Ask Dr. Z

What comprises a complete aorta-only Doppler (93978), and what comprises a limited aorta-only Doppler study (93979)? My understanding is that code 93978 is for complete study of the aorta, IVC, iliac vasculature, or bypass grafts, while code 93979 is unilateral OR limited study of the aorta, IVC, iliac vasculature, or bypass grafts. 

This is an image-guided sclerotherapy of a right knee low flow vascular malformation. "Under direct ultrasound guidance, a 22 gauge needle was advanced through the anesthetized tissues and into the vascular malformation. An ultrasound image was recorded. Under fluoroscopy, hand injection of contrast confirmed position. The angiographic study of the malformation revealed filling of the dysmorphic irregular veins/venous lakes within the malformation in the lateral aspect of the femoral condyle. The malformation has two small draining veins at its proximal aspect emptying into the right popliteal vein, likely the genicular veins. Next the foam was injected into the low flow vascular malformation until filling of the draining veins was identified. There was good distribution of the sclerosing agent within the malformation..." With the new codes for 2014, we are pretty sure we would report this sclerotherapy with code 37241. But what, if anything, should we use for the needle access and angiographic study?

This seems like a simple code issue, but I continue to debate with myself over it. "(AVF) Forearm native radial artery cannulated retrograde beyond arterial anastomosis. Retrograde brachial angiogram done, which shows patent brachial ulnar, interosseous, and radial artery. Native radial proximal and distal forearm stenosed. Sheath repositioned and fistulogram done." What is the proper use of code 36120? I research code 36120 and it states retrograde brachial access, but the physician is accessing the radial artery retrograde. Is code 36120 only for retrobrachial, or can it be used for retroradial access as well? And would I code for retrobrachial angio 75658, as well as 75710 and 75791? Thank you in advance for your time and expertise.

Can you please offer clarification on modifier -51 and how claims are subjected to a payer reduction for the second, third, etc. claim lines? How can I assist my providers with understanding this modifier and why the majority of carriers are directing us to apply?

Can the both the physician and facility report code 36620 for aortic pressure measurements obtained above and below the stented iliac arteries during an abdominal aortic angiogram? The report stated, "Catheter was advanced into the mid abdominal aorta, and a flush abdominal aortogram obtained in AP projection. Catheter was then pulled down to the aortic bifurcation and bilateral pelvic oblique angiograms obtained. A pressure transducer was then attached to the pigtail catheter and a pressure measurement obtained. The pigtail catheter was then removed and a pressure measurement obtained at the level of the 5 French vascular sheath." Codes 75625 and 36200 were reported. Can code 36620 also be charged?

We had an MRI order from the referring physician stating an MRI of the left trapezius muscle. The MRI report reads MRI of the left shoulder and trapezius muscle. Should we only bill using 73221? Or, should we bill using non-joint code 73218 since the trapezius muscle is a non-joint? Please provide us with the correct coding.

Does the ramus artery have any additional branches to it in which you could bill out for if there were multiple interventions to them? I have a cardiologist who wants to bill an angioplasty and stent of the ramus intermedius, stating it has two branches in which he intervened upon with two different drug-eluting stents. He would like to bill codes 92928 and 92929. I was unaware that the ramus intermedius had any branches. Please advise.

I need help on coding the attached 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."

Procedure: femoral AV fistula, fistulogram, stents outside fistula, upper extremity venogram, and IVUS (several vessels including fistula). Can IVUS inside the fistula be billed?

I would appreciate your assistance on an issue we are having with the correct codes to use in the following situation: Access was from the right common femoral. The catheter was placed in left internal iliac, superior gluteal, and two separate branches of the superior gluteal (36247, 36248). The left external iliac was then catheterized. I feel that the left external iliac should be reported with code 36248 since these vessels are in the same vascular family (contralateral common iliac family per vessel ordering table from the SIR manual). The other opinion is that the left external iliac should be reported with code 36246 based on your pelvic arterial anatomy chart. Can you clear this up for us?

Patient with ESRD and left forearm AV graft placed one month ago, referred for fistulogram. Ultrasound evaluation showed a thrombosis of the graft, so fistulogram was not performed. Per "Ask Dr. Z" question ID #5508, Dr. Dunn advised not to report code 36147-74, as a vessel was never assessed. Is there a code for reporting ultrasound of AV graft? How will this be reported?

We are hitting an edit whenever we code an FFR 93571 with a drug-eluting stent procedure. We are told that we need a primary procedure code with 93571 and that C9600 is not acceptable. (Note, this is a hospital.) The acceptable codes for 93571 are the heart catheterization codes and the bare metal stent codes. I would appreciate you help.

Hybrid PDA stent and ASD stent along PA banding was performed. Code 37236 is reported for the PDA. Can we report unlisted code 93799 for a stent into atrial septum in right atrium free wall and needle poke through secundum septum? Do you have any other suggestion instead of using unlisted?

What CPT code should we use to report the new Nellix Endovascular Aneurysm Sealing System (EVAS)?

The physician performed SFA atherectomy and placed the drug-eluting stent. I'm billing for the physician's services in a hospital setting. Does code 37227 include this stent, or is there another code for this type of stent?

My doctor reported thrombectomy from beginning and throughout the report, but I think a couple of words at the very end of the report may have changed the coding from a thrombectomy to an endarterectomy. Does this limited documentation support reporting code 35371? "Incision overlying the femoral vessels... dissected out the common, superficial, and profunda vessels. Controlled vessels... arteriotomy extensively on the CFA and extended to the SFA. Fogarty catheter was placed, retrieving thrombus from the distal SFA out of the arteriotomy… thrombectomized the profunda vessel - flushed all the thrombus and clot out of the proximal CFA and actually endarterectomy of the CFA was also done with some degree of endovascular plaque disease, typical of atherosclerosis as well."

Our doctor performed an AV fistulogram in an ESRD patient and documented his finding as subclavian stenosis. How should I code his diagnosis? Should I code it as an AV fistula complication (996.73 and 459.2)? According to CPT P216, AV shunt is defined as beginning with the arterial anastomosis and extending to the right atrium. Would the definition apply to ICD-9 coding too?

I was taught that if an intervention was done after venography and access I should code only the intervention. I seem to have come across some confusion with this. I think I understand that if intervention was done on one leg, and just venography done on the other leg, I can bill the venography for the other leg separately, and just the intervention on the other extremity. Can you please give me some guidance as to how these are to be billed?

Can we bill code 92941 if patients are diagnosed with NSTEMIs but are stable and not taken to the cath lab until the next day and an intervention is performed?

I have an aortic arch aortogram that was done.  I have been coding 36221 and 75625, but my case was done from a left arm approach. Here is the report:

Procedure Description: The right radial artery was cannulated. The right brachial artery is occluded. An attempt to traverse a large collateral branch was unsuccessful. The left radial artery was cannulated. Catheters and various guidewires could not be manipulated into the ascending aorta, although the guidewires readily prolapsed back up the innominate artery. Biplane aortic arch angiography was performed, and the procedure was then terminated. Aortic arch: The catheter enters the aortic arch from a left arm approach. There is a linear impediment to flow and passage of the catheter from the arch into the ascending aorta, except for a very small communication at the postero-medial edge of the barrier. With injection into the arch, there is excellent opacification of the three brachiocephalic vessels and RIMA, and only faint penetration of contrast down the descending thoracic aorta.

Would it be correct to use codes 93451, 36011, and 76942 for this operative report?

"Right heart catheterization. Smart needle/site. Right hepatic vein venogram was prepped and draped in the usual sterile fashion. Under lidocaine 2% local anesthesia, an 8 French sheath was placed in the right internal jugular vein using the modified Seldinger technique under ultrasound guidance. A 7 French balloon-tipped catheter was advanced through the right atrium into the IVC. The catheter was positioned into the hepatic vein, and wedge hepatic vein pressure was obtained. Confirmation of wedge position was confirmed by hepatic vein venogram via hand injection of 5 cc of contrast. Multiple measurements of WHVP and FHVP were obtained per study protocol. Repeat FHVP measurement was obtained about 1-2 cm from IVC. IVC and RA pressures were recorded. Following the procedure, the sheath was removed and hemostasis obtained with manual pressure . There were no immediate complications."

Please assist with coding of the following scenario. There is debate between codes 19083 + 19084 OR 19083 + 38505 (with 76942). "Patient taken to ultrasound suite for biopsy with history of large mass lateral right breast. Right axillary adenopathy. Using direct ultrasound visualization, vacuum-assisted automated core needle samples were obtained from the large mass in the lateral breast using a Celero biopsy device. A marker clip was deployed at the biopsy site under ultrasound guidance. Next, the right axilla was cleansed in a sterile fashion. 1% lidocaine was used for local anesthesia. Using direct ultrasound visualization, vacuum-assisted automated core needle samples were obtained from one of the abnormal axillary lymph nodes using a Celero biopsy device. Pathology report for the axillary tissue shows complete replacement by ductal carcinoma…lymphoid tissue not seen…shows staining with CK7 and GATA, in keeping with breast primary."

I have a follow-up to question #5129. My surgeon is treating an endoleak for an AAA. The original surgery was done at an outside hospital, and now my surgeon is placing the Heli-FX to resolve the Type 1A endoleak. Any suggestions on what code should be used for this?

We have had several cases (CCLV or EP) lately that have been cancelled or rescheduled due to labs being off. They made it as far in the department as the lab and then our pre-procedure area, where the nurse continues the process in prepping the patient (IV, consent, fluids, shaving etc.). Once the labs come back, we've had to reschedule or cancel the procedure. I was told that I should be coding the procedure with a -73 modifier. Is this correct? What would the appropriate situations be where this would apply, and does that cover any procedure under those circumstances?

During the creation of an AV fistula my provider ligated two veins off the cephalic vein to aide in maturation of the fistula. He used two separate incisions to do so; is this billable? Here is an excerpt from the operative note: "The cephalic vein appeared to split into two veins in the proximal forearm with one coursing laterally and not being fairly superficial of excellent size. There were two branches connected to this vein. In order to allow maturity of this branch as well, I proceeded to make a very small stab just proximal to the entry of this branches to the cephalic vein, and these veins were clipped. Each small stab was closed with 1 interrupted 4-0 Monocryl suture."

If a patient has endarterectomies performed in the common femoral, profunda femoral, and superficial femoral, can all three be coded? Do the territory rules apply for the PTA/stent/atherectomy rules to the endarterectomy procedures (35301-35372), which only allow one intervention in the fem/pop region?

The CPT Codebook seems to have conflicting verbiage; new 2014 instructions at the heading "Vascular Embolization and Occlusion" state that the embolization codes include "imaging necessary to document completion of the procedure". My physician also submitted code 75898 (angiography for follow-up study) for embolization, which sounds right. I just want to be sure that I'm not removing a billable service.

How would you code the following?

"In prone position under sedation, right back and flank were prepped and draped. External portion of indwelling nephrostomy tube was transected. Limited nephrostogram shows good position within right kidney lower pole calyx, filling of collecting sytem, and right ureter, but obstruction of distal ureter (50394, 74425). Indwelling nephrostomy tube was replaced over a Glidewire, followed by placement of introducer sheath with tip into lower pole infundibulum. Guidewire and catheter technique used for placement of Kumpe glide catheter and glide wire into distal ureter. Contrast injection with 99% stricture at distal right ureter, was traversed with glide wire, and allowed advancement of glide cath into bladder. Guidewire was advanced into bladder, and catheter was exchanged for a 3 mm x 40 mm angioplasty balloon. Inflation to 10 ATM with parallel balloon walls, sustained approx 2 minutes (53899, 74485). Double-J ureteral stent was advanced over guidewire, and a distal pigtail was formed in bladder and proximal in renal pelvis (50393, 74480). An 8 French nephrostomy tube was replaced into right renal pelvis (50398-RT, 75984, C1729)."

This is an "appeal to common sense" question. We've reached out to our Carrier, and now I'm inquiring on your thoughts. The new 2014 stent codes (37238/37236) reflect on the CMS RVU table that there is a 000 global period; therefore, a global modifier would be necessary if performed within the global period of another service. Submitting with a global modifier of -78 (related, unplanned procedure) denies the charge for "inconsistent"; however, modifier -79 (unrelated/unplanned) is acceptable. I am using modifier -78 in the context of dialysis graft that declotted patient returns due to a subsequent declot and stent is additionally placed due to persistent recoil. Can you make the case the stent is "unrelated", as the recoil is due to current visit, or related since it is all being performed in dialysis graft?

"Patient presented for TEVAR for thoracic aortic ulcer. Bilateral femoral cutdowns were done (34812-50). On the right, pigtail was passed for diagnostic angio (36200). Device sheath could not be advanced due to iliac disease. Common and external iliac stents were placed (37221/37223). Still could not advance device sheath. Right side was abandoned. Device sheath couldn't advance on the left either, so an iliac conduit was placed (34833). Catheter was advanced into arch through conduit (36200-50). TEVAR not covering subclavian was placed (33881/75957). Conduit was then converted to a ilio-common femoral bypass (35665)." Since the right side was abandoned and the stents were placed to facilitate passage of device, can I still code the stents? Can I code the conversion of the conduit as a bypass and as a conduit? Can I report code 36200-50 since the catheter was for the TEVAR, not the stents? Your expertise is greatly appreciated.

A new single chamber pacemaker was implanted in attempting to screw the lead to the right ventricular, which would not hold. They also implanted an ICD lead for additional support, but leads implanted same location with both leads being attached to the system. Lead placement is right ventricle. How should this be coded?

I have a question regarding Q&A 4409. Are you saying if a rescue thrombectomy is performed in the popliteal, and an atherectomy is performed in the SFA (both with the same device) that you only code one procedure? Is the reference you are using from the NCCI Policy #18? Is there another reference? There is no NCCI edit and 37186 is not in the Policy, specifically.

We did a right Elbow Complete 73080 and a left Elbow Complete 73080 for comparison purposes only. Are comparisons able to be billed seperately? Do I add a modifier? Some say do not charge and some others say yes charge if you have print views, or charge if the doctor order. Please advise.

When placing a CVC line from the subclavian with an occluded SVC into the azygos system, would this be considered a central line placement?

Patient has a previous fem-anterior tib bypass with vein. He is taken back to the OR for stenosis of bypass at outflow. Physician did an interposition jump graft from distal bypass to new location of distal anterior tib. Would this be a revision of bypass or a new bypass code like 35571?

"Right femoral artery was accessed with Microvena puncture kit. A 5 French sheath was placed. Angled pigtail was then advanced over the 0.035 wire and positioned in the aortic arch. Aortic arch angiography was performed. A JR4 catheter was then advanced over a 0.035 guidewire and engaged into the left subclavian. Left subclavian and left upper extremity angiography was then performed. The JR4 catheter was then directed up the right innominate, and the right upper extremity angiography was then performed. Catheter was then removed. A 6 French AngioSeal was then used to obtain hemostasis. Arch Angiography: There is a widely patent right innominate, proximal right common carotid artery, normal left common carotid artery and left subclavian. Left Upper Extremity: No significant stenosis in the left subclavian artery and left upper extremity extending to the wrist. Right Upper Extremity: Right subclavian, axillary, brachial, and ulnar arteries are normal."  I reported codes 36215 and 36215-59; however, the facility thinks code 36221 is more appropriate. What are your thoughts?

If catheter placement in the thoracic aorta is documented with angiography, what vessel findings need to be documented in order to code for 36221? Do we need findings of the left common carotid and vertebral if unilateral left is done? If both vessels aren't documented on, do we add a -52 modifier to 36221? Also would you add a -52 modifier to 36221 when aortic arch angiography is performed with further selective catheter placement into the subclavian (36215) and upper extremity angio (75710) (due to the catheter placement in the aorta being bundled into 36221)?

"Procedure performed: Through an Aegilis deflectable sheath system a Freezor Xtra 3 6 mm cryoablation catheter was introduced into this location. Cryoablation was performed under 3-D electrode anatomic mapping and intracardiac echo guidance with temperatures down to -80°C with continuous monitoring of the AH and HV interval. Pre-excitation and premature atrial contractions were ablated within 10 seconds of the first lesion with prolongation of the HV interval to 58 ms. Three continuous lesions in a freeze thaw freeze cycle were placed each of 240 to 300 seconds duration. Patient was then observed for 30 minutes post ablation with isuprel infusion up to 10 mcg/min. Antegrade and retrograde pacing protocols were performed during this time including Wenkebach cycle lengths. HV interval was 58 ms." Question: Can code 93623 be reported in addition to 93653? Or is code 93623 reserved for pre-ablation drug infusion? Your feedback is greatly appreciated.

Patient was sent to the cath lab with a central line removal and possible surgical intervention. The central line catheter was placed from subclavian vein and ended in the innominate artery. We imaged this to confirm placement. We changed out the central line catheter to a 4 French sheath and used an AngioSeal to close. We then accessed the groin to do an aortic arch to be sure that there was no extravasation. I have reported code 36221. Can we code for the injection through the central line?

Why is the current MUE edit for 92973 equal to 2? That number doesn't seem to fit with coding logic for either reporting that code once for all vessels intervened on, nor does it fit for coding once per coronary territory. I have a case where AngioJet or coronary thrombectomy was utilized during an AMI on the left anterior descending and ramus, so I'm thinking of billing it twice. Thoughts on this MUE?

Can a CT scan can be billed and paid as part of a pre op for a lead extraction - inpatient or outpatient?

Can RNs perform the initial stick for an EVLA and do sclerotherapy themselves under general supervision? Also, is there an NCD to cover EVLA for coumadin patients? NGS is our Medicare Part B administrator for Illinois and does not allow this per LCD25519.

Can you help clarify what CPT code should be used for this new injectable reveal device? There is contrversy over unlisted vs CPT code 33282.

Is it enough to dictate that 6 minutes of fluoroscopy was used to support the use of the code 77001 or 49440? If not, what would be the appropriate documentation? For example, if the dictation stated that the wire was advanced under fluoroscopic guidance, is that enough? Or should the use of the fluoroscopic guidance be matched up with the final placement of the catheter?

What is the appropriate coding to charge out a renal stent along with a renal angiography? Is it appropriate to charge for both or just the stent? Please advise.

Is there a code for FFR performed in a non-coronary vessel - in this case the subclavian artery?

Attempt to access right femoral vein was unsuccessful, left femoral vein and right femoral artery were accessed instead. Guidewire into atrial sheath advanced to ascending aorta, blood gas obtained in ASAO and pullback pressure from ASAO and DSAO. Aortogram performed in proximal descending aorta. Measurements of PDA obtained and decision to close with Amplatzer Ductal Occluder-II. Guidewire placed in venous sheath, advanced across ductus, catheter exchanged over wire and Occluder advanced through delivery catheter until tip of device was at tip of sheath. Aortic disc exposed and pulled back against aortic ampulla. Rest of device then exposed so central pug was contained within PDA, proximal disc against PDA-PA junction. Small residual shunt with good device position. Device released and PA disc reoriented. Pressure obtained from LPA and MPA, significant gradient was found, decided to remove device. 5 mm Snare was inserted but device couldn't be pulled. Changed to 10 mm Snare and device was removed through the sheath.

For the case that follows, I don't think code 61055 is correct (puncture not at the cervical level). I don't think this qualifies as a myelogram (62884). Is it correct to use code 62311 or lumbar puncture 62272? Radiology code 70015. Could you please clarify? "Patient has CSF leak from nose. Procedure: Fluoroscopically-guided lumbar puncture for cisternography. Under fluoroscopic guidance a spinal needle was advanced into the thecal sac at level L3-4; clear CSF return was noted. Omnipaque was instilled under fluoroscopic guidance."

I am not sure on how to code the following: "Right common femoral arterial stick was done. Patient had the Omniflush catheter placed in the mid descending aorta and a descending aortogram. Selective peripheral angiography was done by introducing the catheter other the Glidewire into the origin of the left SGA, and a selective view was obtained of the right lower extremity as well selectively by the same way."

What documentation is required to bill for a post biopsy diagnostic mammogram, providing that biopsy guidance was of different modality? Is a statement documenting only a clip placement enough?