Ask Dr. Z

Code G0365 confuses me. Code 93971 is a complete upper or lower extremity study. For code G0365 to be used on the same day it has to be a different site. That would have to be a different extremity, correct? It says code G0365 may only be utilized in patients who have not had a prior hemodialysis access prosthetic graft or autogenous fistula and is limited to two times a year. Then it says, if code G0365 is performed on the same date of service as 93990, append modifer -59 to code G0365. Does the second statement mean that if the graft/fistula becomes unusable then the first statement does not apply and code G0365 can be used on a site away from the graft?

Thank you in advance for your help: Access right femoral artery unsuccessful. Left femoral artery entered percutaneously & sheath placed. Cath inserted into arterial sheath advanced to systemic ventricle with guidewire. Oximetry & blood gas obtained from descending aorta. Pressures obtained from descending & ascending aorta, left ventricle. Thoracic aortogram performed cath removed. Cath inserted into arterial sheath advanced to mid-thoracic aorta. Visualize collateral arteries. Intercostal artery angiogram performed. Transit cath inserted & advanced to lower left collateral artery. Tornado coils injected through transit cath, transit cath removed. Visipaque used to visualize higher collateral artery. Transit cath advanced over glidewire into second intercostal artery, coils injected through transit cath, transit cath & glidewire removed. Cath & guidewire advanced to mid-thoracic aorta. Middle left collateral artery engaged, cath recoiled. Artery reentered, no flow, descending thoracic aortogram performed.

We have a patient who was scheduled for a cardiac ablation. The EPS catheters were inserted; however, when they got to the IVC they were unable to advance further. Imaging was done of the IVC, which showed occlusion. At this point, the procedure was cancelled. Do you recommend coding the ablation procedure with a -74 modifier (93653-74), or do you feel it would be more appropriate to code the venous catheterization with IVC imaging only? I'm not sure if what was done is enough to justify coding an attempted procedure.

These cases still confuse me. Patient had a dual pacemaker and right ventricular lead replaced with a biventricular ICD with left ventricle lead. It's the replacing of the generator that throws me off because we are replacing a pacemaker with an ICD.

What is the appropriate DOS that shoud be used when billing for the interpretation/report of a diagnostic test (when the interpretation/report are done on a differant date than the diagnostic test itself)? Would you use the date the test was performed or the date the physician did the interpretation/report?

Our patient had bilateral tPA infusion catheters placed in each radial artery for frostbite in thumbs and fingers. On the subsequent day, follow-up angiography was done through each catheter. The catheter in the right arm was removed, as flow had improved. The catheter in the left arm was exchanged and tPA continued with hopes of improvement in flow to the digits in this hand. The plan is to return in the morning for another follow-up. I get edits if I try to put code 37213 for the left arm and 37214 for the right arm. What are your thoughts on how to charge this bilateral follow-up/cessation of the tPA infusion?

When billing for non-selective injection of the ileofemoral system during cardiac catheterization, Medicare recognizes code G0278. For carriers that do not accept this code for this service, can we bill code 75710 or should we not bill for this service at all?

How would you bill for ligation of axillary vein and its tributaries to control bleeding from a gunshot wound?

Procedure in detail: Patient's right anterolateral thoracotomy generously exposed the third portion of the axilla and the axillary artery and vein. Myriad tributaries and the axillary vein itself were lacerated, both by direct impact and cavitation. Serial Prolene 4-0 sutures over sewed, ligated the venous tributaries, as well as the anteromedial wall of the axillary vein itself. Copious irrigation was used. Hæmostasis was achieved, though the pectoral muscles (minor and major) were injured from the GSW blast. The axillary artery was palpated, and no overt injury was noted. Closure is under the ægis of Dr. X.

For place of service 11 (doctors office) can we bill code Q9967 (contrast material) when we are performing a procedure such as fistula angioplasty, fistula angiogram, etc.? And, if we can, are there any Stark rules we should be aware of?

The physician performed a TEVAR with coverage of left subclavian artery (open exposure to left brachial and right CFA) with an "added iCast stent in the left subclavian to achieve nice Snorkel technique hybrid type repair". No detail other than this sentence. "T" codes are gone, but they were for renal Snorkel. Is there a code for a subclavian Snorkel, or is it included in the "coverage of subclavian"?

The physician here wants to charge for selection of third level vessel on the second day of thrombolysis. From what I am reading, catheter repositioning or exchange of previous placed intravascular is included. An example of dictation is as follows: "There is apparently a stenosis in the proximal anastomosis site probably that is the culprit causing the shutdown of the graft. There is still a decent amount of thrombus also in the anterior tibial artery, which is her main runoff, and there is a lot of thrombus in that artery, so we decided to do thrombolysis further into that artery. I was able to pull the catheter from the peroneal artery, which was a donor before, and then reselect the anterior tibial artery. Then we changed a new catheter and pushed the catheter into the artery, and we could not push further, just to the mid calf, so we then placed an infusion wire over that catheter and into the distal end of the anterior tibial artery. We could not do thrombolysis again today, so we are going to take patient back to check."

During a shoulder arthrogram, I understand that you report code 73040 if images were taken before and after injection. If only spot films were taken, you would use code 77002. Can you tell me if it matters what kind of images were taken? I am including a clean copy of the report for your review. "Exam: Right shoulder arthrogram. History: Right pain since October. History of prior rotator cuff tear. Scout images of the right shoulder were obtained. An appropriate site for skin entry was chosen, marked, prepped, draped, and anesthetized in the usual sterile fashion. The right shoulder joint was entered using a 22 gauge spinal needle and 9 mL of the standard mixture of non-iconic intravenous contrast and gadolinum were injected. The needle was withdrawn, bandaid applied, and no complications were noted. Contrast is suspected in the subacromial/subdeltoid bursa, and the appearance is certainly worrisome for and compatible with rotator cuff tear. 3.5 minutes of total fluoroscopy time was used. The patient was sent to ME in stable and satisfactory condition."

In your 2014 Interventional Radiology Coding Reference, you instruct to code by lesions not by the breasts - if biopsy was performed in right and left breast (using the same guidance modality) to code using a primary code with an add on code. It's conflicting with 2014 CPT Codebook, which instructs you to use one code (the primary one) with modifier -50. Thank you for your help in advance. 

I have asked other coders and no one really can give me a clear answer on this... A patient develops a seroma, and an incision is made and it's drained, then the decision is made to excise the capsule. Since it is connected to the artery normally, it is more complex than just an incision and drainage. So what would you code the excision as?

From a claims review perspective for interventional radiology procedures that include angiography in the CPT description, would the procedure note include documentation to support billing a diagnostic angiography procedure? It's not always clear, especially if there is no prior angiography, change in the patient's condition, etc. referred to in the note and could result in non-reimbursement of a code (which is unfortunate considering the work that was done).

Can you help with coding for the Snorkel repair in 2013?

"DX: infrarenal abdominal aortic aneurysm. 2. L & R common iliac artery aneurysm 1. Percutaneous endovascular repair of the abdominal aortic aneurysm as well as the common iliac artery aneurysms using the Endologix AFX graft (main graft 22 mm x 120 mm x 16 mm in diameter for both limbs with suprarenal extension measuring 28 mm x 75 mm and a second suprarenal extension placed for proximal endoleak measuring 28 mm x 75 mm. 2. Left limb extension 16 mm x 75 mm and right limb extension 20 mm x 120 mm. 3. Snorkel repair of left hypogastric artery using an 8 mm x 15-mm Gore Viabahn covered stent...The left hypogastric artery was then selectively cannulated using a crossover sheath followed by deployment of an 8-mm x 15-mm Gore Viabahn covered stent in this area and a left-sided limb extension was then placed measuring 16 mm x 75 mm. On the right side, a right-sided limb extension was then done using a 20 mm x 120 mm in length covered stent sealing above the right hypogastric artery. Balloon angioplasty was then perfo..."

Is a mammogram separately reimbursed when performed either before or after the surgical procedure when using the new CPT code 19081?

Would you report the following with code 50395 or codes 74475/50392/74480/50393? "Percutaneous access for PCNL contrast. Air was injected, and spot film imaging was performed as a percutaneous antegrade pyelogram. A 5 French Bernstein catheter was advanced into the distal ureter. Over the Amplatz Extra Stiff wire, a 10.2 French Dawson Mueller was placed."

I'm unsure on what to code for the chemical thrombectomy in the following case?  "Using SL10 and SynchroSoft, the left posterior communicating artery aneurysm was accessed, and multiple coils were deployed successfully, and the purpose was to partially thrombose the aneurysm. Then using Marksman and SynchroSoft, the pipeline stent was deployed successfully across the aneurysm and below the bifurcation. This pipeline measured 4.0 x 18. At the final deployment, we noted that at the middle of the stent, it was narrowed as a sand hourglass. We did multiple attempts to open this stent; however, we were unsuccessful. At one point, the ICA was completely occluded and that was for only about 30 minutes to 40 minutes. We were able to finally use a balloon and were able to angioplasty the stent and open it up completely. At the end, the aneurysm was at a stagnant flow, and there was filling of both the ACA and MCA as a baseline. There was no extravasation except for a small fistula created between the carotid and the cavernous sinus. There was also no hyperemia or pathologies noted."

I have a radiologist who has told me whenever he does a biopsy of the thyroid it is always core; however, he never dictates "core" in his reports... he always just says "tissue". Pathology from the hospital always says FNA. So my question is, do I report code 60100 because that's how he instructed me to code, or do I go with the pathology and report code 10022?

When we do a congenital right and left retro catheterization (93531) and take sats in the LV, then later in the case they go across the ASD to the LA (and don't take sats), but go on into the pulmonary veins for pressures or angio, how do you code the catheterization???  With code 93531 or 93533? Is going across the septum for any reason cause to change to code 93533?

How would you code a CT-guided breast biopsy? The patient was an inpatient and unable to go into MRI scanner, and this radiologist prefers CT guidance over ultrasound. I am at a loss.

I know I asked you previously about the Baylis Power Wire. The question of the use of code 36475 for these upper extremity (subclavian primarily) cases has come up. Is there any recent data that restricts the use of code 36475 to the greater saphenous vein or its branches (as this has been the most common site)? Would the use of the Baylis Power Wire qualify these cases as an RF ablation?

Is it appropriate to report codes 34111 and 34101 when two separate incisions are made, but there was only thrombus in the brachial artery? The report states the following: "Brachial artery was opened transversely at the site of catheterization. A thrombus was present. This was thrombectomized with a 4 Fogerty catheter. Several passes were made and an excellent inflow obtained. Fogarty catheter was then passed down distally with further thrombus returned. The transverse arteriotomy was closed, and clamps were removed. At this time, distal dissection was carried along the brachial artery down to the orgin of the radial and ulnar arteries, which were encircled with vessel loops. The brachial vessels were controlled with clamps. A transverse arteriotomy was made in the brachial artery proximal to the takeoff of the forearm vessels. A 3 Fogarty was then passed down the radial and ulnar arteries. No significant further thrombus was removed."

We have a vascular surgeon who wants to start performing and billing ultrasound guidance (76937) for every patient. He said it is a clinical decision he made based on quality data from the VSGNE. My question is, can he routinely do this, or does it need to be based on the patient's condition? If he can, is there any special documentation that needs to be done?

Please tell me which codes you recommend for this procedure that was performed in 2013.

"PROCEDURE:Ultrasound and fluoroscopically-guided sclerosis of a venolymphatic malformation in the subcutaneous tissues of the right buttock. CLINICAL HISTORY:  Female with painful subcutaneous venolymphatic malformation in the subcutaneous tissues of the right buttock. TECHNICAL DESCRIPTION: The patient was brought to interventional radiology and positioned prone on the fluoroscopy table. The right buttock was sterilely prepped and draped. Under ultrasound guidance, the venolymphatic malformation was accessed with a 25 gauge needle. Contrast was injected through the needle to verify positioning within the malformation. Approximately 3 mL of Sotradecol foam (four parts 3% Sotradecol, four parts air, one part lipiodol) was injected into the malformation under intermittent fluoroscopic visualization. This was repeated at two additional sites of the malformation. Needles were removed from the patient. Hemostasis was achieved with manual compression."

Patient had a stent intervention in the right coronary and then aspiration thrombectomy in the PDA. Should the unlisted code be assigned for the aspiration thrombectomy, and if so, do we use a modifier for this?

The 2014 version of your Diagnostic & Interventional Cardiovascular Coding Reference it says (page 526, #3): "There is no code at this time to report 3D echocardiography. When 3D echocardiography is performed for medically indicated reasons and requested by the treating physician, report code 76376 or 76377 in addition to the echocardiogram code depending on whether an independent workstation is utilized for the 3D rendering."  Then page 557 indicates the following: "10. Do not report 3D reconstruction codes separately (76376 or 76377). 3D reconstruction is included in the basic procedure codes." I am billing for a diagnostic echo, and the above two statements seem to be contradictory. Is the second statement referring to surgical procedure vs. diagnostic procedures? Is code 76377 appropriate to bill with a diagnostic echo when medical necessity is documented? 

Patient scheduled for a pocket revision, but the day of the procedure only two superficial skin lesions near the pacemaker incision were removed and placed in Formalin. What should the hospital code?

I have something different to code that I have not come across before - a Methylergonovine injection into the RCA during a heart catheterization. Is this separately coded? And, if so, what would the code be? I have looked everywhere for this and the only thing that I found was that you should not report code 37202 or 93463 for injection of drugs into the coronary arteries. Note states: "Methergonovine challenge to the right coronary artery in view of the patient's persistent symptoms and unchanged anatomy decided to continue with a metahemoglobin challenge to the right coronary artery. Methergonovine was given in three-minute intervals, initially at 0.05 mg up to 0.15 mg with presence of angina, as well as diffuse coronary spasm of about 70% to 80% stenosis, especially distally in the posterior descending artery and posterior left ventricular branches."

This is a follow-up to your question ID# 5395. I thought I could report a primary stent code 37236 for each side (one was left renal and one was right renal)... thoughts?

With regards to Question ID #5330, we have a similar case with balloon inflation throughout the graft across the anastomosis to the right external iliac vein, with stent placement across the venous anastomosis into the venous limb. In #5330, you agreed with codes 36147, 37221, which is an arterial stent placement. I keep coming to code 37238, but it excludes lower extremity. What code will be used for iliac venous anastomosis stent placement?

My radiologist wants to report both codes 49406 and 49803 for this procedure.  "The skin overlying a large collection of free fluid was marked and prepped and draped in the usual sterile fashion. A paracentesis needle was advanced into the collection with ultrasound guidance, and fluid return was obtained. Fluid was aspirated and sent for evaluation. The needle was removed. A 0.35 wire was advanced into the fluid. An 8.5 French pigtail drainage catheter was passed over the wire. The catheter was secured and connected to drainage bag. The patient tolerated the procedure well without immediate complication." Although they do not hit an NCCI edit, my gut is telling me that without documentation of a separate percutaneous puncture site I would not be justified in billing for both procedures. What are your thoughts? I feel uncomfortable coding both because the needle or catheter is removed at the completion of 49083, and the way this report is documented I do not see two separate procedures but just the placement of the drainage catheter with drainage of fluid.

"Pre-procedural planning was discussed in detail with the patient prior to initiation of the localization and injection procedure. No pertinent allergies are reported. Lesion localization was performed following procedural timeout with CT scanning of the patient in the prone posistion. 1% lidocaine was infiltrated into the subcutaneous tissues following skin cleansing with Betadine x3. A 22 gauge spinal needle guiding needle was advanced into the left S1 neuroforamen. Extraluminal extra thecal placement was confirmed with a small amount of Isovue 200 A 1:1 solution of 0.75 percent Marcaine, and Celestone solution was then administered. No procedural complications were encountered."  I was not sure if this would still be reported with code 27096...or possibly 62319/64483?

I noticed in your 2014 Interventional Radiology Coding Reference, page 261, coding instructions #8, it says, "Selective catheter placement and imaging are separately billable."  The cervicocerbral angiography codes include the catheter placement, so the catheter placement would not be reported, correct?

The IRs are recently using the Endologix AFX device, but dictation is very poor, making it difficult to decide if I should be using codes 34804/34825 or 34845. I am leaning towards code 34845 because, in their reports, they state they are placing the main body device and then placing a proximal device in the infrarenal location without comprising the renal arteries.

A report for a UGI stated: "A normal swallowing mechanism was noted with free passage of barium through the esophagus and into stomach. There is a small hiatal hernia with trace gastroesophageal reflux. The stomach is distensible throughout. Visualized gas mucosal was unremarkable." Is this enough documentation to support code 74246 for a double contrast UGI? I was told the "visualized gas mucosal" indicates the air contrast.

What codes to apply for CT-guided 14 French pigtail placement in remnant stomach that is distended ten years post gastric bypass? Yes, we would report code 75989, but what other code(s) would be appropriate?

"Procedures performed: Bilateral groin cutdown with common femoral vein exposure. Extensive left  common femoral vein endovenectomy followed by patch angioplasty. Focal right common femoral vein endovenectomy with primary closure. Kissing stents from IVC into the iliac system... Left groin venotomy was made and extended. An extensive amount of scarring was saline(?) as typical of chronic thromboses with recanalization and anatomy was seen. Extensive endarterectomy of the common femoral into the profunda and also the femoral vein and distal external iliac vein was performed. A bovine pericardial patch angioplasty with 6-0 prolene running suture was performed." We were unsure if open thrombectomy code 34421 would be appropriate in this case without findings or removal of thrombus. Is the reference to the scarring typical of chronic thromboses sufficient? We were unable to locate a venous equivalent to an endarterectomy. Your guidance is greatly appreciated.

I may be overthinking this, but I need your expertise. Patient presented for intervention for a pseudoaneurysm within the arterial end of an upper extremity dialysis AVG. In addition, he had 70% stenosis in the venous outflow. Balloon angioplasty of the venous outflow and stent of the arterial pseudoaneurysm were performed, two distinct locations but within one graft. My inclination is to only code the stent, as PTA is bundled into stent placement and the AVG is considered one vessel. Is this correct, or may I separately code for the PTA?

I have had two situations with procedure (93458) where the MD has gotten radial access, advanced to the coronaries, and was unable to select them. The other case he was able to select the left, but not the right, coronary artery. Both changed their approach to femoral and were able to complete the procedure. Are these coded differently with the second access site? Since both times the catheter was advance beyond the access site?

When coding a bilateral L4 lumbar artery embolization, can I report code 37242 twice?

Our end coder, Code Correct, is advising that code G0275 has been deleted for 2014, but that G0278 is still active. Is it true? And if so, is MCR accepting any other code? I could only find a vague reference to it on MCR under Part A.

I am looking for info on if you use an additional code (unlisted or whatever) to report 3D tomosynthesis for a mammogram. Medicare just gave their opinion about a month ago, that said they cover 3D mammogram, but there is not a separate code, so hospitals should report it just like a 2D mammogram. I am hoping that Dr. Z has commented on that ruling by Medicare. 

In our pediatric electrophysiology studies, an assistant physician is always present. This physician helps with real-time interpretation of the intracardiac electrograms to help with mapping. They help with determining where to place the catheters for mapping, as well as localizing the accessory pathway for ablation. By having an attending physician assisting with the mapping, this helps reduce anesthesia time by more efficiently identifying subtle signals that determine where to perform the ablation. They also help to monitor for any possible complications during the ablation, such as complete heart block. In pediatric electrophysiology, since the hearts are smaller than adult patients, we are more careful with number of burns that are placed, because they can have more harmful consequences. The assisting physician uses his/her expertise to help determine the best site of ablation and, therefore, minimizes the number of burns needed for a successful ablation. It seems to me this is a dual surgeon case. How would this be coded?

Presacral fluid drainage via transgluteal approach using a 18 gauge Yueh needle. Which code is appropriate - 10030 or 49406?

Can we bill the PA angiogram (93568) if done as a follow-up to verify the occluder is in the appropriate position after a PDA closure? My concern is that this is a follow-up, and a PA angiogram is not done prior to device placement.

At our facility, the interventional cardiologist routinely performs a diagnostic right heart catheterization with transplant heart biopsy. He documents cardiac output, wedge positioning, etc. What would constitute medically necessary for a diagnostic right heart catheterization when evaluating a transplanted heart and performing a heart biopsy?

Recently our cardiologists have started prophylactically inserting a "permatemp pacemaker" at the end of all TAVR procedures as part of a new guideline (I'm not sure whether this is an internal policy or a new guideline for standard of care on all TAVR). If no significant heart block develops, they are removed later. I feel that we should not bill for prophylactic care and that code 33216, and then the subsequent 33234, should only be billed when the patient is documented as having heart block necessitating the continued pacing after the removal of the pacing wire/balloon used during the TAVR. What are your thoughts?

I am working on a case where the patient has a history of an aortobifemoral bypass with graft. In this surgery the patient has bilateral femoral pseudoaneurysms at the aortofemoral groin anastomosis and the femoral anastomosis. The fem-fem graft is taken down, then the physician repairs the right pseudoaneurysm with an interposition graft and states he completes a similar procedure on the left side. After this there is poor blood flow on the left side. The physician then creates a fem-fem bypass one end, which is on the Darcon graft to repair one of the pseudoaneurysms. He also does multiple thrombectomies, as the patient has prothrombin gene mutation. I know the thrombectomy (34201-50) is bundled. And the aneurysm repair (35141-50) seems to bundle with the bypass (35661). Can I code for the aneurysm repair on the side that the bypass doesn’t terminate on, or is it still bundled?