Ask Dr. Z

Do you think it is appropriate to use codes 36595 and 75901 for the disruption of any "potential" fibrin sheath during the exchange of a tunneled CVC?

"Transverse, longitudinal, and oblique ultrasonic sections of both neck were performed. Color Doppler evaluation also was performed. Entire study was real-time with no images. Right lower neck and left lower neck level VI lymph nodes are localized on the overlying skin. Right neck level III and level II jugular chain of lymph nodes are identified and localized on the skin. Findings were demonstrated and discussed with physician on real-time images. FINDINGS: Bilateral lower neck level VI and right level II and level III nodes were identified and localized on the skin for surgical planning."

I'm not sure what the appropriate CPT code to use would be. I'm thinking of maybe unlisted code 38999 for lymphatic system. Any suggestions?

With the new pacemaker requirements from CMS taking effect July 7, 2014, I need to know how we should bill for pacemaker implant inserted for atrial fibrillation with future plans of AV node ablation. There are a few physicians who implant pacemakers for a-fib and then ablate the node (in a future procedure), inducing complete heart block, which then makes the patient dependent on the pacemaker. The Medicare instructions specifically state that any pacemaker code (33206, 33207, 33208) billed with 427.31 will be denied. How would you recommend billing this? I don't see how we could use 426.0 (CHB), as the patient isn't in CHB until the AV node is ablated in a future procedure.

When we are coding for biventricular pacemakers, we are having a conflict with the NCD for Single and Dual Chamber Pacemakers. The claims are being held if they do not have diagnosis acceptable for this NCD. Is there a separate NCD for biventricular pacemakers? We can only find NCD for biventricular defibrillators. This seems to be a recent development.

Hi Dr. Z, I'm a PB Coder for several Cardiologist MDs who have started seeing patients now to do peripheral interventional type of cases. They need help in their documention to explain their catheter placements, repositioning, etc. for proper assignment of codes. The start out explaining their access site but then go into the findings of the cases. Do you have any recommendations that provide detailed information that they can use as a teaching tool for both MDs and Coders to use? I know they are doing a lot of work but they are not seeing the proper reimbursement for it. Thanks!

We often bill for multiple embolizations in a single AVM procedure (embolizing multiple arteries). For external carotid embolization, such as particle embolization for epistaxis, does the same apply? Routinely we inject particles into the IMAX artery on each side. Can we bill multiple (two) extracranial embolization codes for those cases?

When coding the following scenario, we thought this to represent 36216, but we also question 36225. There was selective catheterization of the right subclavian and innominate with dye. Could you please clarify the difference? Operative note excerpt: "We then used a Shuttle sheath and a Vtech introducing cannula and catheterized the innominate artery. A 6 French Shuttle sheath was placed. We obtained a selective innominate angiogram with 10 cc of dye. We cannulated the right subclavian artery and performed a selective catheterization of the subclavian artery. This study revealed a chronic occlusion of the axillary artery. We did attempt to pass a wire through this area, which appeared to be chronically occluded. The catheter and sheath were removed, and a Mynx device was used to close the groin."

I was hoping you would help to clarify some global surgery modifier usage for me on the following: "Patient is brought in for AV fistula creation for dialysis access. Weeks later it is found that the AV fistula is not maturing, so the provider decides to bring the patient back electively for balloon-assisted AV fistula maturation." In a few cases I've seen, the patient is brought back for this same procedure multiple times during the post-operative period. I feel like the first balloon-assisted AV fistula maturation procedure should be coded with a -78 modifier due to a non-maturing AV fistula. In his operative report for the first procedure he indicates that the patient will be brought back again in 2-3 weeks for another balloon-assisted maturation procedure. Do you think the first procedure should be billed with a -78 modifier and then all subsequent procedures with a -58 modifier since the provider is indicating in his previous operative report that the patient will be brought back again?

We are currently discussing the new way of implanting an ICD via subcutaneous device insertion and lead placement via tunneling the lead to beside the sternum. It has been stated by one of our physicians that we should charge code 3918T. So, what I am wondering is, do we report code 33249 and then a tunneled catheter charge (36558)? Or the 3918T?

"Patient has multi-lead ICD. Generator was explanted and replaced with pacemaker generator. Atrial lead was capped, then existing right ventricular and left ventricular leads were attached to new pacemaker generator." How would this be coded? Would it be reported with codes 33213 and 33241?

In reference to question IDs 5422 and 5442... You mentioned coding a right heart catheterization if done with ICE (93451 and 93662). We get an edit indicating that code 93451 isn't a valid base code for 93662. Is this correct?

Seeing patients with advanced vascular disease we run into patients with multiple diagnoses outside of the vascular specialty. Once we report the E&M code and determine the appropriate principal vascular code(s), is there a benefit to submitting additional non-specialty vascular codes such as ring worm or diverticulitis (etc.) when submitting a claim? Is there anything lost or anything gained by including diagnosis codes that are outside the vascular specialty when submitting claims?

Highlights of procedure: "Left femoral artery cannulated. Catheter from left femoral into aortic arch. Aortic arch angiogram. Catheter to left subclavian artery, selective left subclavian angiogram. Total occlusion of left subclavian artery. Angioplasty attempted with several wires and catheters. No access. Total occlusion appeared to be extremely chronic. Under ultrasound guidance, visualized the left brachial artery. Using micropuncture needle, artery was cannulated. Catheter was advanced from the left brachial artery up to the subclavian artery and selective subclavian angiogram. Again used mutiple wires and catheters and were unable to cross the lesion. Procedure was terminated." The codes I came up with are 35475-53 (x2?), 75978(x2?), 75710, and 36216. What else am I missing? Can they be billed x 2 since he tried from the femoral approach and then from the brachial approach?

Can you clarify why embolization of collateral vein(s) would be reported with codes 36011, 37241, and 75791 and not 37241 and 36147 if an angioplasty is done first? The outflow was access next to the anastomosis, catheter was placed into the superior vena cava, and the angioplasty was done of the cephalic vein. Then the embolization of the collateral vein of the fistula was performed with only one access. I am trying to explain this to our analyst.

Patient has a history of ELG with a type 2 endoleak (not global). During an open embolization of the aortic sac and ligation of IMA, the physician inserted a sheath into the aortic sac and obtained intra-arterial pressures. Is that a separate billable service? If yes, what code(s) would I be able to use? We currently have code 37244 for the embolization and code 35221 for the ligation of the IMA.

The cardiologist coded this as atrial septostomy (92992), which can't be right. Except for transseptal puncture nothing else is the same. The report reads more like percutaneous LVAD, but not quite. The patient was on ECMO from the day before. According to this report, transseptal puncture was to place a venous cannula and connect it to the ECMO circuit. So would this be reported with codes 36822, 93453, and 93462 if the report says only right heart catheterization was done? Dx 425.4 

"The RFV was accessed percutaneously. A 10 French sheath was placed in the vein. Right heart catheterization was performed without incident. Cardiac output was determined using FICK method. A 7 French adult transseptal sheath was advanced to the SVC. A transseptal needle was introduced, and the sheath was brought down along the atrial septum. The needle was used to puncture the septum, and the sheath was advanced across the septum. An Amplatz superstiff wire was positioned in the left atrium. The long sheath was exchanged for a 17 French ECMO cannula with the tip and drainage holes in the left atrium. The ECMO cannula was sutured into place."

Patient has a coronary/LV angio (93458) and attempted FFR via radial access. FFR is unsuccessful due to spasm, so it wasn't charged. The angio findings are documented with a note that the patient will return at a later date for FFR and possible intervention by another physician. This occurs nine days later. The second dictation gives the findings of the FFR x two vessels and states that no intervention is needed. After querying the physician, he states that a repeat angio was performed, but not dictated, because the findings were documented in the initial report. He added the angiogram in an addendum. Initially I felt that that we would not be able to charge for the second procedure at all because the repeat angio was not indicated and 93571/93572 are add-on codes. With the addendum, would it be appropriate to charge codes 93454-77, 93571, and 93572? Also, what if there was no addendum?

Would aspiration of hydrocele be reported with code 55000? I noticed this is not listed in the ZHealth IR book and just want to be sure this is the code you would recommend. "Title of Procedure: Ultrasound-guided aspiration of hydrocele. Under sonographic guidance one step needle advanced into the left scrotum and a total of 470 mL of straw/amber fluid was removed. Catheter was removed at the termination of the procedure. A 22 gauge needle was advanced into the right scrotum where a total of 80 mL of straw-amber fluid was removed."

Our EP physician brought the patient in for what he thought was a dislodged or malfunctioning pacemaker lead. Once the pocket was opened and the leads were detached from the pacemaker and examined, it was determined that they were fine. There was a set screw that was loose, and this was tightened down. Leads were attached to the same pacemaker and pocket closed. Our EP lab manager has only seen this a few times. What can I code for this, if anything? If fluoroscopy was used, can this be charged? Any suggestions would be most beneficial.

Right and left venous access, two kissing stents placed in the vena cava, two stents placed in right and left common iliac, two stents placed in superficial femoral vein. All lesions were separate and distinct. Bilateral diagnostic venogram also performed.

For your answer to Q&A ID# 5393 regarding coding for bilateral pulmonary thrombolysis, did you mean code 37212? Is the code for pulmonary thrombolysis venous rather than arterial?

Our physicians placed an abdominal modular bifurcated endograft, but they did not place the contralateral iliac docking limb. Instead they went through the brachial artery (due to left iliofemoral disease) and placed three iCast stents sequentially in the left common iliac artery. Should we charge code 34802 for all the work, or should we charge code 34805 and an iliac stent placement (37221)?

What code should we use when a doctor creates a thigh AV fistula using the saphenous vein (femoral-saphenous fistula)? When they state they "harvested the entire saphenous vein through the knee... tunneled and anastomosed to femoral artery", is this reported with code 36821 (possibly with -22 modifier), or is it reported with code 36825 (possibly with -52 modifier)? Or would it be unlisted?

If a patient has two breast lesions (one lesion is a core biopsy 19083 and second lesion is a final needle aspiration 10022) that are performed with ultrasound guidance, may we report code 76492 for the fine needle aspiration? Should we report a -59 modifier with code 10022?

Our general surgeons perform the exposure of endovascular AAA surgical cases for the interventional radiology group. The general surgeon performs a bilateral exposure (34812) and inserts the sheath. He leaves the OR at this point, and the interventional radiologist then presents to the OR and performs her portion of the AAA. The general surgeon then returns to the OR, removes the sheath, and closes the surgical site. The general surgeon dictates for the exposure and closure of the wound. Both the interventional radiologist and the general surgeon dictate as “co-surgeon” their individual portion of the case. Can we, as the general surgeon's office, bill for both the exposure (34812) and the repair of the AAA? The general surgeon is not in the OR during the time the interventional radiologist is doing her portion of the case. According to the interventional radiologist they suggest the general surgeon bills code 34802-62, as they say the general surgeon is there for the “critical” portion of the case. What are your recommendations on coding this?

Our cardiologist stated he did a "right heart catheterization and retrograde left heart catheterization" in a patient who has a history of AV canal defect with hypoplasia of the left ventricle, single atrium, single right ventricle, D-transposition of the great arteries, and subaortic stenosis with an interrupted inferior vena cava with azygos continuation into the SVC, status-post bulboventricular foramen enlargement, Damus-Kaye-Stansel procedure with placement of graft between the proximal pulmonary artery and the ascending aorta, as well as bilateral bidirectional Glenn shunt. At some point the patient also underwent an extracardiac Fontan completion. In the description of the procedure, access is gained in JV/FV/FA - does go into the Fontan, the Glenn anastomosis, into the right ventricle and into the (right?) atrium. We aren't sure if he truly has a single atrium or if it's just that the septum has been removed for the extracardiac Fontan (is that that done?). No left heart cath pressures are recorded. Is it because there isn't a left heart cath per se and one chamber is acting as systemic chamber? Is this really a left heart catheterization?

I have a question about the EP study with the ablation. Your cardiology coding book said the physicians don’t have to do a complete study when it is not necessary. Do you have to document a reason the complete study wasn’t done in the report? If not, do you bill with the reduce service modifier? The reason for my question is I was told by an EP consultant that I must have the reason the complete study was not done in the report to bill the ablation without a reduce service modifier for the incomplete EP study. I would like to know your opinion on this as to what a good documentation policy should be regarding this.

We get different information from different sources regarding downcoding venous duplex studies. Here is an example report. How would you code it? "Lower Extremity Duplex Venous Ultrasound: Technique: Doppler examination of the right lower extremity was performed for evaluation for deep venous thrombosis. Findings: The common femoral vein, superficial femoral vein, popliteal vein, and posterior tibial veins are all well visualized. There are no intraluminal echoes. The veins are all compressed with minimal transducer pressure. Doppler interrogation yields good venous signals in the above veins. In addition, there was significant augmentation with manual compression of the lower extremity inferior to the transducer. Impression: No evidence of deep venous thrombosis of the right lower extremity."

We need your help, as we are seeing conflicting guidance on the use of code 74485 on the day a lithotomy is performed. If the patient has existing access and the tract is dilated by the IR doc, but the nephrolithotomy is performed by a different physician, can code 74485 be reported? Or is that still bundled with the nephrolithotomy? Or is it more appropriate to report code 50398, 75984, or 50387 for the IR doc (depending on the position of the sheath) or if the tract isn't dilated?

Patient has a large pelvic tumor through the left gonadal vein, the left renal vein, and the suprarenal IVC, and a retrohepatic IVC forming a large mass filling her right atrium and causing severe R heart failure. My surgeon performed the abdominal and caval component, and the CT surgeon performed the cadiac portion. A transverse venotomy from the left renal vein and into the IVC was made, and the tumor thrombus was removed. Along with the CT surgeon the tumor was removed. The cavotomy was repaired. The tumor thrombus extending from the ovarian vein into the left renal vein was then retrieved through a separate venotomy ofn the left ovarian vein. The only code I can come up with is 34401-22, but this doesn't seem adequate for all the work that was done. Do you have any suggestions on the correct way to bill this? Would you suggest an unlisted code? And, if so, what comparable code would you use?

Please advise on how you would code the following procedure. "Given the large size of the IVC it was not felt safe to deploy the Option filter in an infrarenal location, as there is significant risk for filter migration. Unfortunately, the Birds Nest filter, which is approved for IVC >28 mm, was not available in our department or in the operating room. Subsequently it was decided to place bilateral iliac vein filters. The Option filter sheath was exchanged over a wire for an MPA catheter. The external iliac veins were then selected with the MPA catheter over a Benson wire. Left and right pelvic venogram was then performed. Subsequently, the Option filter was then replaced over a wire to the common iliac veins respectively. The filters were deployed. Post-filter venography demonstrates appropriate location of the filters with their apices at the most distal aspects of the common iliac veins."

2014 codes, balloon angioplasty and stent placement left proximal and mid subclavian, also with left subclavian angiogram. Also for angiogram the vertebral was viewed and noted to have stenosis. Diagnosis for subclavian is PVD with claudication.

What is the correct CPT code for right brachial artery angiogram and PTA of the right radial artery? And what books can help me to get more understanding of selective catheter placement (choosing first and second order, etc.). I am confused. I am a new coder for vascular surgeries.

How would you code for the ascending aorta stent grafts in the following scenario? "The physician joined me during this portion of the case. He selectively cannulated the left ventricle using a combination of angled Glidewire and angled glide catheter, and a wire exchange for the Lunderquist wire was performed into the left ventricle. This was left in to mark the ostium of the left coronary artery. Injection of contrast allowed us to perform left coronary angiogram. Wire was left in the anterior descending coronary artery, and catheter was left in the ostium. I proceeded with stent graft repair of ascending thoracic aorta. Cook 38 x 77 stent was introduced and advanced and deployed 5 mm distal to the left coronary artery, then ballooned and pulled distally so the distal portion of the graft abutting the ostium of the innominate artery. Next a Cook 42 x 81 stent graft was then placed and deployed 5 mm distal to the left coronary artery. Two stent grafts were then placed T11 to T4. Additional stent graft was placed just distal to the subclavian artery down to the previously placed stent."

We have performed left iliac artery aneursym decompression and ligation of hypogastric artery and right iliac artery aneursmorrhaphy using Dacron graft. Can I bill this procedure with code 35131 x 2?

Is it enough to say the C-arm was used to confirm to support using code 77001? Or does the physician have to say fluoroscopy guidance was used?

"Patient has AAA and prior endoprosthesis now with endoleak. Access via right CFA, micropuncture catheter was removed, and a series of dilators were passed until a sheath was positioned, extending into aortic stent graft via right iliac system. Selective catheter was advanced and positioned above the stent graft. Contrast was injected; multiple attempts to advance catheter into SMA were unsuccessful due to dilated AO. This was abandoned in favor of direct injection of endoleak under CT guidance. Site was selected, marked, and prepped on skin of lumbar region. Using coaxial Chiba needle, a 22 gauge Chiba needle was advanced into site of enhancement with subsequent return of blood flow. Needle was flushed, then n-butyl cyanoacrylate glue was injected. Needle was withdrawn." Is there a code similar to 36002 for percutaneous injection of an aortic aneurysm? Please advise how this is coded.

During a cardiac catheterization, the physician attempts to place a stent, but due to the tortuosity of the vessel he is unable to deploy it. Instead he places three smaller stents. Can the non-deployed stent be billed to the patient account?

We had a patient come in and the order was for CT abdomen with contrast. The tech did both the abdomen and pelvis, so of course our dictation reads for both and we charged code 74177. A pre-authorization was done for code 74160 and now the facility is wanting us to change the code to 74160 due to tech error. My question is, can we do that since the documentation states both, or could we separate the charges to 74160 and 72193 and not charge the pelvis and rebill code 74160? What would be the best way to handle this?

The reason for the exam is h/a with photophobia. Bilateral petrosal canal studies, right and left trigeminal ganglion injections, right and left sphenopalentine block. The nasal studies were simply "visual" studies, so there are no CPT assignments for that, correct? The left SPG block and the left trigeminal ganglion injection were performed from the same catheter, with manipulation to perform the injections, but no separate catheter access, with the same procedure repeated for the right side (and 64400 is bundled into 77002). Would this be reported with codes 77002-59, 64400-50, and 64505-50? Or would this be reported with only codes 77002 and 64505?

I appreciate your feedback on the following question regarding billing of two MitraClips. "PROCEDURAL DETAILS: 1) 7 French sheath was placed in the right femoral vein. 2) A Baim-Turi catheter was used to perform right heart catheterization. 3) Using TEE guidance, transseptal access was performed using lamp 45 catheter and BRK1 needle. 4) The lamp catheter was used to position an Amplatz Super Stiff wire in left upper pulmonary vein. The dermotomy was enlarged with a 16 French sheath. A 24 French clip delivery sheath was inserted into left atrium. 5) MitraClip was advanced into left ventricle. After several attempted grasps, A2 and P2 were successfully approximated slightly medial to midline of the line of coaptation. This resulted in reduction of MR from 4+ to 3+ with no change in transmitral gradient. The clip was deployed. A second clip was positioned just lateral to the first clip and grasped A2-P2 relatively easily. MR reduced to 1+ with no change in transmitral gradient. The second clip was deployed."

I was just wondering what the coding protocol would be when we angioplasty the arterial anastomosis and place a stent in the graft venous outflow. Would one procedure override the other, as arterial angioplasty would be coded instead of venous angioplasty, but since stenting now includes any angioplasty does it matter that it's arterial anastomosis angioplasty?

What are the inpatient billing guidelines for Revenue Code 636 on commercial (non-Medicare) facility claims? Our facility would like clarification regarding when it is appropriate to bill pharmacy items under Revenue Code 636 on commercial (non-Medicare) inpatient facility claims, as some of our commercial contracts have inpatient reimbursement clauses outlined for Revenue Code 636. We know that for Medicare claims, Revenue Code 636 is used for: 1) Inpatient – exclusively billing hemophilia clotting factors. 2) Outpatient – billing for "Drugs that require detail coding" (i.e., pharmacy with HCPCS). Are commercial (non-Medicare) claims required to adhere to Medicare inpatient billing guidelines for Revenue Code 636, or can "drugs that require detail coding" (i.e., pharmacy with HCPCS) be billed under Revenue Code 636? If possible, please provide references so that we may support our decision.

How would you code the following scenario? "Known CBD stricture, intrahapetic access obtained unable to cross the stricture. Alligator forceps biopsy performed. External drain placed but bleeding noted. Sheath choliangiogram performed, showing opacification of the portal vein. Portal veinogram done, two portal vein communications found. Larger external drain inserted, bleeding still noted, external drain left in place. Celia and SMA angiograms done with angio-seal to close the femeral artery access."

In an earlier question, you recommended using code 37242 for embolization of the GDA or right hepatic if performed at a separate session to prevent errant embolization with particles into normal structures during the Y90 embolization a week or two later - rather than 37243. What embolization code should be used for a patient who has bleeding, but the source of the bleed cannot be found, and so vessel(s) are embolized prophylactically - 37244 or 37242?

I have a case where the physician injected bilateral S1, S2, and S3 LATERAL branch block for bilateral sacroilitis. He states he used a 25g spinal needle directed to os lateral to the S1 foramen at the 3:00 position. He then injected bupivacaine. Procedure was repeated at the 11 & 5 o'clock positions. He then repeated this at S2 and S3 bilaterally. I am not quite sure what this is. Any help would be appreciated.

I cannot locate information for coding femoral endarterectomy and stent placement. "Operative Note: After completion of the endovascular stent graft, the external iliac, profunda femoris, and SFA were clamped and the sheath removed. A longitudinal incision was created in the common femoral artery, and extensive plaquing was noted, necessitating endarterectomy of distal external iliac, common femoral, and profunda femoris origin. Additionally, a stent was placed in the proximal superficial femoral artery to tack down the plaque at this level. This was performed, and then a patch angioplasty was used to close the arteriotomy." Would it be appropriate to code for the endarterectomy (35371) or the stent (37226), as I don't feel you can code for both procedures since they are within the same vessel.

"Patient had surgery two weeks prior with left ureteral stent and right nephrostomy with known hydronephrosis with obstruction. Here now for right ureteral stent. Under fluoroscopy, needle was passed into right kidney. Injection of contrast showed hydronephrosis and hydroureter to approximately 4 cm from UVJ where there is total occlusion, markedly redundant ureter. A 4 French catheter was placed, followed by an 8 French sheath. A 4 French angled catheter was used to gain access into bladder. A stiff guidewire was placed. Then, an 8 French by 26 cm ureteral stent was deployed with distal pigtail in bladder, proximal pigtail in right renal pelvis, and was noted to function." Codes 50393-RT and 74480 were assigned. Would you consider it appropriate to also report codes 50390-59RT and 74425?

Initial percutaneous placement of G-tube into the jejunum or duodenum is reported with codes 49440 and 49446. Using that same logic, would it be incorrect to report codes 43752 and 43761 for G-tube placement into the duodenum via nasal approach for enteral nutrition? The description of code 44500 in the Coder’s Desk Reference does not seem to describe what was actually done. Example: "Under fluoroscopic guidance, a 10 French nasoduodenal/jejunal feeding tube was advanced using real-time fluoroscopic guidance as well as a 0.035 stiff Terumo Glidewire and positioned in the proximal jejunum."

Would you report codes 47511, 47500, 47555, 47999 (balloon sweep), 75982, 74363, and 74320 for the following case? "An 8 French sheath was placed into the common bile duct and a cholangiogram performed. A 5 French KMP catheter was then advanced over the wire and negotiated into the small bowel. The Glidewire was exchanged for a 0.035" Lunderquist wire. The catheter was removed over the wire, and a 10 mm x 4 cm Conquest balloon was advanced to the ampulla and sphincteroplasty performed to 8 ATM. Next, the Conquest balloon was exchanged for a 7 French Fogarty. The common bile stone was then swept into the bowel. A post cholangiogram was performed. The sheath was then exchanged for an 8 French internal external biliary drainage stent, which was secured to the skin and attached to external gravity drainage bag."