Ask Dr. Z

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?

How would you code a clogged G-tube clearance using soda water with follow-up contrast injection to confirm patency?

I reported code 34805 for revision of a bifurcated endograft with creation of an aorto-uni-iliac graft, and Insurance denied as not performed. Can you advise me on what code this should be and let me know why code 34805 would not be correct? This is an abbreviated version of the note due to the space constraints. "Via the left transfemoral approach utilizing standard technique, 36 mm x 14 mm x 102 mm Endurant aorto-uni-iliac device was introduced. The superior mesenteric artery was utilized as a landing zone to elongate the proximal attachment site. Patient is in chronic renal failure and has no renal function. Both renal arteries will be covered. The graft was deployed without incident. The iliac limb was then created with a 16 mm x 16 mm x 124 mm Endurant iliac limb. This was completed with a 16 mm x 16 mm x 8 2 mm Endurant iliac limb. All attachment zones and overlap zones were dilated with a Compliant balloon catheter. There appeared to be a defect in the AUI device. At this point a 36 mm x 36 mm x 49 mm Endurant aortic cuff was positioned, and it was deployed across the expected location of the graft disruption."

Your February 2014 Q&A answer to the question on sclerotherapy for lymphatic malformation was not to use an unlisted code for this type of embolization in 2014. Would this also apply, for example, to direct access for sclerotherapy (i.e., facial AV malformation - 37799/37242)? Would I also report unlisted code 36299 for direct access if 37242 is to be used?

Would you use code 64640 for a radiofrequency ablation to a third occipital nerve (TON)?

An ultrasound was used in addition to the fluoroscopy. Fluoroscopy is bundled in other codes. Can we bill for the ultrasound? If so, what is the code you would use?

I have a physician dictating angioplasty of a high grade stenosis of the fistula adjacent to the arterial anastomosis. He does not state that he's actually doing the plasty of the arterial anastomosis, just the high grade stenosis adjacent to it. For the angioplasy of the arterial anastomosis (35475), I need the doctor to state that is what was plastied as opposed to a stenosis proximal to the arterial anastomosis or adjacent as this one is dictated... am I correct?

When a patient is in for a planned staged intervention on a chronic total occlusion, and the physician is unable to cross with a wire after a prolonged attempt, do you recommend coding 92943-74 or 92920-74? The reason I’m asking is in the past you’ve recommended using the lowest level intervention when it’s aborted for this reason. The code for a chronic total occlusion is weighted much higher for the facility, the same as a stent or atherectomy. Should we use the lower weighted intervention code for an angioplasty instead?

This is probably a silly question, but I am billing my first venous stent codes for the year, and I am getting an NCCI edit when I am billing out codes 37238 and 37239. The edit is telling me that I need a -59 modifier on code 37238. Why is that, when code 37238 is my primary stent code?

Our physician did a diagnostic left heart catheterization with left ventriculography, coronary artery angios, and bypass graft angios. He then did an angioplasty at the anastomosis of the LIMA graft to the distal LAD. Following this, he placed a drug eluting stent in the circumflex artery and performed a kissing balloon angioplasty of the proximal circumflex and the proximal LAD. I am thinking of reporting codes C9600-LC, 92937-LD, and 93459-59. Could I also report code 92921-LD for the proximal LAD kissing balloon angioplasty since it was via the native arteries and not through the bypass graft?

What codes would you recommend for endovascular reconstruction of the aorto-bi-iliac vessels for occlusive disease? Exact same technique as an AAA repair, but not for aneurysm. Bilateral cutdowns. Bifurcated endoprosthesis deployed in aorta and bilateral iliacs, and iliac extender. Would you recommend unlisted? Or code it with the new stent codes (37236/37237)? According to the CPT Codebook, 348XX codes are exclusive to aneurysm repair.

Is a non-STEMI equal to an acute MI? The last response seen on this website was in January 2013 (question ID #4429).

I am hoping you would be able to help me. I am trying to get clarification on MCOT codes 93229 and 93228. The practice bought the MCOTs from Cardionet. They also pay Cardionet a fee (not sure if it is monthly or per monitor usage). Cardionet is telling the doctors to report both codes 93229 and 93228. Also, would it make a difference if they bought them or rented them?

For a left or right heart catheterization, my physician is currently documenting the following: "Access was obtained from the right femoral artery, and a left heart catheterization was done using standard guide wire approach using standard Judkins catheters." For correct coding guidelines, should the physician be more specific in stating where the catheter goes? Such as stating the complete path of the catheter through the femoral, iliac, aorta, and over the arch into the left marginal artery? Would this have anything to do with ICD-10 -PCS coming?

"Patient with recurrect CVAs. Hypercoagulable workup negative, TEE with postive bubble study, thought to have PFO. Presents for closure. PROCEDURE: 10 French venous sheath was placed in left femoral vein, and 8 French Lamp catheter was advanced with wire into SVC. Bolton catheter was used, and intra-atrial septum was interrogated with ICE catheter. We were unable to cross septum with multiple catheters. Lamp catheter was advanced and demonstrated tenting. Agitated bubble study x 3, 2x with Valsalva maneuver, and we saw no bubbles across septum. Detailed interrogation of septum showed no evidence of PFO. Agitated bubble study negative, and septum couldn't be crossed. Procedure was discontinued. Impression: No intra-atrial septal defect, no PFO identifed."

Not sure how to code 93462-74 and 93662, but these are add-on codes with no base code. No pressures were taken. What are your suggestions on how to code?

CT myelogram was performed with contrast was injected via an already existing lumbar drainage. Would we code this by using code 62284 with a -52 modifier? "Using the patient's existing lumbar drain, the side port was accessed. 15 cc of Omnipaque 180 mg contrast was administered intrathecally through the spinal needle. There was no fluoroscopically noted extravasation during the contrast injection, and the needle was removed. Multiple fluoroscopic radiographic images were obtained, after the table was tilted with the patient's head moving up and the feet down, to keep the contrast in the lumbar spine and define the inferior margin of the thecal sac."

We have a discussion going on regarding the coding of other ultrasound-guided procedures done at the same time as 19083. Can code 76942-59 be used for the other ultrasound-guided procedures (i.e., 38505, 19000, and 10160)? Some feel that since code 76942 can only be used once per encounter that it is implied with code 19083 and cannot be used. I would appreciate your advice.

Last year, I'm thinking we could have used 0078T/0079T for visceral extensions. But now they have changed to fenestrated graft CPT codes. What can we use now to show a Viabahn graft to repair the celiac during a TEVAR? Could you code this out for us? "Percutaneous endovascular repair of the 5.5 cm descending thoracic aortic aneurysm using a Gore TAG grafts (45 mm x 15 cm and 45 mm x 10 cm x2) placed from the level of the mid descending thoracic aorta to just above the superior mesenteric artery. Snorkel reconstruction/repair of the celiac axis using an 8 mm x 10 cm in length Gore Viabahn graft. Selective cannulation of the celiac axis with selective angiography before after placement of the Gore Viabahn graft. Percutaneous access left brachial artery. Application of the Aptus Endostaple X 4 at the distal attachment site to seal leak at this area."

Given the severity of the OM ISR, the AV circumflex stenosis, and the ostial PDA stenosis, a decision was made to perform an intervention. Through 6F guide, a coronary wire was advanced to the distal AV circumflex. A Sprinter OTW balloon was attempted to be advanced, however was unsuccessful as the AV circumflex was jailed by the previously placed ostial OM1 stent. Attention was then turned to the ostial OM1 ISR. A wire was advanced to the distal OM1. The ISR was dilated using a 3.0 x 10mm Angiosculpt OTW scoring balloon at 14 atm. Post angiography demonstrated an excellent angiographic result with TIMI 3 distal flow. Attention was then turned to the ostial PDA lesion. Through a JR4 6F guide, a coronary wire was advanced to the distal PDA. The ostial PDA lesion was dilated using a Sprinter 2.0 x 12mm OTW balloon at 14 atm for 78 seconds. Post-angiography demonstrated an excellent result with TIMI 3 distal flow in the PDA and minimal residual stenosis. How should this medicare case be coded? 92920 x 2 or 92920 & 92921? 2 consultants-2 different opinions

I do coding and billing at an MRI office, and recently we have had a few patients who have had MRIs done of the lumbar spine. Furthermore, the referring physician(s) have ordered another MRI of the lumbar spine, but this time using the technique of a sagittal STIR sequence imaging. So, how should we code procedurally, the second MRI visit with sagittal STIR, if the same area was scanned one month early?

When an ICD (right ventricular) lead is repositioned, and then the defibrillator is tested, would that be reported with codes 33215 and 93641? Nothing is technically implanted. Although it is a surgical procedure, I did not know if code 93641 would be appropriate.  Code 93462 did not seem appropriate since it is with an invasive procedure. Or, am I looking at an unlisted code?

It is my understanding that billing for contrast injection/evaluation of drains is discouraged in 2014. There are instances in which our doctors evaluate these because of rising bilirubin (biliary), obstruction (urinary, biliary), etc. We are a cancer center; therefore, there is quite often obstruction. In what instances are we allowed to bill for these? This is an example: "Bilateral biliary catheters were removed over a wire and bilateral cholangiograms performed from the skin surface, demonstrating poor opacification of biliary tree, worse on the right than left. Plans were discussed with patient for possible need for a third biliary catheter in future. New bilateral 10 French internal/external biliary catheters were placed over the wires and sutured to the skin." In this example would you bill for these bilateral evaluations? Am I correct in billing codes 47505/74305 twice for these (injection was performed "from the skin surface")? There are also times when a cholangiogram is done in order to determine whether internal/external drain can be internalized. Would this also justify?

Is it okay to use code 35571 for distal bypass graft to dorsalis pedis artery using cryopreserved saphenous vein? Or should we use code 35671?

Is code 0075T appropriate for transcatheter intrathoracic carotid stent placement when embolic protection is unable to be used? If not, what is the appropriate code?

We are having trouble with how to code for a pocket revision when the pocket is not relocated. It is our understanding that the revision is bundled into the placement or replacement of the pacemaker/AICD. What do we code if all that is performed is a revision of the pocket?

Access via right common femoral artery, descending aortogram (75630-59) then selective angiogram of contralateral popliteal artery. Decision made to intervene on SFA in-stent restenosis & to open up PT lesion. Attempted to cross PT lesion with a wire with support from an 0.018 Quick Cross catheter then a TruePath device but was unable. Sheath pulled back to LT CFA, then 6.0x150mm Savvy balloon inflated to 10 ATM in SFA for 1 min in stent w/excellent results. 37224-LT assigned. CPT Assistant, Oct 2011 p9, 11 LRevascularization of lower extremities & associated catheterization, advises a higher-level cath can be reported additionally w/-59. Although both are 3rd level selectivity, tibial/peroneal territory is further advancement than SFA in femoral/popliteal territory. Can we report 36247-59 for the cath placement in the PT?

"Diagnosis of left arm pain. Femoral artery cannulated. Selective left subclavian arteriogram done. Results of left subclavian angiography show 99% stenosis beyond the origin of the LIMA. Intervention was done on this, balloon with angioplasty, and then a stent was placed." Is code 36215 with 75710 included in the stent placement of 37236?

Congenital heart catheterization...."There was important pulmonary vein desaturation in the right and left pulmonary veins. I placed a wire into the left upper pulmonary vein. I test occluded the defect with a 10 mm x 2 mm Tyshak II balloon. I measured the arterial saturation, which was unchanged. There is no improvement in her pulse oximetry despite complete occlusion by TEE. Could not demonstrate that a reasonable benefit would be achieved with device closure."

When a patient arrives with an abnormality in the breast, and an aspiration is attempted and no fluid is obtained, and then the procedure is immediately switched to a core biopsy, the attempted cyst aspiration is not billed... am I correct (i.e., the code would be 19083)? The second part of the question is when a patient comes in and the cyst aspiration fails to acquire any fluid, but there is no other intervention performed, the cyst aspiration IS charged... am I correct [i.e., 76942 (ultrasound-guided) and 19000]?

The doctor did a FEVAR (with the graft covering the entire abdominal aorta) with placement of stents into bilateral renals and bilateral femoral exposure. One side was inserted through the "scallop" and the other through the fenestration. Is this reported with code 34846? Or with codes 34845 and 37236?

Please explain when to code for catheter placement when diagnostic angiography is done followed by an intervention, such as angioplasty/stent in the lower extremities. The procedure today contained the following: "Catheter inserted in left common femoral (contrast injected here), then placed in the distal aorta with angiography and repositioned in right superficial femoral artery with angiography, and then repositioned in the right poplitieal artery with angiography. Then a catheter was inserted in the left common femoral artery with angioplasty of the left posterior tibial artery (same leg)." Should code 36247 have been reported?

Also, is the following still true for 2014 (CPT Assistant July 2011): Code catheter placement codes when diagnostic angiography performed at the same time as the intervention(s) requires a higher degree of selectivity than does the intervention." If so, can you provide an example? What should I look for regarding coding catheter placement with lower extremity angiography/intervention (for example, code when diagnostic angiogram is through a separate access)?

How do you know which types of contrast are chargeable? I've been told that oral/rectal contrast is intergral to the study and the charge for the contrast is included in the charge for the study. They also do not charge for myelogram and arthrogram contrast.

In Changes in the NCCI Manual for 2012 it is noted you longer recommend reporting temporary pacemaker insertion during procedures from 33202-33249 or 93600-93662. Previously we were advised to report 33210-59 if patient was pacemaker-dependent. Can we no longer report this with a generator replacement?

I have a question on new code 37236. The surgeon did a selective placement of each renal artery. Due to stenosis he then placed stents in each renal artery. Is it to correct to report codes 37236, 36252, 37237, 36245-LT, and 36245-RT?

"Patient with congenital VSD is brought to cath lab for transcatheter VSD closure. They are unable to properly place the device, and the device and catheters are removed. They then make a small thoracotomy incision and place a sheath through the RV and deploy the closure device from there. Sheath is removed, and the RV and thoracotomy incisions are closed." Would this be reported with code 33999 (unlisted cardiac surgery), or could it be reported using code 33681 (closure, VSD with/without patch)?

Does code 37241 replace your previous recommendation for direct puncture access and treatment of lymphatic/vascular malformations? (Previous recommendation: "We recommend codes 76496, 36299, and 37799 for direct puncture access and treatment of lymphatic/vascular malformations as described here, regardless as to in the face, tongue, arm, or foot. Pricing will be based on complexity and the report.")

Would you report code 37186 twice if clots noted as rescue but documented in femoral and common iliac? What about common iliac and external iliac? I believe this code should be charged once per extremity.

Are codes 93451, 37211-50, and 36014-50 correct for the following procedure? (Patient had diagnostic CT priot to this procedure.)

"A balloon-tipped Swan-Ganz catheter was advanced serially through the right heart chambers (pressures were measured) and was then advanced up into the right main pulmonary artery into the wedge position where pulmonary wedge pressure was measured. Another wire was advanced through the catheter lumen and advanced into the mid lobe of the right pulmonary artery. Another wire was able to be selectively directed into the left main pulmonary artery and the left mid branch. It was used to perform selective angiogram of the main pulmonary artery. This catheter was removed. The 12 cm long EKOS catheters were then advanced along each of the two V-18 wires and positioned carefully with their proximal infusion edge being above the level of the pulmonic valve. Following positioning, the V-18 wires were removed and replaced with the inner core wires of the EKOS catheters to provide ultrasonic drug delivery. The catheters were then sutured in place and connected appropriately to the infusion devices. Thrombolytic infusion was initiated per protocol."

Is a mammogram done after a breast biopsy (19081-19086) or breast localization (19281-19288) separately reportable? Or is it included in the new codes?

"Thirty minutes prior to the procedure, I placed 2 mg of tissue plasminogen activator into the graft. This was allowed to dell. We then accessed the graft initially near the arterial limb, but I could not be sure if I was in. Therefore, I went further distally and accessed antegrade towards the venous limb. We were able to successfully place a 6 French sheath. I was able to aspirate thrombus. Imaging revealed a high grade stenosis at the saphenofemoral junction and the previously stented area. We then treated the outflow with a 7 x 40 mm balloon. An arterial sheath was placed in the opposite direction near the same area, and a wire was able to be advanced up into the left external iliac artery through the common femoral artery. We then treated the first segment of the arterial limb of the graft with a 7 x 40 mm Dorado balloon. Finding stenosis at saphenofemeral junction, proximal portion of venous outflow and first segment of the AV graft near the arterial anastomosis." I reported this with codes 36870, 372220, 35476, 75978, 36147, and 36148.  Am I correct?

I have two questions on the following case. The physician performed imaging of the cervical carotid and cerebral imaging from a cervical carotid catheter position. He then advanced the catheter into the MCA (no imaging) and initiated tPA infusion over a period of 2.5 hrs. Since we no longer have code 37201, would this infusion be reported with code 37799? And since there was no imaging of the MCA, would you report the highest catheterization (code 36224)?

For services of 2014, what is the suggested code for the Lariat suture of the atrial appendage, transcatheter?

With the new drain codes I am confused on why and when would we use code 75989 or 77012 with 10022 versus 10030, 49405-49407?

I received the following statement from a cath lab director: "What I saw about injections integral to a procedure is that for cardiac cath, the only injections integral to the procedure are the basic sedations, which we don’t charge for. Anything else such as NTG given intracoronary, metopralol IV, Integrillin bolus, and then infusion are not integral to every case. Those are very specific instances and in my mind it seems we should be able to charge for them." My feeling is that separate billing for the administration of these drugs with code 96374 or 96365 would not be appropriate when administered during the course of a cardiac cath or a coronary intervention due to well established NCCI bundling edits. The reason why I say that is that the cardiac cath/coronary intervention would not be considered complete or performed properly on a patient without the performance of these infusions, therefore integral to the main procedure. Is this take more conservative than it should be? Do you agree with it, or is there another code that should be considered?

When an iliac stent (37221) is coded outside the treatment zone when doing a AAA endograft (34802), is the catheter (36200) and open cutdown (34812) bundled on that side? My final codes are (not adding my co-surgeon modifier): 34802, 34812-59 (no bilateral modifier due to one side is bundled), 37221-59, 36200-59 (no bilateral modifier due to one side is bundled), and 75952. I am getting contradicting answers from the resources I have.

Are you aware of a CPT code we can bill for putting in a conduit on the axillary artery for Impella placement? Or should we bill an unlisted code?