterine varicosities."

Venogram

We have a physician who has us take a venogram via the existing sheath (36005). What I'm wondering is if we should also be charging code 75820 for the S&I of the venogram. Do we charge the same thing if he gains access to the vein with a micro needle and sheath?

Bypass Using Cryopreserved Artery

Procedures: 1) Redo left axillo-bi-femoral bypass graft using three pieces of cryopreserved superficial femoral artery. 2) Right common femoral to upper superficial femoral artery bypass using cryopreserved femoral artery. Physician used an unlisted code, and Medicare has continually denied for description issues. What would the proper codes be for these?

Pacemaker Upgrade with LVL Placed

Patient has single chamber pacemaker with right ventricular lead who came in and was upgraded to a biventricular pacemaker with only left ventricular lead added. So no right atrium lead was added. How would you code this? I would code as a multi-lead change-out (33229) and left ventricular lead add-on (33225). Would this be correct?

Aortic Valve and Aorta Procedure

I need help with coding this case. The patient underwent a three-vessel bypass a couple of years ago. Now, he/she has returned because of ascending and arch aneurysm and needs aortic valve replacement. The physician performed the following procedures: 1. Redo sternotomy (33530), 2. Ascending and total-arch replacement with a 32 mm Gelweave graft under circulatory arrest and with proximal anastomosis at the sinotubular junction (33860, 33870), 3. Aortic valve replacement with a 27 mm Magna pericardial tissue valve (33405), 4. Saphenous vein interposition graft placed from the neoaorta to the right coronary graft (I don't have a clue), 5. Reimplantation of the right internal mammary artery free graft with aortic patch into the neoaorta (I don't have a clue), 6. Placement of atrial and ventricular temporary pacing wires (bundled no code), 7. Endoscopic vein harvest (33508). These are the only codes I could figure out: 33860, 33870, 33405, 33508, and 33530. I'm having trouble with procedures 4 and 5.

Roadmapping a Vertebral

Could you please let me know if I need to report code 36226 if the physician states, "Right vertebral artery, roadmap images. Roadmap images of the right vertebral artery were obtained, showing normal caliber and contour of the right vertebral artery." The right vertebral was listed as one of the vessels selected during cerebral angiogram. Please let me know if you need additional information.

Retrieval of Migrated Stent

Can we bill this stent placement even if they had to remove it? Physician angioplasties two areas in the venous portion of an AV graft. In one of these areas there still remained a lot of dz, so it was decided at that point to place a stent. In deploying the stent, because of the narrowing, it created a "pumpkin seed" and migrated into the subclavian vein. They had to remove it by accessing the common femoral vein and used a snare device to remove it. They did not place another one after this. Would I code for the stent placement and/or code for the retrieval?

Transtelephonic Monitoring

Per the CMS NCD, frequency guidelines for TTM are divided into two categories: Guideline I and Guideline II. Can you clarify these two categories? Are they divided by specific devices?

Surefire Filter to Prevent Non-Target Vessel Embolization during Y-90

I have a patient whom we are mapping for a Y-90 embolization. The physician comes back on the same date of service and places a Surefire Filter for infusion of Technetium 99m MAA. Is there a separate code for this? I was just going to code for the catheter placements on this particular exam and not the S&I since we had already done a diagnostic exam earlier in the day.

Biopsy of Mediastinal Mass After Pneumonectomy

I would appreciate uour input on this report. I was thinking this should be reported with codes 32405 and 77012. "History: Patient is status post left pneumonectomy due to lung cancer. Procedure: CT-guided biopsy performed of soft tissue mass in left hemothorax along the left heart border. Patient was supine with the left side elevated. Local ansthesia administered and skin nick made. A Cook 18-150-20 coaxial biopsy system used and trocar advanced to the lesion. CT images confirm proper localization. Several samples were obtained. Needle was removed, and hemostasis was obtained. Impression: CT-guided biopsy of mass long the left heart border in the pneumonectomy site."

Contralateral Leg Intervention and Catheter Placement

I was reading an article published in an endovascular magazine. They had several examples, one of which was a peripheral intervention. We understand that if a true diagnostic study was done prior to an intervention in the leg, we can code it, however, not to show the catheter placements. In the example we are questioning is the following quote: "Code 36246 is reported in addition to the stent placement because the higher degree of selective catheter placement was performed for the diagnostic study, not the intervention." Is this true? If so, then would then the reverse be true on greater selectivity for interventions that don't include catheter placements (say diagnostic cerebral imaging and then greater selectivity to do the intervention)?

KX Modifier

Since the NCD for single and dual chamber pacemakers has been put on indefinite hold per MLN Matters CR8525, does this mean that we should not be appending the -KX modifier to pacemaker implants to indicate the patient has documented symptomatic bradycardia?

Repeat Diagnostic Imaging

Am I correct in assuming that if a patient has a liver chemoembolization, let's say 75726, 75774, 36247, 37243 was initially billed. Now the patient returns for a repeat chemoembolization a month or so later, maybe a few months...for that return visit, would it be correct to bill just 37243/36247 unless the diagnostic imaging was done for a different purpose? You wouldn't re-bill the diagnostic imaging, correct?

SAFARI Procedure

How is a SAFARI procedure coded ("subintimal and arterial flossing with antegrade-retrograde intervention")?

Angiography During Head and Neck Angio

Our physician recently has inquired about billing for angiography of the iliac system. In part he is doing this to ensure adequate sheath placement and for closure. He is also noting any underlying pathology, but is not treating any stenosis found, etc. In the past this was treated as road-mapping. As long as his documentation supports that he is performing a diagnostic angiogram of the iliac, is it billable? He is documenting the following: "...performed dedicated diagnostic angiogram of the left iliac system to evaluate for underlying pathology as well as to ensure adequate sheath placement." The findings are then detailed in the S&I section of the note.

Code 37186 Twice

How would I code for secondary thrombectomy in both fem-pop and tib-peroneal zones (in addition to primary atherectomies)?

MRI of the Abdomen With/Without Contrast, MRI Same Visit

We had a patient who needed an MRI abdomen with and without contrast for a pancreatic cyst for which the physician also wanted MRCP. We billed code 74181 for the MRCP and 74183 for the MRI abdomen, and our billers are requesting that we delete code 74181. This is a hospital setting. The patient was non-Medicare. What are your thoughts?

Epicardial Ablation

I have a couple of ablation cases that are confusing to me and wonder if these should be considered unlisted codes or if they are like the other ablations and are diagnosis-driven. I have one case that is left atrial and right atrial ablation for numerous atrial macroreentrant atrial flutters, vein of Marshall alcohol ablation for mitral isthmus-dependent flutter, antral pulmonary vein isolation, and CAFE ablation for atrial fibrillation. The other case is an epicardial ablation with a subxyphoid access for VT. My question is, do we use unlisted codes for the alcohol ablation and the epicardial ablation to capture the extra work ? Or should I consider using a -22 modifier?

LD Stent Via Right and Left Femoral Accesses

Would you report codes 92928-LD and 92928-59LD for the following case? "Right femoral access: Stent to the LD with subsequent angio showing excellent results. Removed wires and started to close groin when patient went into cardiac arrest. Angio showed thrombosis of LD. Could not access left femoral for IABP. Had to pull wires from right to insert IABP. With chest compression and IABP support we were finally able to access left common femoral and place a stent across LD thrombosis."

IVUS or FFR Without Heart Catheterization

I am writing about a scenario that we sometimes see in the cath lab. The first physician performs a diagnostic heart catheterization, and then physician #2 comes in and performs the IVUS/FFR (one or the other). Most of the time, the patient leaves the lab and is held in the holding area and is then brought back to the lab for physician #2 to perform the additional procedure. Occasionally, there is no further intervention. So, how does physician #2 bill for his services since he only performed the IVUS/FFR, which are both add-on codes (either 92978 or 93571)? We were specifically wondering if it was appropriate for an unlisted code (93799)?

Peripheral Angio Report

Here are details from a peripheral angio report: "Right radial artery was assessed, and a BMW wire was used to wire vessel due to size, then advanced multipurpose catheter to the abdmonal aorta. That was replaced with a pigtail catheter, and abdominal aortogram with bilateral run-off was done. Finding of that was the artery was fairly normal proximally, ands both renal arteries were patent but not the ostia. Both iliacs were occluded. A large collateral artery was seen on the left side filling the left leg. This filled the SFA right after the femoral artery bifurcation. The SFA on the left was patent. Collaterals to the right leg was less developed. I took multiple pictures at the level of the hip, thigh, and knee to try and see any reconstitution of the patient's native arteries. I thought I saw a small segment of the femoral artery, but no SFA or popliteal artery was seen." May I report codes 75625 and 75716 for this?

Aspiration Biopsy

If my note only states “aspiration biopsy” and not "fine needle aspiration", would you code it with a fine needle aspiration code or a biopsy code? Does the note have to be specific enough to state that a fine needle was used?

Empyema Drain 2014

Initial Question: Can you please clarify whether an empyema drain would be reported with code 49405 or 32557 for 2014?

Follow-Up Question: I have a question about your response I received. Code 49405 lists lung/mediastinum in parenthesis in the CPT Codebook, and I have heard this is the way to bill for an empyema drain. If not, when would it be appropriate to bill code 49405 for the lung/mediastinum?  Thoughts?

49405   Image guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); visceral (eg, kidney, liver, spleen, lung/mediastinum), percutaneous

Maceration of Clot during Thrombolysis

For codes 37211-37214 (infusion therapy), if they are using a Mustang balloon to macerate the clot during infusion therapy, is this included in the codes above? Is there anything we can bill for the maceration procedure?

Need to ask Dr.Z?

Don't see the answer you're looking for in the knowledge base? No problem. You can ask Dr. Z directly!
Ask Dr. Z a question now!