Ask Dr. Z

When a patient is in the EP lab for an ablation, and a coronary angiogram is done (to determine ablation locations so as not to disrupt coronary), the coronary angiogram is performed by a cardiologist during the EP ablation, not by the electrophysiologist who is performing ablation.  Can we charge code 93454?

A patient with liver mets had a tunneled drainage catheter in place for management of ascites. During the first procedure the catheter was flushed, and peritoneal fluid was aspirated. The catheter was left in place. One week later the paracentesis catheter was studied under ultrasound and fluoroscopic guidance. The catheter was found to be encased in a fibrin sheath. A multipurpose catheter and glidewire were used to clear the side-holes in the drainage catheter. The catheter was flushed, drained, and capped. I'm having trouble finding codes for both these situations in the code series for abscess drainage or ascites. Would code 49021 work for the flush and aspiration in the first case? Do I have to use an unlisted code for the fibrin sheath removal in second procedure? Would codes 49424/76080 be used for the study?

We are having a debate in between a couple of us and would like your opinion on this case. Patient comes in with hemochromatosis and hepatocellular carcinoma. MRI shows persistent nodular enhancement with in the right lobe medially. Right CFA approach. Cannulates the celiac, pic. Advances into two right hepatic branches, pic. Both are embolized. Moves to left hep, pic. Moves to right inferior phrenic artery off celiac, pic. Embloizes phrenic artery. The physician cannulates the accessory right hepatic off SMA, pic. We have codes 36246, 36248 x 3, 75726 x 2, 75774 x 5, and 37204/75894. The debate is... are we missing a 36247? And can we not bill code 75898 for follow-up from the embolization?

Patient comes to the cath lab through the ED and the physician performs a diagnostic coronary artery study followed by a stent placement in the right coronary (92928). Then later in the day, the doctor is notified of increasing chest pain, and a bedside echo demonstrates new inferoseptal wall motion abnormality with no effusion, so repeat right coronary angiography is performed with a change noted in RPDA, now complete occlusion; stent placed. Can both diagnostic studies be reported on the same day? I came up with codes 93454-26 and 93454-2676 because the initial diagnostic indicated, “…RCA: large, dominant. 90-95% prox. Small PDA with 50-70% mid… There was TIMI 2 flow into the distal PDA, which in the absence of symptoms, we elect to treat medically. Patient was given multiple IC doses of nitroprusside and nitroglycerin and begun on IV nitro drip.” And, there appears to be a change in clinical status with total occlusion. (Would a -78 modifier be appropriate on the second stent?) What are your thoughts?

How would you code a core biopsy of a sacroiliac joint lesion? MRI showed possible infection. Bone or joint aspirate maybe.

"Mid back was prepped. Expert CT was obtained of the aneurysm sac. Under CT guidance, a 21 gauge needle was used to access the aneurysm. Contrast infused and multiple images angio images obtained. Subsequently, 3 cc of Onyx was infused into the sac as the needle was pulled out. Needles removed." Any help you can provide with codes is appreciated. I believe this would be reported with unlisted code 37799 and 76380 CT? Not transcatheter based for 37204.

For echo (93306), what are the minimum required statement/elements needed to be mentioned or described by the dictating physician in order to code a full study?

In a facility setting, how would the following procedure be coded? "The patient presents with a 10 French Malecot type catheter in a pelvic collection previously shown to be associated with a colocutaneous fistula. Catheter has been connected to a bag with minimal drainage. Aspiration of the catheter yields only 1 cc of serous fluid. The catheter was NOT injected with contrast material or saline. The suture material retaining the catheter is removed. The catheter is advanced out about 2 cm and resutured to the skin under local anesthesia. Total fluoroscopy time 0.6 minutes."

Is there CPT code for use of a Trerotola device used to mechanically clean out a PBD Stent? The IR physicians are using this device to remove occlusive debris.

A question has come up regarding the correct CPT code to use for a second stage brachial vein transposition for dialysis access. Based on the CC for HCPCS directive it appears that code 36832 may be appropriate, but others are suggesting an unlisted code (37799). Could you give your thoughts? Here is the operative report (edited for space): "Procedure: Right brachial vein second stage transposition fistula...Indications: ...Right brachial vein second stage transposition fistula...Procedure in Detail: ...We divided the vein from the previous anastomosis at the antecubital region and tunneled that through the superficial tunnel in the brachial artery that was dissected free. The venogram was then performed demonstrating no evidence of kinking or twisting of the brachial vein, patent axillary vein, subclavian vein, brachiocephalic vein, and superior vena cava. An anastomosis was then performed to the brachial artery with running Prolene suture in an end-to-side fashion."

I had previously submitted the question, if a biopsy and a fiducial placement were performed at the same encounter, could they both be billed. You answered that they COULD both be billed. My compliance department wants to make certain they can both be billed if the biopsy and fiducial marker placement are performed from the same access point with the same needle.

HCPCS code G0275 is inactivated effective 12/31/13. This has previously been used to report non-selective angiography of the kidneys (unilateral or bilateral) at the time of catheterization. I know that if the renal artery(ies) are selectively catheterized, we should use codes 36251-36254. CPT code 75625 (abdominal aortogram) includes non-selective imaging of the renals. However, what code do we report if the MD documents non-selective imaging of the kidneys at the time of cardiac catheterization? Should we use CPT code 75625 since it includes non-selective imaging of the kidneys?

Will your 2014 live seminars discuss ICD-10-CM and/or ICD-10-PCS coding? If so, in how much detail?

2013 Book Errata 2/5/13, pg 412, Coding Instructions, 8., states “According to the Heart Rhythm Society 2013 Coding Guide, ablation of Aflutter after PVI is reported with add-on code 93657.” 3/29/13 Question ID 4737 you advised to use 93656 and 93657 for a pt with both Afib & Aflutter. (OK so far.) 7/2/13, Question ID 4950 you advised “As the physician never documented ‘persistent Afib’ after the PVI, I would not report any additional codes for the additional ablation locations in LT atrium. I would report the Aflutter on the RT side with 93655 currently (as it is not persistent Afib).” (Confusion begins.) 7/9/13 AMA Errata, pg 20, beneath 93657 and 93662, states “Revise the intracardiac electrophysiologic procedures/studies guidelines to: 1) allow reporting code 93622 & 93623 with 93653-93657; 2) remove the terms “treatment of atrial fibrillation”; Where is the term “treatment of atrial fibrillation” being removed from, code 936537? Please clarify when it is appropriate to use 93657 vs 93655 with 93656 for Aflutter ablation after PVI.

My question is regarding the new codes for fenestrated grafts for repair of the visceral aorta. Am I assuming these codes apply to grafts from the manufacturer and ones that are custom made by the surgeon in the OR suite?

With the new embolization code 37242 (arterial embolization) for radioembolization procedures, is it appropriate to also bill for a visceral angiogram (75726)? Should you report code 75726 when performing a mapping pre-procedure for radioembolization?

What will code 75989 be used for in 2014 now that there have been extensive changes to percutaneous drainage in 2014 that include RSI bundling (i.e., 49405-49407)?

I have a question regarding the 2014 NCCI narrative instruction Chapter 9, subsection D, #11, and I would like to get your opinion on what this means for outpatient radiology facilities. It is regarding post procedural mammograms and that there should not be a separate charge reported when the breast procedure is done with mammographic guidance. Does this mean that if the breast procedure (biopsy or needle loc) is done by ultrasound or MRI guidance that a post-procedure mammogram can be reported?

I have a physician who does all of his thyroid biopsies using "capillary technique". In researching this type of procedure, the only thing I was able to find was that this would be considered an FNA. Specimen is actually contained in the needle without using aspiration. Clearly it is not a core biopsy, but would you still consider it an FNA?

The patient has a pacing defibrillator with the tachycardia detections turned off for several years. The underlying rhythm is complete heart block, so he relies on the pacing function, and the device is at elective replacement indicator status. He comes in to get this replaced with a dual chamber pacemaker. Leads are atrial and ventricle, and only the generator was changed. Would you recommend coding it as a downgrade from AICD to pacemaker or as a pacemaker change?

Is there special coding for using RF ablation for recannulization of a CTO in the left subclavian vein? Baylis Power Wire was used. PTA and stent placed after RF ablation performed. Initial access via right groin, second access left arm vessel. I've read the material for the Power Wire, but that does not provide any information for coding. I'm thinking all we can code for is the accesses, possibly the PTA if documentation supports this, and the stent placement.

Initial Question:

We have a physician who does embolizations on the gastroduodenal artery, left gastric artery, and thoracic arteries (normal anatomy), and I was wondering if we could not charge two embolizations since one is above the diaphragm and one is below the diaphragm and in two different coding family sets? I know it is once per surgical field and have heard if you make one puncture it is considered one surgical site, but if you do two different abdominal areas (e.g., liver, pancreas, spleen) it is considered two different surgical sites even though you go through one puncture site. Could you please clarify when charging two would be acceptable billing?

Additional Info Provided Following Inquiry from Dr. Z:

Most of the dx are a primary cancer (rectal, colon, etc.) metastatic to the liver and he says intercostal on the thoracic arteries. It looks like most of them are evualating suitability for Sirtex radioembolization. Please let me know if there is additional information I need to supply; I know nothing is ever black and white in coding.

I've been told that as of 2014 that HCPCS G0275 is being deleted and the replacement code is 75625 (abdominal aortogram). I'm having a hard time believing this, but if it's correct, do I also charge for catheter placement (36200)? And what does the physician need to dictate for reimburse of code 75625 during a catheterization?

I would appreciate clarification in charging aortography followed by:

1) Selective celiac artery catheterization/angiography and non-selective SMA angiography (shot from aorta, description of findings). Would that be reported with codes 36245 x 1 and 75726 x 2? Or, 36245 x 1 and 75726 x 1?

2) Selective celiac artery catheterization/angiography and selective SMA catheterization/angiography. Would that be reported with codes 36245 x 2 and 75726 x 2?

3) Considering either of the above two scenarios, would there be anything additionally reportable for non-selective left renal angiography (if findings were documented)?

Patient had an abdominal aortogram, selective bilateral common iliac artery angiograms, and runoffs from a left radial artery access. We know these are reported with codes 36245-50, 7625, and 75716-59. Following this, catheter was withdrawn into the left brachial artery with angiography performed and left radial artery with angiography performed here too. As these are “pull-backs”, my first thought was that they would not be reported. Is this correct? If incorrect, how will they be reported?

An IR doctor has asked me if we can bill for measuring interstitial pressure with a device. They will be doing a biopsy of a tumor, and the plan is to place a needle to measure pressures in a tumor. A component of the tumor pressure is transmitted arterial pressures. The plan is to simultaneously measure the pressures when the biopsy is done. What code(s) can be billed for this (in addition to the biopsy/guidance for biopsy)? I would appreciate any recommendations you may have for billing this additional procedure.

The patient has extensive RLE DVT and failed anticoagulation. The doctor placed a vena cava filter through an internal jugular vein access. He then accesses the popliteal vein, injects contrast, and does a RLE venogram. He places the catheter to the external iliac vein and injects contrast again, then angioplasties the femoral vein. He places an EKOS thrombolysis catheter from the external iliac vein to the popliteal vein. I know that the filter placement usually bundles catheter placements and imaging; however, since a separate access was used, can I code for the catheter placement and venography of the lower extremity? I'm thinking code 37191 for the filter placement, code 37212 for the thromboysis catheter initiation, codes 35476 and 75978-26 for the venoplasty of the femoral vein, and possibly code 75820-2659 for the venography of the RLE.

Is there an IR procedure for treating liver tumors using brachytherapy, Ytrrium 90? It is a form of radiation that is injected into the tumor bed? Is there a dosimetry charge that can be billed? If so, is there any specific FDA-approved treatment planning or wordage that is necessary? Also, what about the use of SPECT/CT or PET/CT being reimbursed afterwards?

A patient had an EVAR done and is now returning due to an endoleak. Do you consider this a complication or more extensive repair of the original AAA? I am trying to determine whether correct coding for the endoleak should be billed with 996.1 and a -78 modifier, or whether the original AAA dx 441.4 with a -58 modifier should be used.

"The patient had a previous brachial vein to brachial artery anastomosis created near the right antecubital region. The patient is brought in now for a planned second stage transposition fistula. A long incision was made in the right arm, and the brachial vein was dissected free from the antecubital region up to the axillary region. Branches were divided with clips and ties. We divided the vein from the previous anastomosis at the antecubital region and tunneled that through the superficial tunnel in the brachial artery that was dissected free. A venogram was then performed demonstrating no evidence of kinking or twisting of the brachial vein. An anastomosis was then performed to the brachial artery with running prolene suture in an end-to-side fashion. Clamps were released, hemostasis obtained, drain was placed, and the wound was closed."

For code 93325, Doppler echocardiography, color flow velocity mapping, will documentation of “no PFO by color Doppler” or “color Doppler” listed in the TEE findings support this code? What documentation is necessary to support code 93325?

I have a radiology physician who does pre-Y90 mapping and MAA shunt evaluation when he infuses the intra-arterial administration of 6.5 mCi Technetium 99m labeled MAA for the shunt evaluation. Is there a way we can capture this charge? I am only coming up with a HCPC code C1204 for this, and I'm wondering if there is an additional CPT code we can use to capture this.

Rapid atrial pacing induced left A-flutter into A-fibrillation back into A-flutter into A-fibrillation. Ablation of the roof near the LSVP terminated the A Fib. Ablation contined down the posterior antrum of the L atrium which induced A-Flutter. We ablated around the entire L antrum, the tachycardia continued. We ablated the roof of the LA, from LSPV to RSPV as well as the posterior line from the L antrum to the R antrum and the left A-flutter terminated. The left flutter was posterior wall dependent. Multiple ablations were done in the mitral isthmus region and the corresponding contralateral CS region. After ablation was complete, EPS was done with no inducible atrial tachydysrhythmia. Adenosine bolus was given to induce pulmonary vein fascicles. None were induced. Post op dx are atrial fibrillation and two different left atrial flutter. Should this be coded to 93656, 93657 x 2 or 93653, 93656, 93657 x 1? In this case, would 93623 be billed for the adenosine?

Psoas muscle (abscess) aspiration - what is the CPT code for this procedure? Site muscle unlisted code 20999 or what?   How does this related to the "findings" description? 

INDICATION: Left central and muscle fluid collection r/o abscess. PROCEDURE: Patient placed lateral decubitus on CT gantry couch. After induction of anesthesia, pre-procedure scan performed to select an appropriate entry site. Mark placed on the skin overlying left lower axilla, which was prepped in the usual fashion with wide barrier chlorhexidine preparation. Site then anesthetized with 1% lidocaine. Under fluoroscopic guidance, an 18 gauge trocar needle was inserted from 6 x 4 cm cystic fluid collection in the left psoas muscle. Approximately 52 mL of series fluid was aspirated. Needle withdrawn. Patient tolerated the procedure well without procedural complication. Multiple fluoroscopic spot images confirmed intra-articular location of contrast. FINDINGS: A well-circumscribed cystic fluid collection measuring 6 x 4 cm in the left upper pelvis/left lower quadrant of the abdomen. Impression: 1. Successful and uneventful CT-guided left psoas muscle aspiration. 2. 52 mL of serosanguinous fluid collected and sent for culture analysis and cell count.

I was just at the conference in Las Vegas. Outstanding. Great information. You mentioned something related to when you, as a radiologist, could order further tests, and I am asking if you have further guidance regarding this issue. When is a radiologist required to contact the referring physician before performing additional tests? I know you mentioned that if the radiologist was the treating physician, further tests could be performed without an order. Do you have anything is a little more clear? My radiology director is a great guy, but I have discussed this with him and he hasn't been able to clarify it for me. Any further help will be appreciated.

The radiology department has submitted code 49460 for the following case, which we are not sure is correct. Will you review and offer how this service should be reported? "History: G tube removal, unable to deflate balloon at bedside, no longer needed. Using sterile technique, the existing PEG tube was injected with contrast and multiple images were obtained catheter within the gastric lumen. A 035 Amplatz guidewire was then advanced through the catheter into the stomach lumen. Gentle pulling traction was applied to the catheter coupled with the Amplatz guidewire. The retention dome was then easily pulled through the gastrostomy site. The catheter was removed intact. A sterile dressing was applied."

Do you have any information on what code will be replacing deleted HCPCS code G0275?

We have a patient with a hip seroma post soft tissue lipoma removal. The ordering physician has requested we place a catheter in the seroma and inject betadine through the catheter to sclerose it. On the patient's first visit, we used contrast and placed the tube under fluoroscopy. I used codes 76000 and 10160. I am not sure what to use on her next to visits where no contrast was injected, only betadine. Would you code this like a sinus tract injection with a -52 modifier?

Patient with two coronary fistulae had a preliminary LT coronary arteriogram in AP, RT anterior oblique with caudal angulation working projections, predetermined from review of patient’s previous cardiac cath, no interval changes (no mention of when previous cath was performed). Origins of both coronary artery fistulae visualized, guiding cath into distal circumflex with control arteriogram through it, then axium coils placed. Left coronary arteriogram confirmed occlusion. Embolization of proximal circumflex coronary artery fistula in same manner. We reported codes 37204, 75894, and 75898. As catheter placement for embolization is supposed to be assigned, can we use code 93454? Or will the “guiding cath” not be coded due to mention of prevous heart catheterization?

What code should I use for a Medicare patient with popliteal aneurysm when the physician plans to repair with percutaneous placement of a covered stent graft?

I have a report for a TIPS with variceal sclerosis, for a patient with cirrhosis and GI bleeding. I know the TIPS is reported with code 37182... and a coil embolization was done on the gastric varices, so I would use codes 37204, 75894, and 75898. Do I code the sclerosant solution that was injected into the varix also, or is that part of the embolization? If it is coded separately would the unlisted codes be used like with the venous malformations of the head and neck? Or is it a different code?

Thank you for sending out your recent communication about the new embolization codes. I understand that these new codes package the S&I 75894 and roadmapping and imaging 75898. Am I correct in my thinking that the diagnostic angiogram 75726 and additional selective 75774 would also NOT be billed by the facility and the physician?

How do I code for a fluoroscopically-guided spinal marker placement at the T8 level over the left pedicle?

We had a patient who had a left heart catheterization with PTCA and stent placement in the left circumflex. The patient was transferred back to a room and about a 1/2 hour after that procedure she developed acute onset substernal chest pain, ST elevation, nausea, vomiting, and diaphoresis. She was taken back to the cath lab and showed to have acute stent thrombosis after the previous stent placement. A successful PTCA of the stent thrombosis was done, and a stent was also placed distally in the left circumflex to ensure that there was no distal edge dissection. We billed codes 93458 and 92928-LC for the first procedure and codes 93454, 92928-LC, and 92941-LC (for PTCA of stent thrombosis) for the second procedure. Can we bill for both procedures done on the same day since the code is the same for the stent placement? And can we bill for two separate heart catheterization codes if they were done on both procedures?

I have a report for an epicardial VT ablation. The physician advanced a Biosense-Webster NaviStar ThermoCool ablation catheter into the pericardial space and ablation was performed. The dictation states, "The pericardial space was periodically aspirated throughout the procedure and the fluid remained clear." The physician has checked off 33010 on the encounter form. I did a little research on the catheter and it sounds to me like the physician is aspirating fluid accumulated from the irrigation catheter. There was no mention of an effusion and, in fact, an echo earlier in the day stated that none was found. Should I bill code 33010? Or in this case is the aspiration just part of the ablation?

Bilat common femoral artery & common femoral vein cannulations Selective right iliofemoral Angio Intracardiac echocardiography (ICE) guided interatrial transseptal puncture. TandemHeart left ventricular assist device (LVAD), left atrial sump, right common femoral artery outflow. TandernHeart right ventricular assist device (RVAD), right superior vena cava (SVC)/right atrial sump, main pulmonary artery outflow. Replacement of a defunct pulmonary artery catheter. Report is to long to fit...Using the 2nd left common femoral vein access site, a 2nd 21-French venous catheter was advanced to the level of the SVC/right atrium. This venous catheter was clamped and secured at the groin using suture. The cannulae were further secured using 4 Hollister patches, and the 2 TandemHearts were secured in saddles on the right and left lower extremities. Finally, the malfunctioning PA catheter was removed and a new PA catheter was advanced under sterile conditions using fluoroscopic guidance.Not sure how to code this. I came up with 33991, 33991-59 & 93503? Correct?

We had a patient with MR angiogram, evidence of distal left SFA calcific occlusion. Initial antegrade attempt from right common femoral access was not successful in traversing the lesion. Then, patient was placed prone and again traversal attempted from left popliteal retrograde access. It was again unsuccessful in reentry into true lumen (failed subintimal dissection technique). What would be the appropriate CPT codes for this patient? Is it possible to code failed percutaneous revascularization attempt when you have prior CT or MR angiogram?

We have a report that documents placement of two bifurcated grafts - please see below. How should this be coded? "Patient has a 5 cm AAA and right and left iliac aneurysms. Abdominal angio was done. After careful measuring of the aortic and internal iliac artery dimensions, the bifurcated component that is to be deployed in the left common iliac artery was prepared. This consisted of partially unsheathing of the 23 x 13 x 124 mm Endurant II Stent Graft System and removing the suprarenal fixation prongs. This graft was successfully deployed in the left iliac. They then deployed a Viabahn and ICasgt stent in the left internal iliac. Next the main body of the bifurcated modular Endurant II AAA stent graft (measuring 25 x 16 x 166 mm) was advanced into the abdominal aorta. This one was deployed in the aorta. Next, attention was made to bridge the main body of the bifurcated graft with the bifurcated graft placed in the left common iliac artery."  They used an iliac limb graft and a stent graft in the right iliac. Thanks for your help!

We had a patient who had a diagnostic celiac and superior mesenteric arteriogram performed in the IR suite. This showed high grade narrowing of the origins of both vessels. The vascular surgeon, on a different day, decided to take the patient to surgery (on the outside chance that he would need to open the patient) to place stents in the celiac and superior mesenteric arteries. What is the proper way to code this procedure? Do operating room charges include arteriograms? Shouldn't the stent placement be charged separately from the operating room time charges?

I am setting up new orders for our hospital. I see the new embolization codes bundle the imaging guidance. For 2013 we use codes 75894 and 37204. I see code 37204 is being deleted, but not 75894. When would you use 75894 if all of the new embolization codes have the guidance bundled?