Ask Dr. Z

Patient had severe vasospasm in the left M1, left ICA, and right ICA. The doctor did a nicardipine infusion over time in all three arteries and then had to do a balloon angioplasty of the same arteries. The doctor only placed the catheter into the cervical portion of the right internal carotid. Would it be permissible to use code 61642, or would you consider using an unlisted code for the right internal carotid extracranial portion?

How would I code the following? Specifically the catheterizations of the Sphenopalantine arteries. Would you only code based on the angiograms that were performed? CATHETERIZATION OF THE FOLLOWING VESSELS: 1. LEFT COMMON CAROTID ARTERY. 2. LEFT EXTERNAL CAROTID ARTERY. 3. LEFT INTERNAL MAXILLARY ARTERY 4. LEFT SPHENOPALATINE ARTERY 5. RIGHT COMMON CAROTID ARTERY 6. RIGHT EXTERNAL CAROTID ARTERY 7. RIGHT SPHENOPALATINE ARTERY DIAGNOSTIC ANGIOGRAPHIC INTERPRETATION OF THE FOLLOWING IMAGES: 1. BILATERAL CERVICAL CAROTID ARTERY ANGIOGRAMS 2. BILATERAL EXTERNAL CAROTID ARTERY ANGIOGRAMS.

If bilateral vertebral stenting is done, would it be reported with codes 0075T and 0076T? Or should it be reported with code 0075T x 2?

Is code G0269 bundled with the 2014 new embolization codes? It's not showing that it is on NCCI CodeManager. When would this code be applicable for billing with embolization?

Can you please help clarify catheterization of just the external carotid? "Patient presents for arteriogram and embolization. Femoral is accessed and catheter is placed in the thoracic aorta with angiogram revealing common carotid, subclavian, and innominate patency. Wire is changed followed by selective cath of the external carotid into the thyroidal vessel with angiogram, revealing AV malformation, which was coiled." What do we do with procedures when a carotid wasn't performed, only external carotid? Codes 36227 and 36228 do not work with 36221 per coding guidelines. The verbiage suggests that the physician was going to perform embolization but was verifying condition. I have seen two of these cases where they only select the external carotid (36227) and, in this case, went beyond into the thyroid artery. Code 37242 is for coil, but can we proceed to 36217 for thyroid cath? And in the other case where they went directly to the external for angio, how do we code?

Please clarify the coding (catheter placement and S&I) associated with selective innominate venography in conjunction with a congenital cardiac catheterization procedure (93530-93533) from both an ipsilateral and contralateral internal jugular vein approach, as well as an ipsilateral and contralateral femoral vein approach.

What is the procedure code for total artificial heart device interrogation? Code 0306T vs. 93750, which one is more appropriate? Is there any other guidance you can offer?

I need help with the coding of the catheterizations and angiograms for the following procedure: "The patient has an AVM in the apex of the right lung. There was not a previous diagnostic angiogram. He punctured the right brachial artery, then he advanced to the right subclavian where he catheterized and did diagnostic angiograms of the following: 1) AVM feeding vessel that arises from the right subclavian. 2) Right thyrocervical trunk with selective catheterization of the dorsal scapular, the inferior thyroidal, and the suprascapular arteries respectively. The dorsal scapular came off the transverse cervical. 3) Right vertebral artery to verify that it was not feeding the AVM. He then embolized the AVM feeding vessel." With these new bundled codes in the head/neck, I am not sure how to code this procedure. Can I only report vertebral catheterization code 36226 and add 75774 for all of the other angios? Or can I code for the selective caths using the old 36215-36218?

If a warranty credit is received in 2014 for a procedure that took place prior to January 1, 2014, do we still use the -FB/-FC modifiers? Following is an extract from MLN Matters® Number: "MM8572 No Cost/Full Credit and Partial Credit Devices Effective January 1, 2014, CMS will no longer recognize in the OPPS the FB or FC modifiers to identify a device that is furnished without cost or with a full or partial credit. Also effective January 1, 2014, for claims with APCs that require implantable devices and have significant device offsets (greater than 40%), the amount of the device credit will be specified in the amount portion for value code “FD” (Credit Received from the Manufacturer for a Replaced Medical Device) and will be deducted from the APC payment for the applicable procedure."

Should I use code 34808 or 37242? My understanding is that code 37242 is for malformations/congenital anomalies; is that correct? Or can they be used in conjunction with endovascular procedures?

Physician does bilateral renal angiography and bilateral superselective angiography. Would you report codes 36252 and 36254? Then, if he did angioplasties of both main bilateral renal arteries, as well as one 2nd order renal angioplasty and one 3rd order renal angioplasty, would you report codes 35471, 75966, 35471 x 3, and 75968 x 3?

I have a case were a chemoembolization was performed in the hepatic arteries and an angioplasty was performed on the left external iliac artery. The angioplasty was not planned; stenosis was found when trying to cannulize the artery for the embolization. The problem is that I have to use codes 37243 and 37220 for two different vascular families, and due to the fact a diagnostic angiography was performed on the external iliac I have catheter placements for both areas of treatment, so codes 36247 and 36248 x 3 for the hepatic embolization and 36249 for the diagnostic angio in the external iliac. Due to code 37220, codes 36247 and 36246 both require a -59 modifier, but code 36247 overrides 36246. How do we address that so that both catheter placements are paid?

I need your guidance please. Patient has a type 2 endoleak and is coming in for angiography and possible glue embolization. This is the condensed portion of the report: "The right CFA was accessed with a micropuncture system. This was exchanged for a stiff Glidewire, short 5 French sheath, and pigtail catheter. Aortogram with mesenteric run-off was done. The IMA entering the sac was identified. A 0.18 Glidewire and Renegade catheter were used to traverse the tortuous arc of Riolan and access the IMA and the sac. Glue was diluted 1:3 with oil, and 3 cc of this was used to embolize the sac and distal IMA." I am reporting code 37242 for the embolization, but I'm unsure about the catheter placement. The physician indicated that this was a third order. Since the SMA and IMA are two separate families, should I be reporting codes 36247 and 36245-59?

What is the proper way to code a catheter exchange when done over the guidewire? It is for a Quinton catheter.

Indication for procedure was need for ICD generator replacement. Also, fluoroscopy was performed of the right ventricular lead because of its recall status. Fluoroscopy revealed externalization of the right ventricular cable. For this reason, a left arm venogram was performed that demonstrated patency of the left arm veins. Through the axillary vein, a wire and sheath were advanced. Right ventricular lead was advanced through the right ventricular septum and fixed in place. Old right ventricular lead was capped and a new generator placed after recreating the pocket in a better position. Codes 33263 and 33216 as well as 36005 were charged by the Cath Lab. I agreed initially with codes 33263 and 33216 until I saw a similar Q&A from last year that advised different codes but appear to need more clarification. Please advise. Also, would code 36005 be allowed separately with a -59 modifier?

"INDICATIONS/COMMENTS: ORIF LT PROXIMAL HUMERUS IN OR RESULT: Left humerus. Two intraoperative C-arm images demonstrate patient to be status post ORIF of proximal humeral fracture with plate and screw fixation. There is gross anatomic alignment of the fracture. CONCLUSION: Intraoperative images confirming hardware position and alignment."

Can the radiologist report code 73060-26 for the dictation? Can the hospital charge code 73060 for the saved C-arm images since there is a dictation? Is the fluoroscopy CPT code a component of surgical code 23615, or can we report code 76000? If the surgeon must request the dictation, should that be documented in the operative report, radiology dictation, or both?

"The anterior abdomen was evaluated with ultrasound. Contrast was infused into the cavity to distend it and confirm no communication with the abdomen or other structures. The contrast was then removed and 60 ml of povidone iodine was then instilled into the cavity and left to dwell for 15 minutes. This was then aspirated, and the drain was attached to gravity drainage. The tube was secured to the skin with a prolene suture.and statlock device. Findings: Inital ultrasound pigtail catheter is within the cavity, which is collapsed around the drain. The wall appears somewhat thickened to the previous study. Contrast was then injected into the cavity, which demonstrates a similar configuration to the the previous study. Following placement of a new 8 French drain, the catheter is in appropriate location. 60 ml of iodine was then infused into the cavity and left 15 minutes."

I'm not sure of what codes to report. We reported codes 20500, 76080-26, 49423, and 75984-26.

I have a patient on whom the physician has used a DFINE Stabili kit to perform what I would consider a "kyphoplasty" procedure. The physician performed a cavity creation by using a curved osteotome and then placed cement in the vertebral body of the L1. I have had this procedure pulled for an audit, and the auditor counted this as a vertebroplasty because the physician did not use a balloon during the procedure. I was told if the DFINE Stabili kit meets the definition of a kyphoplasty then it would be appropriate to code it as one. Can you give me some insight on this?

Patient has carotid subclavian for stenosis of subclavian artery. Developed stenosis of anastomosis onto carotid artery. Found to have hyperplasia of anastomosis. Pituitary rongeur was used. Patch angioplasty was used. If lower extremity, I would use code 35879. Is this just unlisted?

Access left radial artery with micropuncture, left arm AV fistulogram with interpretation. This is a radiocephalic fistula. Can code 36120 be used for direct radial artery puncture for evaluation of the fistula, or is that code only for the brachial artery (36120, 75791)? When a doctor uses the word "micropuncture", does this always mean percutaneous? First example: "Dissected out the fistula and then accessed the aneurysm with a micropuncture 6 French sheath." Second example: "We then accessed the graft with a micropuncture sheath near the arterial limb towards the venous outflow."

How would you code this scenario? I have a tibial/peroneal trunk atherectomy, a peroneal atherectomy, and an AT angioplasty. The physician would like to bill two atherectomies, but I am thinking I can just bill one atherectomy and one balloon. What are your thoughts?

I have a layered question. First, dictation states "open" thrombectomy with a Fogarty catheter. Physician states an incision is made over the venous side of the shunt and a catheter is used to remove clots. Later, a wire is sent to the arterial side of the shunt. The wire goes into the proximal brachial artery where he removes clot that was blocking the flow right at the anastomosis of the arterial side. Is code 36870 the appropriate code to report? Second, physician states a "venogram that was NOT diagnostic" after the thrombectomy demonstrated a stenosis of the distal basilic vein, axillary vein, and stent in the SVC. Is code 36147 reportable even though it was performed after the thrombectomy? Third, the stenosis at the basilic and axillary was dilated with a balloon. The stent in the SVC is also dilated. Therefore, is it appropriate to report codes 36870, 35476, 75978-26, 35476-59, and 75978-59? What about 36147?

In reference to your February 2014 newsletter concerning CMS required codes for initial permanent pacemaker implants, and the non-covered diagnosis codes that will cause the claim to be denied, are we to assume these are applicable to the biventricular permanent pacemaker implants as well? CMS only references "single and dual", but they also reference CPT code 33208, which could also be an initial biventricular permanent pacemaker.

Condensed version: Physician states, "It was thought at the time that a fem-fem bypass would be required. A PTFE graft was tunneled appropriately the proximal fem-fem was created on the left. Attention was now turned to the right groin, and arteriotomy was obtained. Using a Fogarty catheter, thrombectomy was performed of a large amount of thrombus and was removed until backbleeding was achieved. The PTFE was turned into a patch, and the patch was used to close the arteriotomy. In the left groin the proximal anastomosis was cut, and the PTFE was turned into a patch angioplasty as well." In this case would you only code the patch angioplasty and not for the intended PTFE even though it was placed? The ultimate result was a right thrombectomy and a left patch angioplasty.

Right side femoral was cutdown to do the TAVR, but catheters could not be passed due to PVD, so the left side iliac artery was cutdown and TAVR was performed successfully. Would we code anything for the abandoned initial cutdown? Our TAVR was coded with 33364.

After prep bilaterally, sharp & blunt dissection w/incision carried down to pectoralis fascia on LT side PG pocket site. Chronic LT ventricular & atrial leads uncapped & tested, adequate pacing/sensing confirmed w/ventricular lead & sensing in the atrial lead. 10 volts applied w/no observed diaphragmatic stimulation in the ventricular lead. Copious abx solution used to irrigate LT side pocket. Boston Scientific Model K173 device was connected to chronic leads & sewn into pocket, lead placements again verified, pocket closed. Using a combo of sharp & blunt dissection, incision carried down to level of pectoralis fascia on RT side PG pocket site. Existing RT side PM model K1783 removed from leads. Existing ventricular lead unable to be extracted due to fibrosis, left in place in RV, capped. Existing atrial lead extracted. RT side pocket debrided, irrigated w/abx solution, pocket closed w/deep & subcu Vicryl & Dermabond. Pt tolerated px well, returned to floor in stable condition. Would you would report this with 33222-59, 33228, 33234?

Would it be appropriate to use 78227 NM gallbladder scan with pharmacologic intervention in this case? CCK the pharmacologic to trigger the gallbladder function is not available from mfr. We are utilizing food (half & half cream, candy bar) as a substitute to insight this functionality of the gallbladder. We are still performing all the pre and post imaging food intervention imaging and reporting of the quantitative measures, would it be appropriate to utilize 78227 Hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention, including quantitative measurement(s) when performed

Ethanol nerve block was performed, but my colleague and I are debating whether or not code 64680 or 64530 should be reported. See report that follows: "Under CT guidance, a 22 gauge Chiba needle was advanced to the celiac ganglion bilaterally from a left and right paraspinal approach, respectively. With the target celiac ganglion at the tip of the Chiba needle, the stylet was removed and monitored for any blood draw back to assure the needle tip was not within a vascular structure. Very dilute contrast was injected to evaluate placement of the needle tip and to again assure the needle tip was not within a vascular structure. Approximately 15 mL of 95% ethanol mixed with approximately 5 mL of 0.5% bupivacaine and 3 mL of Isovue 370 was hand injected to the celiac ganglion bilaterally at a rate of approximately 0.5 mL per second while under intermittent fluoroscopic CT guidance." Would this be coded as a nerve block or nerve destruction?

The Aptus Endo-Anchor device is an unlisted code. Is there a similar procedure that you would compare it to for billing purposes?

One of our physicians is asking about an update from Medicare. The hospital he reads at is telling him there has to be a six-week waiting period after the initial diagnosis of compression fracture before the vertebroplasty can be done. Have you heard of anything like this from CMS? Can you maybe point me in the right direction to find the requirements for this procedure or any policy updates?

How do I know which procedure code qualifies to be billed with the add-on code 77001? My doctor has entered several codes, but they are not qualifying as the primary procedures. Please advise.

"Transverse incision was made in the antecubital fossa overlying a new area of the arterial end of the graft. The graft dissected and skeletonized. A separate incision made in the deltopectoral region just distal to where the HeRO graft connected to the outflow component. Both of these areas of the graft were resected and skeletonized. Kelly Wick Tunnel used to make a 7 mm tunnel between these two areas. A 6 mm Acuseal graft was brought to the field. It was pulled through these two incisions. The arterial end of graft was clamped and the other end ligated with a hemostat. Graft was then divided. An end-to-end anastomosis was done between the arterial end of graft using one 5-0 C1 suture under loupe magnification. Attention turned to the venous anastomosis. Again graft clamped just distal to the outflow component; graft was transected. Another end-to-end anastomosis was done between Acuseal graft and the old HeRO graft... with a 5-0 C1 suture under loupe magnification. Post anastomosis, clamps were released. There was excellent flow into graft with immediate thrill."

What code(s) would you suggest for the following procedure?

An adult barium enema tip connected to large bore tube was gently inserted into the rectum. The first attempt at reduction with Gastrografin/warm water demonstrated a tight complete volvulus of the redundant sigmoid colon without contrast proximal to the torsed segment. The second attempt at hydrostatic reduction was also unsuccessful. However, at third attempt at reduction, the volvulus completely reduced. Approximately 2.5 L of stool and fluid were evacuated. Contrast was subsequently identified refluxing retrograde to the level of the distal transverse colon. IMPRESSION: Successful hydrostatic reduction of sigmoid volvulus with water-soluble contrast.

I seem to have a hard time grasping these sclerotherapies. I get the 37241, but I dont know what else I can code with this case. "Using ultrasound, a Chiba needle was introduced through the skin and in between the pancreas and the kidney. Small amount of hydrodissection was employed to make a space between the kidney and the pancreas. After getting past the kidney and the pancreas, the lymphatic malformation was entered. Wire was then placed since the needle into the cyst, and a 3 French portion of the 3-4 dilator was placed into the lymphatic malformation over the wire. Contrast was injected through Touey, which showed filling of the lymphatic malformation. A Rosen wire was then placed into the lymphatic malformation, and a 5 French Yueh centesis pigtail was placed over the wire into the lymphatic malformation. 24 cc of 70% ethanol was injected through the catheter, filling the cyst. Unfortunately at the very end of the injection, the back end of the malformation ruptured. We waited five minutes for the alcohol to react with the lymphatic malformation wall."

One of our providers is wanting to bill for left heart catheterization (93452) with VT ablation (93654). It's my understanding that VT ablation includes a comprehensive diagnostic study of the right heart and left ventricle. I've noticed we can bypass the NCCI edit by adding modifier -59, but I am wondering when it would be appropriate to bill separately when performed with the VT ablation.

Patient had a left fem-tib bypass. Right saphenous vein, right basilic vein, and left accessory saphenous vein were harvested. Can you offer insight on the appropriate coding? It is my understanding that the harvest of the saphenous vein from the same or opposite leg is included and any harvest of vein within the bed you are working is included in the bypass. Would I just code for the bypass (35566) and the harvest of the basilic vein (35500)? I am receiving conflicting information and would appreciate your opinion.

What is your code recommendation of this case? "Upper abdomen was prepped and draped in usual sterile fashion. Contrast was injected into patient's indwelling percutaneous pigtail type gastrostomy tube, confirming intragastric location. Catheter hub was cut, and the catheter was removed over Amplatz superstiff wire. A 12 French sheath was advanced into the stomach in order to facilitate fistula brushing, which was performed with 3 mm bristle Cellebrity Cytology Brush over Amplatz wire as sheath was retracted from fistula. Next, Cook enterocutaneous fistula plug was deployed through 24 French sheath within the fistula. Inner disc was in appropriate position along gastric staple line, as confirmed with fluoroscopy and radiography in multiple obliquities. External portion of the plug was secured to abdominal wall with Molnar disc and trimmed. There were no immediate complications."

Should I report both codes 59000 and 76946 if the radiologist alone performs the amniocentesis? There is no note from the OB physician.

I need help with coding the following: "Contrast was injected through the indwelling catheter, and spot fluoroscopic images were obtained. After aspiration of the entire volume of the cavity, doxycycline was infused and allowed to dwell one hour, after which point the catheter was opened to gravity drainage. IMPRESSION: 1. Successful doxycycline sclerosis of the pelvic collection. 2. The patient will initiate Betadine sclerosis with 25 mL Betadine twice daily."

What are the proper codes and modifiers to use for follow-up mammogram for males with history of breast cancer?

"The balloon was inflated, but there was no reduction in stenosis. An unsuccessful attempt at balloon angioplasty was performed on the 100% lesion in the mid RCA. Following intervention there was no improvement in angiographic appearance with a 100% residual stenosis. This was an ACC/AHA type C 'high risk' lesion for intervention. The residual lesion demonstrated a large filling defect consistent with thrombus. There was TIMI 0 flow before the procedure and TIMI 0 flow after the procedure. There were no site complications. Balloon angioplasty was performed, using a Trek RX 2x12 balloon, with two inflations and a maximum inflation pressure of 6 ATM. The resulting stenosis was 100%." Would a -52 modifier be applied to the angioplasty?  Would code 92920 be reported with a -52 or -53 modifier?

I have an abscess catheter check. A decision was made to place TPA through the catheter. A total of 2 mg of TPA mixed in 15 cc of saline and infused to the catheter with the catheter capped for one hour. What code, if any, can be used for the TPA infusion? The doctor is asking for code 37212, which I believe is incorrect. Some places it states not billable. Could you please clarify if this is billable and what code would be used?

How would you code the following? "Contrast was injected through the new catheter opacifying the collecting system. Given persistent leakage of contrast from the catheter skin exit site and possible compression of the catheter by adjacent internal plastic biliary stents, I elected to remove the biliary stents and further upsize the biliary drainage catheter. The catheter was removed over a guidewire common, and over the wire a vascular sheath was advanced into the small bowel. The distal end of one of the indwelling stents was snared and withdrawn into the sheath and removed. The second stent that had become withdrawn into the biliary tree was snared within the biliary tree and removed as well. Then, over a guidewire, a 14 French biliary drainage catheter with additional sideholes cut in the tube was advanced, and the distal pigtail coiled within the small bowel the most proximal sidehole was positioned peripherally in the biliary tree. Contrast was injected through the new catheter. The catheter was flushed with saline, secured to the skin using 2-0 Prolene suture, and pl..."

If an intervention is performed from the left main into the circumflex or left anterior descending (on a single bridging lesion), do you add -LM as the modifier, or LC/LD?

We have a patient who presented with a nephroureteral stent in place. Patient also has an ileal conduit. They removed the nephroureteral stent/nephrostomy that was in place and inserted a "urinary diversion catheter". The wire originated in the nephrostomy site and exited the conduit. The diversion catheter was inserted via the ileal conduit over the guidewire to the upper pole calyx and extended into the ileal bag. Would this be reported with code 50688 (change of ureterostomy tube via the ileal conduit) and 50389 (removal of nephrostomy tube)?

Which code is more appropriate in this scenario? 27884 or 11042/97605? (Note, seen for peripheral vascular disease.)  "PROCEDURE PERFORMED: 1) Irrigation and debridement of a non-healing below-knee amputation wound. 2) Wound VAC placement. DESCRIPTION: Patient was transferred to the operative suite and laid in the supine position. After proper sedation, she was sterilely prepped and draped in the usual fashion. Proper time-out procedure was performed. Next, we debrided all the necrotic tissue, as well as a tendon that was occupying a large space within the below-knee amputation stump. After this was resected, Pulsavac was used to irrigate the area significantly. There was some bleeding without the wound, although the muscle did not look completely healthy. However, at this point we decided to place a VAC and try our best to heal this wound. VAC was placed without any difficulty. Patient tolerated the procedure. There were no complications. The patient will be discharged to her extended care facility."

One of our physicians performed the following procedures: 1) IV conscious sedation, 2) Left lower percutaneous antegrade pyelogram, 3) Left lower percutaneous nephrostomy catheter placement, 4) Left upper percutaneous antegrade pyelogram, and 5) Left upper percutaneous nephrostomy catheter placement. I've never seen two nephrostomy tubes on the same side. How would you recommend coding this? Can they both be coded?

Status post pacemaker insertion on 4/23/14, patient returned on 5/13/14 for hematoma evacuation at pacemaker site. Can we code for this? Or is this part of doing the original procedure?

 Could you please help with correct coding of following case? "Patient has sternoclavicular lesion. Under ultrasound guidance, a needle was advanced to the right sternoclavicular joint, and a core biopsy was obtained. In addition, fine needle aspirates were obtained."

Day 1: Patient comes to IR for the radiologist to percutaneously place a nephrostomy tube with ultrasound, fluoroscopy, and contrast guidance. Day 2: Radiologist assists urologist by removing the previous placed nephrostomy catheter. Serial dilations to a 28 French sheath. The urologist removes the stone through the sheath, and a nephrostomy catheter is placed by the radiologist. Day 3: The radiologist injects contrast (does a full nephrostogram dictation) and then removes the nephrostomy catheter. Can I only bill codes 50395 and 74485?