Ask Dr. Z

"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?

After a PFO closure procedure (93580) the occluder device was seen to be floating in the left ventricle. During a second procedure, on the same day, the same doctor retrieved the device. To capture the device he actually pulled it back into the ascending aorta and there successfully pulled it into the sheath. Can I use code 37197 for this procedure or go to an unlisted procedure code?

TEE probe passed into distal esophagus and gastric fundus. TEE performed at multiple levels. Findings documented for left and right ventricles, left and right atriums, LAA, LA septum, all four valves, aorta, pericardium. No right-to-left shunt by color Doppler or agitated saline (bubble) study. We reported codes 93312, and 93325, and we wondered what needs to be documented to support code 93320 and what all this code includes?

Patient presented on day 1 as outpatient for bilateral lower extremity Doppler with color flow and unilateral venous reflux study. Does code 93970 cover everything, or do we also use code 93965? Patient returned the next day for separate encounter and had the contralateral leg venous reflux study performed. What would be the appropriate CPT code for this service (maybe unlisted vascular)? My understanding from the department is that this second study is not felt to be a duplex scan, so they didn't think code 93971 was appropriate to use.

Is a biopsy performed at the same time as a fiducial/vesicoil placement inclusive? So, if the physician performed a vesicoil placement in the chest under CT guidance and performed a biopsy at the same encounter, I would report codes 32553 and 77012 only, correct?

We have a biventricular pacemaker insertion. The patient didn't have the atrial lead, but only RV and LV lead. Patient also had an LV lead insertion. Should this be reported with codes 33207/33225 or 33208/33225? According the AMA CPT Codebook 2013, the chart on page 177 showed initial pulse generator insertion multiple leads should be reported with codes 33208 and 33225. The description of code 33208 is for "atrial and ventricular". Code 33207 is more appropriate, but the chart referred to codes 33206 and 33207 as single lead.

On a previous question you stated there is no timeline to define exact timing for an acute NSTEMI, but that it would not extend to several days. What then would be the definition of "several"? We have a patient who was admitted on the 1st and had diagnostic catheterization on the 2nd, but because of patient's history of GI bleed the intervention wasn't done until the 4th. Would this still be considered acute? Also...in the CPT code description for 92941 it states "during acute myocardial infarction".  What exactly do they mean by that?

How do you code a Zevalin IV injection?

I am in the process of getting ready for training with our techs on the new 2014 drainage procedure codes. It appears that the changes will simplify things for the techs that are ordering these procedures. I was confused that code 10140 is not changing. It seems that the new codes 10030, 49405, and 49406 mean almost the same thing as code 10140. Can you please explain the difference and tell me when we will be using code 10140 instead of the new codes in the future?

One of our vascular surgeons performed a carotid to contralateral carotid bypass using a PTFE graft in order to prepare the patient for TEVAR. Code 33891 is a perfect fit for the procedure except the TEVAR procedure was not performed on the same day or by the same surgeon. Can you please let us know if we should use an unlisted code (37799) or if it would be appropriate to bill 33891 in this circumstance?

Per the physician's dictation, aTEE was done, which demonstrated a jet of eccentric severe periprosthetic aortic valve insufficiency. The fistulous tract was crossed with a slip-tip catheter. Through this catheter an AGA patent ductus occluder was deployed through the fistulous tract. Upon release of the occlusion device significant reduction in the periprosthetic valve regurgitation was seen on the TEE and was confirmed by left aortography. The procedure was then concluded without complication. This is not a procedure that we have done in the past and therefore need your advice on how this should be coded/billed.

I've got a couple of questions regarding the below patient. Is femoral cutdown (34812) always performed with these procedures? Our provider didn't document an open cutdown, only that 5 french sheath was placed into the common femoral arteries. "Following deployment of the endograft with intentional partial left subclavian coverage (33880-62) he attempted to close the left femoral arteriotomy using the Perclose Prostar sutures; however, they prematurely knotted in the subcutaneous tissue because of vessel depth in this obese patient. In order to control bleeding without vascular control of the artery established, he used a balloon in the iliac artery so he could surically repair the left common femoral artery with placement of a bovine pericardial patch." I'm thinking I should code this part of the procedure as 37204, 75894, and 35286, but I wanted your expert opinion. Here are the codes I came up with: 36200-50, 33880-62, 75956-26, 37204, 75894-26, 35226.

My doctor is performing a staged embolization, and I'm unsure if this should be billed out with code 61635, and when the patient is brought back 61624-58. These are the details of the report: "Stage 1 embolization of an unruptured 10-11 mm Basilar apex-left posterior cerebral artery broad-based aneurysm using a stryker neuroform EZ device from the basilar artery into the left posterior cerebral artery and an codman enterprise device from the basilar artery into the right posterior cerebral artery...Plan: Stage II Emboliztaion in 6-8 weeks with coils through the Y-Stent construct."

The answer is archival date is Oct 24, 2007. I need to know the answer as I have to same question on how to code. Question: My confusion lies more with which codes are correct for the RS&I portion of the exam if a catheter is used to drain an abscess in the breast and the catheter is left in placed for drainage. Would this be reported with codes 10140/75989 or 10160/77012? Codes 10160 and 75989 can't be coded together... Is this because code 10160 covers when a drainage catheter is left in place also?

We performed a thrombectomy on a patient's POP, ATA, PTA, and peroneal. We also performed a PTA to the posterior tibial artery. I think I have code 37184 for the POP, code 37184-59 for the ATA, code 37185 for the peroneal, and code 37228 for the PTA. My question is, can I bill catheter placements too?

A coronary sinus catheter is placed via left subclavian vein for a CS venogram to locate site of a fistula from distal LAD artery to what appeared to be CS, found to actually be the left ventricle. Catheter was placed into the distal LAD, traversing the fistula to deploy coils and close off the fistula. Verified results with final angiography. We reported codes 37204, 93454, 75894, and 75898. How would the coronary sinus venogram be coded?

Once again I find that I am second guessing myself, and I need to ask for clarification of what is the main difference between codes 37226 and 36246.  When are you supposed to use one set vs. the other? Can you please explain?

Any suggestions on coding the catheterization and imaging of the left subclavian artery if the vertebral artery has been anastomosed to the left common carotid artery and no longer arises from it? This angiogram was done due to post op TIA symptoms the same day as the vertebral reimplantation surgery. Can I bill codes 36225 and 36223 for the following? "Catheter advanced under hemodynamic and fluoroscopic control, positioned selectively into the left subclavian artery, single view cervical zone accomplished. No gradient at catheter tip. Catheter then selectively placed into the left common carotid artery multiple views cervical and intracerebral accomplished. Left vertebral artery anastomosis to the left common carotid artery defined in multiple projections. Complete and diagnostic angiograms were done of both the left subclavian and the left common carotid including extrancranial and intracranial circulation plus the vertebral." (I just did not have room to include the findings in the question.)

If a cutting balloon is used to do an angioplasty, do we report an atherectomy?

Would code 20500 be appropriate for this non-vascular alcohol ablation? What about code 77013? Thanks for your feedback. "Percutaneous ethanol injection into the portal enlarged metastatic lymph node PET positive lymph node. Under CT guidance, Chiba needle advanced into the target lymph node. Anhydrous ethanol was injected in small aliquots with intermittent scanning to observe the distribution and position of the needle. We injected approximately 17 mL of absolute ethanol intralesionally. Particular care was used to avoid needle entry and injection into the biliary and vascular structures."

We have a patient who had an LV lead implant during aortic valve surgery. Four days later patient comes to the EP Lab for implant of dual chamber ICD (RA and RV leads added). I think codes 33240, 33217, and 93641 would be the correct codes to use, but everything I read on code 33240 says implant of generator only, nothing about using code 33217 for placement of additional the leads. Should I just count this as initial insertion of ICD and use 33249? I know I can't code for the lead placed in surgery, but I didn't know if this falls under the description for 33240.

Patient presents with history of coronary artery disease, peripheral vascular disease of the extremities, and carotid artery stenosis, status post PCI and PTA of subclavian artery. Recent stress test and Doppler ultrasound of great vessels had abnormal results. Procedures performed include left heart catheterization plus selective injections of coronary arteries, (native) right/left internal mammary arteries, right/left subclavian arteries, right/left vertebral arteries (from subclavian catheter placement), and right/left carotid arteries. Interpretations include coronary artery stenosis (414.01), subclavian artery stenosis (440.20), normal internal mammary arteries, normal vertebral arteries, and carotid artery stenosis (433.10). Are the following codes appropriate for the combination of coronary and peripheral vascular procedures performed in the same setting: 93459-TC, 36225-50, 36222-50, 36216-59RT, 36215-59LT, and 75716-59TC?

Our pain management physicians are doing facet joint injections, medial branch blocks, and RF ablation of the facet joints. We are having them dictate the joint levels for the RF ablations, as I get that they need to inject multiple levels for one joint, but I’m confused on how we should be coding the facet joint injections and the medial branch blocks. I thought these would still be per injected level. This is what we have been doing for the three areas… what do you think?? L2, L3, and L4 would be three facet injections (64493, 64494, 64495). L2, L3, and L4 would be three medial branch blocks (64493, 64494, 64495). L2, L3, and L4 would be two RF ablations for two facet joints (64635, 64636).

Can you give me your opinion on this type of situation? Our facility is starting to use the Sherlock ECG monitoring device with our PICC lines. Do you know the appropriate codes that we are supposed to use for the ECG? So far I have the PICC line code 36569, then they are doing an ultrasound with hard copy 76937... and what would we code for the ECG?? Would any of these be appropriate: 93000, 93005, or 93010? Or something else? 

I am encountering an issue with the use of the Jetstream atherectomy device. As you know, this device is indicated for both atherectomy and thrombectomy from the same catheter. The physician dictated that he performed an atherectomy/thrombectomy within a lower extremity vessel. There is no mention of the presence of thrombus within the vessel during the procedure. Is it appropriate to charge/code for atherectomy and thrombectomy for this procedure, as the physician only mentioned a calcified lesion in the vessel?

We discovered that the RVUs for code 22524 jumped from 16.61 in 2011 to 223.41 in 2012. Approximately $1463.00 to $22,109.00 in 2013. Is there a specific reason for this high increase? I would appreciate any information you have for us to pass on to our concerned patients and physicians.

Is code 92973 reserved for AngioJet only? Patient with MI had thrombus burden (100% occlusion) in the RCA, where PCI was done with a DES. This led to thrombus embolization into the posterolateral branch(es), which was treated with adenosine and nicardipine. "The mechanical curettage was also performed with guidewire manipulation and passing the previously inflated stent balloon down into the proximal portions of the branches of the posterolateral branch." We were wondering if the intervention here to the posterolateral branches would be considered a mechancial thrombectomy.

Is it appropriate to report a diagnostic CAD and diagnostic mammogram for spot magnification and/or compression views for patients returning following a screening mammogram with CAD?

CT of abdomen/pelvis performed at 10:42 am for acute abdominal pain. Results: The infrarenal abdominal aorta is mildly aneurysmal with atherosclerotic calcification the wall. There is only very slight interval change from previous study. At 12:44 pm a CTA abdomen/pelvis was performed. Results: 3.5 cm aortic aneurysm, slightly increased. Since these were performed two hours apart in different sessions, can I add modifier -59 to 74176? Or should I combine them?

The cardiologist has reported a right heart catheterization (93451) for this procedure, and I'm not sure if his documentation is adequate. The report reads: "The right femoral vein was accessed using the modifier Seldinger technique. I then attempted to use the Edwards pulmonary catheter, but it would not cross into the pulmonary vein. I then switched to the 7 French Arrow catheter. After manipulating for about 5 minutes, I was able to cross into the pulmonary artery. At this point, this was placed in the pulmonary artery, but it would not wedge. I was able to get pulmonary artery pressures with this and then subsequently able to get PA and RV as well as SVC, IVC, and right atrial pressures." Can I assume he went through the tricuspid valve since he went from the pulmonary vein into the pulmonary artery?