Ask Dr. Z

With regards to Question ID #5346, when we have a heart catheterization (for instance 93458) with non-selective renal angiograms, and we assign code 75625-52, we get an NCCI edit on 93458 - that a comprehensive code is paired with another CPT component code to trigger OCE edit 0040 plus 75625-52 with edit of code 2 of a code pair with 93458 that would be allowed if an appropriate NCCI modifier were present. Our options are adding a -59 modifier to 75625-52 or not billing for 75625-52. Will code 75625-5952 be our best choice?

This is the description of what was performed. "The Revolution fixation devices were removed. The external portions of the tubes were then relocated to a more lateral position and new fixation devices applied. This was done due to the patient having pain when supine." I am unsure what to code for this. Fluoroscopy images were taken at the beginning of the procedure to assess the internal portion of the tubes, and everything was fine. Would unlisted be the best option?

In the past, the coding recommendation for direct sclerotherapy/embolization of lymphatic malformations was to use unlisted codes. With the new embolization codes for 2014, would code 37241 be a possibility for these procedures? I looked at code 37244, but since that is referring to extravasation, it doesn't appear to match the intent of the sclerotherapy/embolization. Although code 37241 doesn't use the term "lymphatics", both the CPT Codebook and CPT Insiders refer to these embolization codes to be used when "arteries, veins, and lymphatics may all be the target of embolization". Would you recommend continuing to use the unlisted codes or using one of the 2014 codes?

We had a patient for an initial biventricular ICD insertion. The left ventricular lead was a necessity, so when the attempt to place the left ventricular lead failed, the whole procedure was aborted. Nothing was done but the left ventricular lead attempt and a venogram (which I do not usually charge for). I reported code 33225-74. Medicare has rejected it for lack of a primary procedure. How should I have coded this?

I have had inquiries from several physicians regarding the change to codes 33222/33223 that dropped "revision" from the code description. To clarify: in order to report codes 33222/33223, a new incision in a location different from where the current pocket exists would need to be documented, along with moving the implant and any leads. It would not be appropriate to use the relocation codes if all the work is done through the existing pocket, and no new pocket is created.

Is there a code for measuring the blood flow rate using an intravascular heat exchange catheter?

When I attended the seminar in Maryland you stated that there may be a new code added for a synovial cyst rupture. The interventional neuroradiologist I work with is using this code with epidural injections. I am currently using code 22899 (unlisted procedure, spine) to code the synovial cyst rupture.

I have a client wanting to bill code 96374 with -59 modifier as well as G0204, being done at the same time as breast biopsy. "100 cc of isovue 370 was injected using a power injector at a flow rate of 2-3 cc per second. GE senograph essential full field digital system was utilized to perform data acquisition at multiple after contrast administration. Both low energy and subtraction views were reviewed to determine the presence of abnormal contrast enhancement." Then the next paragraph is the biopsy documentation.

In your book you state that an elective cardioversion can be billed separately when done before an EP study. Does this hold true for coronaries too? The CPT Codebook does not have any guidelines to go with a cardioversion. We have a physician who is starting to schedule cardioversion with his cardiac catheterization as routine cases.

Under what circumstances would you use abdominal paracentesis (49083) vs. new drainage code 49406? I know code 49406 is for catheter-based, but I was always under the assumption that code 49083 was appropriate for needle or catheter drainage.

"Patient with malpositioned port cath here for repositioning. Access via right common femoral vein, pigtail cath advanced over Bentson wire into right internal jugular vein and manipulated around misdirected port cath. Common femoral vein accessed a second time with endovascular snare cath and advanced over a wire into right atrium. Bentson wire directed through pigtail and ensnared. Both snare and pigtail cath were withdrawn as a unit, successfully repositioning port cath into right atrium." We assigned code 36597 (repositioning of previously placed CVC under fluoroscopy guidance). Your book advised to also use code 76000 — why, when fluoroscopy is stated as part of code 36597? IR advised that code 36010 is specifically for this type of catheter placement. Dr Z’s coding book gives this example on page 178. "4) The port is checked (36598) showing fibrin sheath. Via separate femoral access, a snare is used to perform fibrin sheath stripping of the catheter tip in the superior vena cava (add 36010, 36595, 75901)."  No fibrin sheath is documented. Please explain what codes are correct on this case.

We need your help with this scenario. Outpatient comes in for biventricular pacemaker generator change. Lead testing for left ventricular lead was 5v. MD states that he "decided to proceed with PM generator change and bring her back for lead revision after proper consent was obtained for possible laser lead extraction." Generator was changed (33229), and the patient left the area only to return later that same day for replacement of the left ventricular lead. Later that day patient returned to cath lab and had a new left ventricular lead inserted (33224). Old lead was capped. Can we bill for each encounter? Can we use a modifier -59 on one of the procedures? What is the correct way to code these two procedures?

Patient presents with microcalcifications at the 6 o'clock position on the left breast. The surgeon performs a stereotactic biopsy with mammotome device, and a post biopsy specimen x-ray is taken. It is my understanding of the new CPT codes for 2014 that this is all included in code 19081. After the specimen x-ray showed only faint microcalcifications, the surgeon repeats the stereotactic biopsy using a larger mammotome needle and places another marker, as well as takes another specimen x-ray. The first marker is removed by the second set of mammotome samplings. Is it correct to report another 19081 with a -59 modifier for this repeat procedure done immediately after the first biopsy of the same area of microcalcifcations?

Patient has a macrocystic venolymphatic malformation in the neck. Drainage catheters were placed in the two largest cysts, and sodium tetradecyl was injected into the cysts through the catheters. Bulb suction was applied, and then doxycycline was injected. The doxycycline was aspirated and the catheters left to suction drainage. What CPT codes would I use, and what is the ICD-9 code for a macrocystic venolymphatic malformation in the neck?

I am seeing a lot of denials for when we bill the OCT (0291T/0292T) concurrent with the heart catheterization codes. Currently there is not an LCD for this procedure other than the "L31832" for Category III codes. The denials are basically stating that "the effectiveness of this service has not been established and is considered to be investigational". I was curious if you had any tips on how to get these paid? Or are they going to continue to deny because the procedure still does not have an LCD specific to these codes?

To use the new drainage codes (e.g., 10030), does the catheter need to be left in? I am trying to understand when code 10160 would be appropriate to use. I have been told that code 10160 is only used when the catheter is removed after the procedure and not left in.

Alcohol embolization of a true venous malformation of lower extremity. Direct needle puncture used to access venous sites. In 2014, code 37241 is used for the embolization of the venous malformation. What about the needle placement? Should we use code 36299? Or is direct puncture included in code 37241?

Coding guidelines state, "Do not use 93503 in conjunction with other diagnostic cardiac catheterization codes." 1) If a Swan is inserted in the cath lab with other diagnostic procedures, but no pressures are taken, am I correct in thinking that we would have to charge code 93451 because of the coding guidelines? 2) If a right heart catheterization is scheduled with a pericardiocentesis, but pericardiocentsis is not completed and the physician dictates the "catheter was sutured in place for subsequent bedside monitoring", should we charge code 93451 based on the fact that a right heart catheterization was done? Or, does the specific dictation for monitoring make it a Swan insertion?

With the new 2014 embolization codes, is code 76377 reported separately from codes 37241-37244 since it is inclusive of all S&I done in the procedure?

When the physician selects the right hepatic artery for a tumor embolization we would no longer report code 36247, correct? Because new embolization code 37243 includes the selection codes now?

I seem to be getting more confused on when it is appropriate to assign code 93623. I thought code 93623 should only be assigned if done prior an ablation. Per question number 5091, it states that code 93623 may be billed if done prior to the ablation or after. I also have another reference that has the following example: "EP performed, catheters in RA, RV for pacing and recording, etc. SVT is induced; ablation for SVT performed. Isoproterinol is administered to determine efficacy of ablation (93653 and 93623)." So, can code 93623 be reported regardless of when it is given, and can it be coded when only to check for efficacy? Does an arrhythmia need to be induced after the initial ablation? Also, if the isuprel infusion further induced an arrhythmia, does an ablation need to be done in order to report code 93623?

We have been reporting code 79445 for the MAA injection for Y-90 planning and code 77778 for the actual Y-90 injection, according to an SIR article written by Dr. Siskin back in 2007. For the CY 2014, the CPT Codebook suggests that code 79445 now be reported for the Y-90 injection. What code would you suggest for the MAA injection performed weeks prior to the Y-90 injection? We are also reporting for the planning, handling, and dosimetry, when applicable.

What can we code for the following?  "A nephrostogram was performed on the left through the existing nephrostomy tube. The left nephrostomy tube was then exchanged over a stiff angle glide wire for a new nephrostomy tube and anchored in place. An antegrade nephrostogram was then performed on the right through the existing nephrostomy tube. The nephrostomy tube was exchanged over a stiff angle glide wire for a new nephrostomy tube. A follow-up nephrostogram shows fistulization from the lower pole calix of the right kidney to small branch of the right renal vein with rapid opacification of the main right renal vein and inferior vena cava. The nephrostomy tube was exchanged over stiff angle glide wire, which was passed down the right ureter. A peel-away sheath was then placed over the wire into the right renal pelvis, and a C1 gliding catheter was advanced into the lower pole calix and in the fistula to the vein. The fistula was then embolized with multiple gelfoam torpedos. A follow-up nephrostogram shows occlusion of the fistula without oppacification of the renal vein. A new nephrostomy tube then placed."

Patient arrives to EP lab for comprehensive SVT ablation (93653). During mapping, the physician decides to do a retrograde Ao root angiogram at level of aortic valve to map coronary arteries in order to possibly ablate a focus. No primary heart catheterization is done. On occasion a coronary angio may be performed, but not always. How would I code the aortogram?

Bilateral uterine fibroid embolization with catheter placements in both uterine arteries and selective right/left internal iliac artery angiograms. We should now be able to report codes 36247 and 75736 with 37243, correct? No longer inclusive like code 37210?

I understand that embolization is based on surgical site, so all embolizations done in AVF would only be billed one time. However for pulmonary AVMs, what is considered the surgical field when multiple lobes are treated? Are the entire lungs considered one surgical field? Per embolization? Any guidance is greatly appreciated.

Based on the report below, my question is as follows: Is an additional angioplasty code used for the "profundus" since it branches off the common femoral? If so, which code? I used codes 37221 (EIA stent), 37224 (fem/pop PTA), 75710-2659 (iliac imaging), and 75774-2659 (SFA imaging).

Access from right. Cross-over to left iliac via omniflush and glide wire. Angiography showed occluded external iliac artery just after internal takeoff. Glide wire passed into SFA. Catheter advanced to SFA, and angio showed patent SFA. Then 0.018 wire placed in SFA and another wire in profunda. Angioplasty was done in SFA, profunda, and left iliac with thrombectomy through the 7 French sheath. This restored flow. A stent was placed in iliac to cover left iliac dissection with slight extravasation at end of procedure treated with reversal of anticoagulation.

The patient had an alcohol ablation with temporary pacemaker. The 2014 code (93583) includes the temporary pacemaker. But what if the temporary pacemaker is in place for 48 hours post procedure? Can we report code 33210-59 then?

Patient has colorectal liver metastases. Yttrium 90 mapping arteriogram performed. Documentation indicates that left gastric artery microcoil embolization performed with post coil embolization arteriogram, right gastric artery embolization with post embolization imaging, medial branch gastroduodenal artery embolization with post embolization imaging, and lateral branch gastoduodenal artery embolization with post imaging are all performed. I am thinking this is one surgical field and would be reported with codes 37204 x 1 and 75898 x 1 (2013 case). The facility wants to report the embolization x 3 for the three separate vessels. Would this be considered one surgical field or more? 

Code 38999 (unlisted CPT due to direct approach) vs. 2014 transcather codes... Code 37244 does not seem to fit lymphatic malformation direct approach embolizations. "Ultrasound-guided needle placement: Ultrasound evaluation showed numerous predominantly microcystic changes in a thicken soft tissues in the submandibular and right facial region and in the tongue base. A few macrocystic changes are present. Under ultrasound guidance, 18 gauge catheters were carefully inserted into multiple areas of the macro and microcystic areas. Percutaneous embolization: 6 ml of 3% sodium tetradecyl sulphate mixed with 10 ml of room air and a foamed emulsion was made. The sclerosant was slowly injected with ultrasound guidance at 6 lymphatic micro and macrocystic malformation sites. Firm manual compression was applied after needle withdrawal for 3 minutes. A small amount of fluid was aspirated prior to the cyst injections."

I just found out that codes J0152/G0275 were deleted 12/31/2013.  What are the replacement codes?

Patient with a femoral artery to femoral vein PTFE loop graft. Three separate PTAs are done - one of a stenosis at the venous anastomosis, one of a stenosis in the venous limb of the graft, and one of a stenosis in the apex of the graft. Vibahn stent is placed to the apex of the graft to cover multiple complex large pseudoaneurysms. I know that I can only code one angioplasty for what was done in the graft (35476, 75978), as this is considered one vessel. Now we have a stent placed in the graft and I need to report code 37238, which would include any angioplasty done in that vessel. So, I now need to drop codes 35476, 75978, correct? Am I figuring this out correctly, or am I way off base?

In this scenario, I'm confused if a true right heart catheterization was done. Impella device inserted as well as a Zoll Icy catheter. After the left heart catheterization, a Swan-Ganz was placed into the left pulmonary artery. Pulmonary artery pressures and wedge pressures were taken. No mention of right heart pressures. When reading the CPT description for right heart catheterization, it states "it may include catheter placements in the right ventricle, right atrium and pulmonary artery." You have to go through the right heart to get to the pulmonary artery, correct? So would this be sufficient to report the combination right heart and left heart catheterization code?

Is there any information regarding reporting code 76499 for a 3D breast mammogram? From a recent Medicare newsletter it stated that only a 2D should be charged since the 3D is part of the 2D; therefore, code 76499 is no longer valid to be used for this procedure. In other words, use G-codes for Medicare and codes 77055-77058 for managed care. Please advise.

Reading through your 2014 Interventional Radiology Coding Reference, you state to use code 37241 for treatment of a true venous malformation (via direct puncture or leg vein access). We are wondering if we can use code 37242 for direct puncture embolization of an AVM or aneurysm, or is it still an unlisted code in 2014?

I need help coding the following scenario. Would you report codes 19000 and 76942? "Ultrasound-directed right breast cyst aspiration HISTORY: Nodule in the upper outer right breast. The patient initially was scheduled for biopsy. The procedure of breast biopsy was explained to the patient; consent was obtained. With the patient in the supine position, the skin overlying the upper outer aspect of the right breast was prepped and draped in the usual sterile fashion. While administering lidocaine, the lesion of interest disappeared completely on ultrasound. Follow-up mammogram showed also that the lesion has disappeared. Lesion is felt to represent a cyst, which was completely drained. IMPRESSION: Cyst drained on its own after being punctured with the lidocaine needle."

If the physician documents "we would have to partially cover the subclavian artery" and in the summary states "all head vessels were patent", and there is no documentation of a carotid-subclavian bypass, would you report code 33880 or 33881?

“Do not code for angioplasty and separate stent in the same site or same vessel in 2014. Angioplasty is bundled in ALL stent placement.”  Is this true for ureteroplasty and insertion of stent in the same site? "Contrast was injected through the previously placed right-sided tube. The tube was removed under fluoroscopy over a coons wire. The catheter and wire were manipulated across the distal ureteral stricture into the neobladder. Intraluminal position was confirmed. Exchange was made for an Amplatz stiff exchange wire. The catheter was removed. Angioplasty of the lesion was performed with  6 mm/4 cm balloon catheter (53899, 74485) and inflated to 15 ATM for 60 seconds. The balloon catheter was removed. A 20 cm/8 French Cook double pigtail ureteral stent was deployed (50393, 74480) from the renal pelvis through the ureter into the neobladder. Impression: Right pyelography confirmed persistent previously documented obstructive distal ureteral stricture. Imaging documents catheterization across the lesion,dilation of the lesion and stenting of the ureter."

1. Dual AVN physiology with inducible AVNRT (very challenging anatomy with probable left-sided involvement successfully resolved after right-sided RF and cryoablation and left-sided RF ablation). 2. Inducible right atrial tachycardia arising from the proximal CS, also successfully mapped and ablated with cryoablation.  Would this be reported with codes 93613, 93621, 93623, and 93653? Would I add code 93657 or 93655? Also, do I need to code for the left-sided mapping? ("Because this was so unusual, and in light of the prior failed ablations, we did perform left-sided mapping.")

I have a case where the physician placed two separate VAC dressings on two separate wounds, same leg, same setting. I thought code 97606 would cover both, but he's thinking it should be x 2. What are your thoughts?

"Procedure: CT-guided percutaneous needle localization abdominal wall. Patient supine. CT localized abdominal wall mass. RUQ prepped and draped, and skin entry site is identified. A 10 cm, 20 G Homer BLN hook wire needle is inserted just superficial to abdominal wall mass to avoid penetration as to prevent further seeding, guided by CT in increments. The hook wire is 0.5 cm superficial to mass and sutured in place. Patient is then transferred to surgery for excision." In 2013 there was a preoperative needle localization wire for the breast (19290). My questions is, is there a CPT code for preoperative placement needle localization wire abdominal wall?

Can you take a look at this one for me? Do codes 77001 and 36584 fit this case? Anything else?

"Superior venacavography and right upper extremity venography via the existing PICC site.  Exchange of existing 6 French PowerPICC line for same. The existing catheter was cut over a wire, and a sheath was placed. A 5 French diagnostic catheter was placed to the level of the axillary vein, and venography was performed. The right internal jugular vein was catheterized as well, and venography was performed. This revealed a widely patent central venous circulation. A new 6 French PowerPICC line was placed over a wire  with its tip residing at the cavoatrial junction. The line was sewn to the skin with 2-0 Ethilon, sterilely dressed, and flushed with sterile saline. Spot and digital subtraction angiography was sent to PACS archive. Total fluoroscopy was 7.4 minutes.  Findings: Normal central venography. No evidence of hemodynamic significant stenosis or thrombus. The right internal jugular venin is patent. No evidence of thrombus in the right upper extremity venography."

I am trying to put together a list for my IR department that contains information regarding occlusive device placement charges. Do you have a list of the procedures that bundle the charges for the placement, as well as a list of procedures where the charge is allowed to be added? The devices have C-codes, so I want to have the appropriate charge on the accounts.

Drainage and catheter placement in hip and/or knee. Should you report code 20610 or 10160 with imaging code?

"On day 1 selective catheterizations of the right vertebral artery, the right internal carotid artery, the left internal carotid artery, and the left vertebral artery. Verapamil is infused into each artery." The following codes were charged: 36224-50, 36226-50, 75896 x 4, and 37202 x 4. The following day the exact same procedures were performed (all four arteries selected and verapamil infused in each artery). Would the same codes be charged that day, or would 75898 x4 be used instead of 36224-50 and 36226-50?

I am reading in your example #2 under the AV shunt interventions chapter. It reads "2) Patient with clotted left leg dialysis graft undergoes cross catheter technique (36147, 36148) with shuntogram (included) and declot utilizing a thrombectomy catheter (36870). An arterial inflow stenosis in the native iliac artery 8 cm proximal to the arterial anastomosis is ballooned (36245, 37220) as is a common iliac vein stenosis (35476, 75978)." my question is concerning the 36245 coded with 37220. Wouldn't 36245 bundled with 37220? I would think that you would only be able to capture 37220 and not the cath placement code. What is your reasoning for add both 36245 and 37220? I have a similar situation AV shunt in lower leg venous outflow stenoses treated with stent deployment. I thought I should code with 36147, 37221.

Is the fistula anastomosis considered an arterial anastomosis or a vein anastomosis? I have been coding a stenosis in the fistula anastomosis (like a brachiocephalic fistula) with codes 35475/75962.

Patient presents with upper arm clotted AV fistula. Antegrade and retrograde punctures were made (36147, 36148). Thrombolysis was performed with tPA followed by balloon maceration (36870). Follow-up imaging demonstrates poor flow in radial artery with small embolus (about 3 inches from anastomosis, but not documented as such). Radial artery was catheterized, and suction thrombectomy was performed (36215 and 37186???). Lower extremity arteriogram was then performed, which shows sluggish flow to hand (75710??). Infusion catheter was inserted half into radial artery and half into fistula for six-hour thrombolysis therapy (37211). My questions are, would you charge for the secondary thrombectomy (36215 and 37186) and consider the extremity angio to the hand to be follow-up imaging? Or, would you consider going after the small embolus as part of the AV fistula thrombectomy but then charge codes 36215 (delete 36148) and 75710 for the diagnostic arteriogram to hand, and then commence with 37211 for arterial thrombolysis? I am thinking codes 36147, 36870, 36215, 75710, and 37211.

"Patient was brought into the EP lab one week status post dual chamber pacemaker insertion with leads due to lead dislodgement. The generator was explanted, the leads were removed, and the wound was closed. A new incision was made superior to the previous one, and a new subcutaneous pocket was formed. Through a percutaneous stick, axillary vein access, an 8 French shealth peel-away sheath was inserted. The two previously explanted bipolar screw in leads were then positioned in the right ventricular septum and right atrium successfully. The generator was connected to the leads and then placed in the pocket with the leads positioned beneath it." The physician wants to call this a pocket revision with a lead repositioning. Since the leads were explanted from the body and reimplanted, does this qualify as a repositioning?

"CFA is accessed. SOS catheter is used to selectively catheterize the LRA. Following review, decision is made to embolize two of the three branches of the left renal artery using ProGreat microcatheter, and coil embolization is performed. Following embolization, the percutaneous neprostomy catheter is removed. During removal of this, the existing double-J was also inadvertently pulled through the tract. Removal of the double-J was not intentional and was accidental."  Would we charge codes 37204/75984 twice? Also, would we charge for the accidental removal of the double-J tube? Not sure what all codes would be valid with this report.