Ask Dr. Z

We are wondering if it is proper to charge an E&M code when we are performing a cardiac test on the same day in an outpatient setting. We would be the attending.

The physician wants to perform this in the office during patient office visit. I do not think there is a code for this if done in the physician's office, but of course I can't find anything on it so maybe I'm wrong. Is there a CPT code for a rhythm strip before, during, and after adenosine is given? And is it supported when done in the office?

What CPT code do you suggest for the injection portion of the cisternogram, 62311? "DESCRIPTION OF PROCEDURE: Lower back was localized with intermittent fluoroscopy at the L3-4 level. The L3-4 level was marked, prepped, and draped in the usual sterile fashion. 5 mL of 1% Xylocaine was infiltrated into the skin and subcutaneous soft tissues of the lower back at the L3-4 level. Under fluoroscopic guidance, a 3.5 inch, 20 gauge spinal needle was slowly guided into the dural sac at the L3-4 level, yielding spontaneous return of clear cerebrospinal fluid. A shielded syringe continuing 1.5 mCi indium 111 DTPA was attached to the hub of the needle and injected intrathecally. The stylet was replaced, and the needle was removed."

There is no CPT code for the exchange of a Tunnelled Pleurx Chest Catheter. What is your coding recommendation for the case example below: a) unlisted CPT code or b) 49424/76080?? "Chest and abdomen were prepped and draped in usual sterile fashion. The right-sided chest tube was removed over a stiff Glidewire, which allowed for placement of an 11 French peel-away sheath. After successful creation of a subcutaneous tunnel, the 11 French Pleurx catheter was advanced through the tunnel and through the peel-away sheath into the right-sided thoracic cavity. The incision was closed with 4-0 Prolene. Catheter was secured to the skin at the exit site from the tunnel with 2-0 Monosoft suture."

Please advise on the following. "History: Pelvic trauma and bleeding. Multiple pseudoaneurysms and one actively bleeding. The physician goes into the right internal and into anterior division and embolizes pseudoaneurysms. Then goes into the right internal iliac and into the anterior division and embolizes pseudoanerysms. Next, goes into the IMA and shoots angios of the superior hemorrhoidal artery - not bleeding. Goes into the middle sacral artery, which does show the vessel supplying the aneurysm, which was bleeding. It's embolized." Would this be considered all one surgical site and only code one embolization (37242 or 37244)?? Or do we code two different embolizations since one was for hemorrhaging and the other was to exclude non-bleeding aneurysms?

For PTA of an in-stent re-stenosis of the right common carotid near its origin, would I use codes 35475, 75962, and 36223 (findings were given on common, anterior, and middle cerebral arteries)? Or, would I use the unlisted px code 37799 with a -GZ modifier and 36223 for my catheter placement?

If a patient is having a sclerosis as seen below, would I be able to use code 37241, or would I have to have an unspecified code 37799? "Multiple vascular malformation of left leg and left arm. Percutaneous track puncture sclerosis of vascular malformation. History: Multifocal venous vascular malformation. The patient presents for staged embolus embolization therapy of multiple focal low subcutaneous and superficial venous vascular malformations. Sedation: The patient received intravenous sedation with Versed and Fentanyl. Utilizing a combination of fluoroscopic and ultrasound guidance, access is gained to the multifocal malformation of the left leg and separately to the multifocal malformation of the left arm. With each puncture, embolization is performed utilizing Sotradecol mixed with contrast. Total procedure fluoroscopy time: 0.5 minutes."

I understand embolizations are reported per surgical site; however, I am confused as to how to apply that to pediatric congenital heart cases. If an embolization is performed both arterial and venous, is that only one embolization? Another example is embolization of the internal mammary and then embolization of the subclavian. I appreciate any explanation you can give me.

Should we use code 37217 or 37799 if the doctor directly exposes the carotid and inserts a stent that extends from the ICA into the carotid bifurcation? The stenosis is in the ICA. Code 37217 is intrathoracic, and ICA is not intrathoracic.

Could you please help with this coding scenario? The physician placed a stent in the innominate vein (37238) after accessing AVF (36147) and then placed a stent into the venous outflow, but also performed an angioplasty of the brachial artery. If the second stent is reported with 37239, can I report codes 35475, 75962 instead? Before, the rule was to code the arterial if they did both venous and arterial angioplasty.

Our doctors were delighted to clear up the catheter drainage issue based on your respected publication regarding leave in or take out after drainage. The AMA/CPC and research I have done all agree with your original definition. The doctors said the extra work of catheter for drainage is the same whether it is left in or removed. And with the only publication I found that stated the catheter had to be left in when researched, upon further communication, the author stated it was her interpretation since 2005 that it should be left in and that it was not a direct quote from the AMA/CPC. So my question is, I am curious why the errata regarding catheter must stay in after procedure?

I recently started billing graphics again after many years. Since I last coded them I see they have added the option of a -26 modifier on code 93351. I would like to know if code 93351-26 includes the tracing (93017). My physicians do not do the tracing, so I thought I should be using codes 93350-26, 93016, and 93018. However, in a past question here, the answer stated that code 93351-26 includes codes 93350, 93016, and 93018 with no mention of 93017. In the CPT Codebook it says when all professional services of a stress test are not performed by the same physician to use code 93350 with the appropriate codes (93016-93018) for the components that are provided. Since my physicians do not perform the tracing, this sounds to me like I should be using codes 93350, 93016, and 93018 instead of 93351-26. Thoughts?

There is some disagreement on billing the following situation: "Patient presents with subarachnoid hemorrhage. Diagnostic cervicocerebral was performed with catheter placement in both right and left common carotid arteries. Angiography was performed, showing critical narrowing of the left middle cerebral artery due to vasospasm. There was also narrowing of the right middle cerebral artery. Catheter was removed. Then a microcatheter was positioned in the left internal carotid artery, which was confirmed by angiography. The catheter was infused with 10 mg of verapamil for 40 minutes. Follow-up angiography was performed after the 40 minutes of infusion." I would bill codes 37202-59, 36223-50, 75896-26-59, and 75898-26. Others feel code 36216 should also be billed for the microcatheter in position in the left internal carotid artery. What are your thoughts?

"MD Summary Conclusion: Unsuccessful attempt to 'upgrade' a dual chamber defibrillator to a biventricular defibrillator due to unsuitable venous anatomy. The left ventricular lead could not be passed beyond two of four electrodes in any given vein branch. Three separate vein branches were cannulated during these attempts. Three hours and thirty-six minutes were spent attempting to place left ventricular lead before upgrade procedure was aborted." If I code for successful procedure, it would only be a venogram (36005), which we don't typically bill. If I code for attempted left ventricular lead insertion (33225-74), it will edit due to add-on code without primary. I was considering using code 33224-74 because it most captures this situation. What would you recommend?

Can this code be used for re-stitching the catheter place? Or is it only for replacing the hubs? Are there other uses for this code?

The physician made several attempts to cross the lesion in order to place a stent. It was unsuccessful. He ended up doing a plain old balloon angioplasty. The stent will be replaced by rep. What should we bill for hospital, code 92928-74FD or 92920? And what codes for physician billing, code 92928-53 or 92920 (with location modifier added also)?

I am trying to determine coding for excision of previously placed carotid bypass and placement of another carotid-ipsilateral carotid bypass. Does this qualify for code 35501 or repair blood vessel code 35231, or is this unlisted procedure? "Procedure Description: We carefully dissected the common carotid artery bypass graft and then extended the dissection more distally and identified internal and external carotid arteries. These were encircled with vessel loops and clamped in order, internal, external, and common carotid. The graft was completely excised, and the proximal end of the greater saphenous vein was spatulated, and an end-to-end anastomosis between the vein and the very distal common carotid artery at the bifurcation was carried out using 6-0 prolene suture. Following completion of the anastomosis, the proximal common carotid artery was spatulated, the vein was cut to appropriate length and spatulated, and an end-to-end anastomosis was then created using 6-0 prolene suture."

We receive orders for patients with a history of thyroid cancer and enlarged lymph nodes. We are asked to perform an ultrasound evaluation of the thyroid postsurgical bed and to map the neck lymph nodes levels I - VI, bilaterally. Are we able to charge more than once for CPT code 76536 because of the amount of work involved and the different anatomical body parts?

Can you tell me what code you would use for an FNA of a mass in the hilum of the right kidney? When I look at code 50390, it states it is used for cysts or urine in renal pelvis. Here is a portion of the report to help clarify. "Indications: An 81 year old female with history of infiltrating mass in the right kidney suspicious for malignancy probably transitional cell carcinoma, however, could also represent lymphoma. Under CT guidance, a 19 gauge guiding needle was advanced into the periphery of the right kidney. Through this access, a 22 gauge Chiba needle was utilized to fine needle aspirate the hilar mass. Three separate fine needle aspirations were performed, and the samples were sent to pathology. The needle was removed, and a sterile dressing was applied. Path report: Bloody material containing discohesive atypical cells and a few cytologically bland glandular appearing cells."

Patient presents for bilateral evaluation of lower extremity varicose veins and venous insufficiency. We perform a venous duplex Doppler examination that includes vein mapping. Are we able to charge anything in addition to code 93970 for the vein mapping?

"Patient has history of end-to-side aorto-bi-femoral bypass and has developed a large AAA anastomotic aneurysm at proximal aorto-bi-fem bypass anastomosis. Aorto-bi-fem limbs are patent. After right fem incision, sheath was advanced up right iliac system. Surgeon placed aortic cuffs starting distally from old aorto-bi-fem bypass and building proximally up to infrarenal aorta utilizing 5 aortic cuffs overlapping. Proximal, distal, and junctions were ballooned. Angiogram revealed junctional leak. Reballooned. Persistent junctional leak. Two more cuffs were placed overlapping in midportion of previously placed cuffs and then ballooned. Leak improved, but was still faintly present. Patient not candidate for open repair. Surgeon feels that with heparin reversal and time this faint leak will seal." Is aneurysm repair with tube prosthesis 34800 and one cuff 34825? Or is the initial code 34825 since he used cuffs and it is for aneursym repair? I see the cuff code descriptions are for inital vessel and each additional vessel. This was all done in the aorta, so only one vessel had intervention. Seven aortic cuffs in all.

"Patient came in for elective subcutaneous pacemaker generator change. This was performed and seemed successful. But, prior to extubation, pacemaker lost capture. It was decided to replace the whole system. Patient was re-prepped and draped. A sternotomy was performed. Bipolar epicardial lead placement, with suboptimal parameters; a unipolar screw-in lead was then placed in the right ventricle at base of heart. Process was repeated, with same leads then placed in the right atrium free wall. Unipolar leads showed good threshold. The pacemaker pocket had been opened and subcutaneous pacemaker removed. All four new leads were tunneled to the pocket. Pocket was revised to hold new hardware. Bipolar leads were capped; original V-lead was also capped. New unipolar leads were connected to new dual chamber pacemaker." I know I need to report code 33202 for the epicardial lead placement. My dilemma is that the CPT Codebook says to use code 33202 with 33213 for pacemaker insertion with existing dual leads, but isn't code 33213 for when a previous generator is not being removed during same session? Would it be appropriate to bill either codes 33202/33228 or 33202/33214 for this scenario?

We are trying to come up with a guideline for this. What is your opinion? If the physician doesn't give a reason for doing less than a comprehensive diagnostic study before an ablation, I believe that modifier -74 should be appended by the hospital rather than the -52 modifier, since the time, staff, and equipment remains pretty much the same. If I remember correctly, modifier -74 is also appropriate to indicate that a planned surgical or diagnostic procedure was partially reduced at the physician's discretion.

What code(s) should be used when angioplasty, atherectomy, or stenting is done to the arteries or veins of the feet?

If attempting venous laser ablation of incompetent vein (36478) and encounter stenosis/blockage that you cannot get wire/cath through, and you abort procedure and do open ligation, would you only code the open ligation and omit code 36478-74 modifier entirely? I cannot find this particular example documented.

Patient with AMI taken to lab. Diagnostic cardiac cath (93455) was performed, and upon trying to intervene on the culprit lesion the physician was unsuccessful in crossing the lesion and the procedure was discontinued. The physician does not document the intended procedure (i.e., angioplasty alone, angioplasty with stent, angioplasty with atherectomy, or all three). In the absence of clear documentation of the intended PCI procedure, considering code 92941 requires combination of angioplasty with either stent and/or atherectomy, should we report code 92920-74? Being conservative rather than assuming without documentation that a stent and/or atherectomy was planned?

Would you please guide us with the following question? We’re going to start a new service where we inject radioactive seeds under mammographic guidance or ultrasound guidance for women who will have subsequent breast tumor removal. The seeds will be removed with the tumor during the operative exam. We need the localization and supply codes for the seeds.

I have a patient that we are exchanging an external biliary tube with an internal external biliary tube. Would I just code for the placement of the new internal external tube?

If remote ICD and ICM interrogation is performed, can the next remote ICM interrogation be performed on day 31? Are the service periods separate for ICD and ICM?

Physician used a Lombard AorFix device to repair a common iliac aneurysm that extended into the internal iliac artery. Internal iliac was embolized, and the device was placed just below the renal arteries, seated at the aortoiliac bifurcation, with one docking limb extending down the common/external iliac and covering the internal iliac. Reason for device was due to torturous aorta in a patient with multiple surgeries for colitis with a colostomy and a chronic abdominal fistula.

How would you code for a core needle biopsy of a mediastinal lymph node? The report stated the biopsy was challenging because the lymph node was close to the heart and pulmonary artery, so it definitely was not superficial. We didn't think code 38505 really applied here, but it is not abdominal or retroperitoneal, so we didn't know if we could use code 49180 here. Would it be appropriate to report code 32405 for a mediastinal lymph node or not?

We've got a physician who just started with us who states that he has been able to bill for independent interpretations of cardiac caths that were previously done on a patient. Is that possible? What code would we use?

I was reviewing chemoembolization guidelines, and it says that code 96420 can be reported per the 2014 CPT Codebook, but I always understood that code 96420 should not be reported in a facility setting for physicians (only in an office setting). I work for a cath lab in a hospital where they perform these procedures. It is considered an outpatient department for billing purposes even though inpatients and outpatients are treated there. I do charge capturing for the facility side and coding for the physician side. The physicians note in their reports that "chemotherapeutic agents were prescribed and administered by (physician name)". I have not reported code 96420 in the past or currently based on guidelines. I do use code 79445 for the Y-90 cases we do. But I've had some of the business staff and physicians asking if I'm coding this because they are doing the work, so they think it should be coded. Am I correct not to report code 96420, or should it be reported? I need some clarification on the guidelines.

A question has come up about vasospasm treatment. Is vasospasm treatment always billable? For example, if the physician documents that there was a mechanically induced vasospasm (meaning that it was as result of the intervention or catheterization), can we bill for the treatment done during that same intervention or cath operative session? I seem to recall seeing somewhere that if we cause the vasospasm we can't bill for the immediate treatment done in the same operative session. However, now I can't find that documentation to support this.

My doctor was treating a patient in a motorcycle accident. He had a traumatic injury to the right subclavian artery with loss of blood flow to the right arm. Due to the extent of injury to the subclavian artery, he decided to do a subclavian-brachial bypass with graft. I’m not coming up with any CPT code to describe this based on the distal portion of the bypass being the brachial artery and the use of the graft instead of a vein. Should I use the unlisted code?

I still need help coding the following two-day procedure. "PROCEDURE DETAIL: Nephroureteral stent was injected, outlining the renal pelvis. Scout films demonstrated calcification in the proximal ureter. An exchange length Amplatz wire was passed down along the tube and into the bladder. The nephroureteral stent was removed over the wire. The wire was then secured to the skin. FINDINGS: Renal stone in the left ureter. Removal of the ureteral stent with wire placed into the bladder. IMPRESSION: Successful removal of left nephroureteral stent over a wire, with the wire left down into the bladder for laser lithotripsy. The following day after patient had laser lithotripsy and insertion of double-J ureteral stent by surgeon. PROCEDURE DETAIL: Using fluoroscopic guidance the Amplatz wire was removed using continuous visualization of the double-J tube to ensure no movement. FINDINGS: No significant movement of the double-J stent upon removal of the Amplatz wire. IMPRESSION: Successful removal of Amplatz wire without disruption of the double-J stent."

I have been told that you shouldn't use code 92941 for non-ST MIs. Is this correct?

My colleague and I would like some coding advice on the following example: "A 5 French Contra catheter was advanced into the abdominal aorta, and an AP abdominal aortogram was performed. The Contra catheter was pulled down to level of the aortic bifurcation, and bilateral pelvic oblique arteriograms were performed. Findings include renal arteries, aorta, bilateral common, internal and external iliacs, and common femorals. The Contra catheter was used to select the left iliac system, and the Contra catheter was advanced into the left external iliac artery (36246), and a left lower extremity run-off arteriogram was performed. The Contra catheter was removed, and a right lower extremity runoff arteriogram was performed via the right groin with 5 French vascular sheath." Would this be reported with codes 75625 and 75716 or with codes 75625, 75716, and 75774?

"Procedures Performed: 1) Left groin access under ultrasound guidance. 2) Bilateral lower extremity angiography with distal aortogram. 3) PTA and atherectomy of right CFA and proximal SFA. 5) Intra-arterial nitroglycerin and Mynx device closure for left groin. 6) Selective catheter placement in the right CFA and angiography." I reported this with codes 76937, 75716-59, 37225, 36247-59, 37202, and 75896. I am not sure about distal aortogram. What code should I use for it?

Patient arrived to the hospital's CCL for outpatient procedure. "Procedure: Transesophageal echocardiogram (TEE). Reason for test: Abnormal echocardiogram (performed in cardiologist's office). Conscious sedation: IV Fentanyl and Versed. After conscious sedation, TEE probe was placed. Unfortunately, the patient could not tolerate the probe. So, the probe was removed, and the TEE was aborted (no images acquired). Physician then performed a limited (per cardiologist) transthoracic echo (TTE) with contrast study using agitated saline (bubble study) to confirm presence of PFO." Charges submitted were code 93308 for the limited TTE, code J3010 for the Fentanyl, and J2250 for the Versed. Should we add a charge for the cancelled TEE (93312-74)?

Is code 34845 the only code needed for extensions done? Do we bill unlisted for the anchors or include? From the report: "I placed an 8 x 5 Viabahn covered stent. This was placed into the SMA, making sure not to cover the bypass or any proximal main branches, and from the left side over the Lunderquist wire we placed a 31 x 14 x 13 Gore excluder C3. We continued deployment of the main body. Over the Lunderquist wire we placed a 23 x 14 limb on the right and placed a 20 x12 extension piece and the left iliac. We post-dilated using a q. 50 balloon. We performed a lateral angiogram, which unfortunately revealed a small type I endoleak seen along the posterior margin, which was not evident on the AP view. Given this finding and the large proximal neck with quick reversed tapering, we decided to place, and this tapers for better fixation particularly in the setting of the patient has had previous slippage of the graft. Two Aptus Endoanchors were placed posterolaterally, each 45 degrees off midline, but in the opposite direction of the snorkel."

I was wondering if you had come across anyone who has had a physician using the Volcano IFR. Code 93571 cannot be used since adenosine is not injected, but I was wondering if you had any ideas if this can be charge captured or not?

The physician's assistant performs the entire procedure. The vascular surgeon, who provided general supervision via the phone, dictates the report. What wording should be used by the vascular surgeon in the body of the operative report to indicate that he provided general supervision and that the physician's assistant performed the entire procedure? Also can you provide guidance to how the vascular surgeon should bill for the physician component in these types of cases?

Could code 37243 be billed with the note below? Our doctor wants to bill code 37243, and I do not see where an embolization is documented, and I don't believe code 37243 should be billed. Could you advise? "Simmons 1 glide catheter was formed over the aortic bifurcation and advanced into the proximal superior mesenteric artery. Arteriography was performed to confirm position. A microcatheter was then advanced into the right hepatic artery. From that position, a subselective right hepatic arteriogram was performed. With the microcatheter in the appropriate right hepatic position, 5.5 mCi technetium MAA was slowly infused from this point. When the infusion was complete, the catheter was removed, hemostasis obtained, and the patient transferred to the nuclear medicine department for liver lung shunt imaging."

Can code 76377 or 76376 be used for a "3D spin arteriogram" of the carotid artery?

What is the correct coding for placement of a chest tube for a pneumothorax when done in an IR lab? There is always disagreement when this procedure occurs.

"Operative report: The catheter was placed in the fistula located in the left abdomen near the lap band adjustment port. Next, contrast was administered during fluoroscopy observation. Contrast is administered, which demonstrates a fistulous track between the skin and the implantable port. There was a contrast leakage along the catheter to the skin surface. No intraperitoneal extravasation or fistulous connection is seen." Code 76080 has been billed for this procedure, but shouldn't a surgical code such as 10030 or 20501 also be reported in this case?

"INDICATIONS/COMMENTS: Poorly functioning access. RESULT: The patient was scheduled for left groin tunneled catheter exchange. The patient stated that the catheter is working well and requested that not be changed. As the initially placed sutures had come out, the catheter was sutured to the skin using sterile technique. The patient tolerated the procedure well without evidence of immediate complication." Is there anything that can be coded here?

Would you assign codes 20500, 76080, and 77002 for a sclerosing of an inguinal seroma? Here is the procedure: "The inguinal seroma catheter was carefully identified under fluoroscopy and the inguinal site sterilely prepared. Through the catheter, contrast injection identified the size and distribution of the catheter. There was no evidence of extravasation or communication with adjacent vascular structures. The catheter was then aspirated and filled with a small dilution of doxycycline for an interval of time. This was subsequently aspirated and put the bulb suction. Impression: Successful inguinal seroma cavity fluoro injection identifying no communication with adjacent structures. This was subsequently infused with doxycycline to help promote sterilization and sclerotherapy of the cavity. The catheter was removed."

One of our providers performed a transvaginal fetal echo. What codes do we use? We are thinking about codes 76817, 76827, and 93325. Is this correct? Or do we need to use an unlisted code?