Ask Dr. Z

The study performed was a myelogram, but instead of using conventional fluoroscopy, they did it under CT (62284, 72270, 72126, 72129).  Please advise us on coding and documentation.  "Patient in CT room, L2-L3 level was localized using CT scouts.  Needle was placed into the thecal sac under intermittent CT/scout guidance. Then underwent multiple CT scans using dynamic CT myelographic method. (1-5) acquisitions were performed using a cranial to caudal technique.  After injection of the full amount of intrathecal contrast to include the cervical and thoracic spine. Cervical: Ventral epidural extravasation of CSF is observed at the C4-5 level where there is also anterior cervical fusion with ventral plate. No other area of CSF leak is identified.  Anterior fusion hardware is also seen at C6-7.  Hardware is intact and unremarkable.  One of the C5 screws extends to the posterior cortical margin of the C5 vertebral body.  Vertebral body heights and alignment are maintained.  No fracture is seen.  Th: Vertebral body heights and alignment are preserved. No CSF leak is evident."

For a Medi-Port insertion (36561), does the name of the device alone (right IJ 8 French power injectable AngioDynamics Smart port) suffice to support the reporting of code 36561, or is it necessary to document the pocket creation? Dictation documents the ultrasound used- with permanent image kept, the fluroscopic guidance for final placement, tunnel creation, just not the actual port pocket.

My docs did a catheterization, and our cath lab charged code 93460. Should this be reported with codes 93531 and 93563?  "Right and left catheterization with selective coronary angiography. Patient has sinus venous ASD and anomalous pulmonary venous return to the right side. Impression large left to right shunt due to shunting at the atrial level. The patient has dilated right-sided chambers, repair of the congenital anomaly as described above is indicated CVT will follow."

We are going to be doing a platelet rich plasma injection with ultrasound guidance. Code 0232T includes guidance, harvesting, and preparation. The harvesting and preparation are going to be done in a physician's office and then the patient will be sent to our outpatient radiology department for the injection with ultrasound guidance. Any suggestions on how to make sure we get paid for the guidance portion of this procedure?

How does one properly code for a failed/unsuccessful procedure to recanalize (cross a CTO) an obstructed peripheral artery (e.g., lower leg)?

I have never coded a procedure like this, so I would love your assistance. The surgeon did a right fem bypass graft to the left iliac artery. He then attached the iliac artery on the left to the previous fem/pop bypass graft on the left. Then from the pop bypass graft he did a graft to the tibial artery. Would you use code 35665 ileofemoral and then 35671 popliteal-tibial? The right femoral to left iliac has got me stumped.

Patient was placed on ECMO device by the cardiac doctor, and the next day one of our vascular surgeons (surgeon A) was called in to place bypass tubing into the patient for ischemia of the foot. This was then connected to the EMCO device. Next, another one of our surgeons (surgeon B) was called in at a later date to remove the device from the LCF while the cardiac doctor removed the venous cannula. Thrombus was found in the LCF, and an open thrombectomy was performed (34201) by surgeon B. How would you code this for surgeon A and B? Is the removal of EMCO coded, or is this bundled with the open thrombectomy?

One of our IR physicians is listed as an "authorized user" on Therasphere embolization reports and is asking to have codes 77263, 77300, and 77790 billed. Can you tell us what documentation must be included in the reports to bill for them? We aren't seeing anything other than, e.g 98% of the prescribed dose was delivered.

Would you use code 34803 for the Trivascular Ovation endograft?

Both common femoral arteries now had 11 French sheaths put in place. On the right side, the sheath was removed and exhanged for the main body TriVascular device; this was passed to the level just proximal to the renal arteries and then deployed with the proximal fabric just distal to the left renal artery. The resin was then inserted into the graft using the automatic pushing device. 11 mL of resin were given. A Berenstein catheter and glidewire were used to cannulate the left short limb of the main body device through the left common femoral artery sheath. A 16 x 100 mm iliac limb was now placed into the main body on the left side and deployed to the level of the mid common iliac artery. On the right, an iliac 16 x 100 mm iliac limb was also placed. Following deployment of the device, the main body resin attachment unit was detached. An aortogram was performed demontrating both renal arteries to be visualized and no evidence of any endoleaks.

Coding guidelines state that when an intervention is performed on an AV Fistula, the arterial and venous sides are considered one vessel. It's understandable when a stenosis exists and requires just one wire to be placed, but I was wondering if there is an exception when a clot is encountered since two wires are placed and two sides are ballooned/stented?

I have recently been receiving rejections from Medicare when I bill bilateral code 34812. After trying 34812/34812-59, then 34812-RT/34812-LT, 34812-50 and 34812 x 2, I filed a redetermination. I was told it was denied because I billed with quantity of "two". Upon looking up the MUE, I found it now states one unit. Is this a new edit?

Can you please clarify what constitutes an atherectomy for crossing a CTO? Would I bill code 37224 or 37225 for the following? "A 12 gram Cook Advance CTO guidewire was then used to try to recanalize the occlusion of the right popliteal and tibioperoneal trunk vessels. It would not pass. A miracle Brothers 3 gram guidewire was substituted and met similar difficulties. A 6 French Cook ansel contralateral guiding sheath was then advanced over a Supracore wire into the right superficial femoral artery Viabahn. Angiography was then performed, and the Miracle Brothers 3 gram guidewire was then reintroduced with use of a Trailblazer catheter for support. The right popliteal artery occlusion was then treated with percutaneous transluminal angioplasty using a 4 mm x 40 mm balloon. This was followed by exchange for the Supracore wire, using a 4 French straight diagnostic catheter. At this point, the Supracore wire was successfully advanced into the peroneal artery."

I have the following case: The patient was prepped and draped in the usual sterile fashion. _____ Xylocaine was used to infiltrate the right groin area. Using micropuncture technique, 5 French sheath was placed, and a 5 French Omni Flush catheter was advanced to the aorta and an aortogram was performed. The catheter was manipulated with a stiff angled Glidewire into the contralateral side and positioned in the common femoral artery and images obtained down to the level of the foot using bolus chase technique. Catheter was withdrawn into the ipsilateral side and positioned in the external iliac vessel and images obtained down to the level of the foot using DSA and bolus chase technique. At the end of the procedure, sheath was removed. Manual pressure was held."  I'm confused about coding an abdominal aortagram. I coded this case with 75716 and 75630. Do I need to add code 36200 as well? If so, can you explain when this code should be added?

Can you bill twice for a bilateral lymphoscintography (78195)? And if you can, would you use modifier -50 or bill twice with a modifier -59?

"Patient comes in and has an embolization of an ACA aneurysm, and a follow-up angiogram shows nonopacification of the majority of the A2 segment of the ACA. Subsequent angio demonstrates thrombosis of the portion of the A1 segment of the ACA and ciling was halted. An internal carotid angio was performed, and the occlusion of the distal aspect of the A1 segment was identified. 7.5 mg of Integrelin was infused into the A1 segment of the ACA. After 10 minutes a repeat angiogram was performed . The A1 segment remained occluded. It was decided not to further pursue thrombolytic therapy and clot retrieval at the current time." Is this a true infusion? Can we report code 37211 for the Integrilin that was given, or is this documentation not enough to support an infusion?

I code for an acute hospital facility. We have been referencing your newsletter dated February 19, 2007 in regards to multiple attempts at angioplasty and the use of the -74 modifier. We are wondering if there have been any updates to this advice since 2007. We have a CTO of the right coronary. Multiple attempts to cross the CTO with the balloon in the vessel were unsuccessful. A diagnostic coronary angiogram was also completed. Is it correct to code for the completed diagnostic coronary angiogram as well as the discontinued angioplasty of the CTO in the right coronary as 92943-74 and 93454?

Can we charge for fluoroscopy guidance (77003) when the fluoroscopy is provided by a radiology tech and the procedure is performed by a surgeon? The surgeon dictates fluoroscopy guidance was used in the operating room procedure. An example is code 62311, epidural injection (myelogram, epidurogram, and arthrogram are not performed in the OR procedure).

A question came up as to whether or not it is appropriate to charge for CAD when performing "spot compressions" on a follow-up diagnostic mammogram. Is there a requirement for the type/number of images on a diagnostic mammogram in order to charge CAD?

I have a physician who is interested in using the Angio Vac for removal of thrombus from the right atrium, IVC, SVC. I think codes 37187 and 37188 would be the appropriate codes to use. Is this correct, or does Angio Vac have a CPT code?

Can I report codes 93656, 93655-59, and 93655-59 for ablations for... 1) Left atrial fibrillation/flutter successfully resolved with successful mapping isolation of all four pulmonary veins. This proved to be quite challenging with dense connections and variant anatomy. 2) Successful resolution of right atrial flutter induced with right atrial flutter ablation in the cavotricuspid region and establishing bidirectional block. 3) Resolution of orthodromic SVT with reablation of a partially recovered left-sided accessory pathway. 4) No further inducible SVT at the conclusion. Here is the longer version: 6) Catheter mapping of supraventicular tachycardia foci utilizing 3-dimensional mapping system (ESI/NavX). 7) Radiofrequency catheter ablation of atrial fibrillation with pulmonary vein isolation. 8) Radiofrequency catheter ablation of additional SVI foci x 2 with right atrial flutter and WPW/PSVT ablation 9) Complex/difficult, 2 hours in excess of standard procedural time.

"Patient has existing liver abscess drain in place; hypoechoic area identified nearby with ultrasound. Contrast injection with spot images done of existing drain. Plan was to access new area and place second drain. Ultrasound guidance used for Accustick access. Contrast injection identifies communication with cavity containing initial drain. Second drainage catheter placement aborted. Existing drain exchanged with manipulation for better drainage position of both areas."  What, if anything, can be charged for the aborted procedure?

How would you code the catheter placement in the aorta for catheter-directed CTA of abdomen/pelvis?

CLINICAL INDICATION: 77-year-old female with juxtarenal and abdominal aortic aneurysm and renal insufficiency. The patient is having aortogram performed to place a catheter prior to catheter-directed CTA. ULTRASOUND GUIDED ARTERIAL ACCESS: Ultrasound evaluation of the right femoral artery was used to demonstrate its patency and its relationship to the femoral head. Images were saved to PACS. Under ultrasound guidance, right common femoral arterial access was then obtained with a 21 gauge, 7 cm needle, through which a 0.018 in guidewire was advanced under fluoroscopy. The needle was exchanged for a 4/5 French micropuncture sheath. The 0.018 inch wire was exchanged for a Bentson wire, and the micropuncture sheath was exchanged for a 5 French working sheath. AORTOGRAM: An Omni flush catheter was inserted through the sheath and positioned in the inferior abdominal aorta. Carbon dioxide was injected through the catheter, and DSA images were obtained. The aneurysm sac and common iliac arteries were identified. The patient was then transported to the CT scanner.

"Earlier patient had thrombolysis, venoplasty, and SVC gram done on SVC. Later same day returns for repeat venogram and evaluation. Then a balloon is inflated across the SVC stenosis and repeat SV gram was performed, and then a new catheter is placed across the area of thrombosis and patient initiated on a TPA drip." Can we code for another venoplasty on the same day (35476 and 75978)? Findings: persistent large amount of thrombus in SVC.

How would you code this? "The pacemaker was explanted. Using a modified Seldinger technique with extrathoracic approach, subclavian vein was accessed x 1. Guidewire was cannulated. Over the guidewire, a Medtronic long sheath to access the coronary sinus was placed. The standard sheath was unable to cannulate the coronary sinus; therefore, it was changed to a wider coronary sinus sheath. The coronary sinus did appear to be cannulated. Guidewire was advanced. The position of the guidewire appeared to be far more lateral on the lateral wall of the ventricle. Therefore, a venogram was performed. The venogram showed that the guidewire and the sheath were actually into the pericardium and it perforated the right ventricle. Therefore, the sheath was withdrawn. A STAT echocardiogram was ordered and showed the presence of approx a 2.5 cm pericardial effusion. An emergent pericardiocentesis was performed. This drained 250 cc of pericardial effusion. The pocket was extended and irragated, and the previous pacemaker was placed back inside."

If the physician does several interventions in sub-branches (for instance superior sub branch and middle sub branch of the OM1), would we be able to show two interventions? Or only one being that it's all in the OM1? Or would these sub-branches each be considered a separate branch?

What is the correct CPT code for radiofrequency ablation of the sphenopalatine gaglion?  I am looking at unlisted code 64999, as there is not a specific code that names this group of nerves under the Destruction section 64600-64681.

"Ultrasound of the right neck was then performed and compared to the outside exam from July 10, 2013. In the interval, the large unilocular area is no longer identified. There appears to be some small cystic areas just posterior to the carotid artery and the jugular vein on the right side of the neck. However, the majority of the lesion is not identified on today's ultrasound. Next, utilizing ultrasound guidance and two 20 gauge Angiocatheter needles, we tried to obtain access into the component noted along the jugular vein and common carotid artery. We punctured this lesion x 2; however, we were unable to obtain either blue blood or fluid from this lesion. Upon puncturing this, appeared to be more solid suggested more of a lymph node. There was also an area that appeared to be cystic, slightly more superficial, which we punctured with a 21 gauge butterfly needle; however, again, we were unable to aspirate fluid given almost complete disappearance of this lesion and what appeared to be very small remnants and the patient being asymptomatic. We decided to stop."  What are your suggested codes?

What is the CPT code for ligation of accessory vein?

ESRD with a poorly matured right arm fistula. Procedure: Balloon angioplasty of the cephalic arch and peripheral cephalic vein, ligation of the accessory vein to improve blood flow. Incision through the subcutaneous tissue to the accesory vein and was freed up from the surrounding tissue and ligated with 2-0 silk tie.

In IR, a patient had a unilateral cerebral angiogram to ensure there was no obstruction. Following this, a microcatheter is placed near the MCA, and a 2-3 minute infusion of auto stem cells was performed. I was thinking code 37799, but do you think code 37202 would be more appropriate?

"Patient initially presented for insertion of a dual-chamber pacemaker. Right ventricular lead is placed. However, physician could not get the right atrial lead to capture anywhere. After attempting pacing at five different positions, physician stopped attempts to place a right atrial lead. Instead, physician decided to place a left ventricular lead since patient was going to be paced 100% of the time. Left ventricular lead was implanted and advanced into the coronary sinus. Then an Evia HF-T generator was connected to the leads."  Would codes 33207 and 33225 be used in this case since this is a CRT-P? There is an edit coming up that indicates because we are billing C1882 as a device code we would need different codes. Will you please comment on how to appropriately code this case? Should it be coded as though the atrial lead was placed and then add a -74 modifier on the code? This one has me stumped.

Is the answer below correct?

February 4, 2013, Question: We did a left heart catheterization (LHC) with left ventriculogram (LV) and coronaries. Because a lesion was found, a left internal mammary artery (LIMA) angiogram was performed to see if it could be used for bypass. We coded 93458 and 75756 for the LIMA. I'm being told that we can't code those together, that we would have to code 93459 for LHC/coro/bypass. I explained that the LIMA wasn't a bypass yet but was told that was how I had to code. Do you know what is correct?

Answer: You should assign code 93459. Before the American Medical Association changed the heart catheterization codes, the description for the add-on code for bypass graft injections was "injection procedure during cardiac catheterization; for selective opacification of arterial conduits (e.g., internal mammary), whether native or used for bypass." That code (93539) was to be used when an artery such as LIMA had already been made into a bypass, or when it was being evaluated as a potential bypass. The new code does not have that terminology.

The following vessels were selectively catheterized: left common carotid artery, left subclavian artery, left subclavian to right internal carotid artery bypass graft, left vertebral artery, and brachiocephalilc artery. Multiplanar cervical and intracranial angiograms of the above mentioned vessels were obtained and interpreted. I want to report codes 36223 (LCC), 36226 (left vertebral), and 36223-59 (brachiocephalic), but what do I code for the angiography of the bypass graft, 36225-59?

We could use your help on coding this procedure. "The patient is a one-year-old with hypoplastic left heart syndrome. Status post Norwood and Hemi-Fontan procedure. Cath was performed to evaluate candidacy for Fontan procedure. Right and left heart catheterization performed from the left femoral vein. Angiograms were performed in the innominate vein/superior vena cava, innominate vein/superior vena cava/right pulmonary artery, ascending aorta, selectively in the right and left internal mammary arteries and right ventricle. Coil occlusion procedures were performed in the right internal mammary artery (three coils were placed through a 4 French Cobra catheter advanced antergrade from the left femoral vein) and the coils placed in the left internal mammary artery (two coils placed through a 4 French Cobra catheter advanced retrograde from the left femoral artery). At the end of the procedure, both renal collecting systems were visualized and normal". Could you please tell us if we coded this correctly? We reported the following codes: 37204, 37204-59, 93531, 93566, 93567, and 93568.

I thought if the physician stented both the LC and LD in the same procedure, the codes reported would be 92928-LC and 92928-LD. But, there is an MUE of one for code 92928. Would this be billed with just 92928-LC?

Since the inferior epigastric artery comes off the external iliac, would codes 75716 and 36247 along with 75898, 37204, 75894, and 75774 be appropriate?

"5 French catheter is advanced into abdominal aorta via left femoral, followed by abdominal-pelvic arteriography. Next, catheter is advanced across aortic bifurcation, followed by more focused angio of right iliac vessels. Extravasation arising from muscular branch of medial inferior epigastric artery. 3 French microcatheter advanced selectively into right inferior epigastric artery. Repeat angio confirms acute hemorrhage. Gelfoam is injected until no demonstrable flow within distal inferior epigastric vessel. Lastly 3 mm microcoil placed immediately proximal to the vessels previously supplying area of hemorrhage. Dedicated angiography of contralateral iliac system is unremarkable."

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

I am not sure how to code this discontinued TIPS procedure. When I look at valid modifiers for 37182, I do not see -73, -74, or -52 modifiers as being okay to use. Should I code this as a diagnostic study and use codes 36011, 75889, 36481, and 75887? Condensed version of procedure: "Approach from right internal jugular. A 5 French multipurpose catheter was placed used to obtain pressures in the right atrium, after which it was manipulated into the hepatic IVC where another pressure was obtained, and then into the right hepatic vein for free and wedged pressures. Several passes into the liver were made with a needle wire and 5 French catheter. The right portal vein branch was entered, but the wire could not be manipulated peripherally into the left lobe. After exchanging multiple caths a stiff glidewire was placed into the more central right portal vein but was not able to cross into the main portal vein. Contrast injection showed filling defect within the main portal vein. Wire, catheter, and sheath were removed, and hemostasis was obtained."

"Deflation of the balloon was unsuccessful with slip-tip syringe. Using a 25 gauge lidocaine needle, the gastrostomy balloon was ruptured for complete decompression. Gastrostomy tube was then pulled with traction. A sterile dressing was applied."  Is there a CPT code for gastrostomy tube explant?

Can I code for laser atherectomy, coil embolization, and follow-up angio? "Diagnostic angio showed subtotal/total occlusion distal right superficial femoral artery. Procedure during intervention: Over guidewire 5 French Rhabie sheath placed from the left common femoral artery to the right common iliac artery right external iliac artery right superficial femoral artery. We chose a 0.9 mm diameter eczema laser catheter, power settings 45/25 flushing heparinized saline through the tip of the catheter over CT 2 guidewire. I could not identify site of occlusion having small collateral type collateral vessel. We proceeded with multiple laser runs. Heavy calcification obvious, progress poor. In multiple projections we attempted to traverse to the distal vessel ultimately unsuccessful. We did penetrate vessel wall, contrast extravasation obvious. A 2 mm diameter 5 mm length microembolization coil then placed through the renegade catheter into the path before extravasation, complete occlusion defined on multiple follow-up angiograms."

We have many physicians who will inject the IMA to determine as a conduit for surgery. We are now getting an audit of over use of this code. We have clear documentation that a catheter was placed in the LIMA and description of the vessel is clear. Has there been a change to the code or an edit added that we need to change our practice?

Could you explain when a cardioversion can be coded when an ablation procedure is also performed? Is the cardioversion coded when it was a planned procedure and not coded when it is for cardioversion of arrhythmias induced during the EP study? Is the cardioversion coded only when it is done prior to the EP procedure? Example: EP evaluation with ablation for treatment of atrial fibrillation by pulmonary vein isolation, intraventricular and/or intra-atrial mapping of tachycardia site(s) with catheter manipulation to record from multiple sites to identify origin of tachycardia, intracardiac echocardiography including S&I, planned external DC CV to SR.

What is a semi-permanent pacemaker? Do you code it as a temporary pacemaker?

I have received conflicting information regarding the reporting of the S&I codes with the procedure codes for the endovascular stent grafts. The question is simple, when coding these procedures wouldn't you code both the procedure code and the S&I for the vascular surgeon? I do find the S&I documented in the surgeon's report. But then I am also finding a separate report done by the interventional radiologist as well. I just want to make sure I am assigning the codes correctly to all the providers who participate in this procedure. I also have not read I can code separately for a cardiologist that would be present during these procedures, as I understand the services are included. I hope this question is clear. I do understand that the vascular surgeon and the interventional radiologist can work together on some procedures. Thank you for any information to clarify my logic.

The radiologist injected bivicaine into the L4-5 & L5-S1 facet joints bilaterally. He also aspirated synovial fluid from the right L5-S1 facet joint. How would you code the aspiration?

When the physician documents ablation of PVC or PAC, would that be reported with code 93653 or 93654? In one instance, the physician documents non-inducible for VT, but PVCs were ablated.

I have a doctor who always dictates "aorto-ilio-bifem angiography" and "abdominal aortography" in the same procedure line followed by intervention of, say, atherectomy of left popliteal. One access, right CFA up to aortic bifurcation (shoot) and down to left EIA (shoot). Findings on right to iliacs, left to foot - then intervention on left. I guess both aortas confuse me. Follow the cath, correct? And code 75625-26 and 75710-26 for the angiography provided no other imaging and ignore 75630 as part of the aortogram?

During a T-12 kyphoplasty, our physician performed a deep bone biopsy and an RF ablation of a metastatic tumor of T-12. These procedures were all done under fluorocopy guidance. I know the biopsy is considered part of the kyphoplasty procedure, but can we separately charge for the RF ablation? If so, would we just add code 20999 to the kyphoplasty charges (22523/72291) and not add any additional guidance?

Code 37204 for tumor destruction: If alcohol ablation was done on two separate tumors in the liver, are they each considered a separate surgical site where 37204 and the S&I 75894 are coded twice? We feel the liver represents one surgical site necessitating 37204 x 1, but we are working with a physician who would like clarification on this, as he is considering each tumor an individual surgical site.

How would you code the following?  Stent graft angioplasty of old cadaeric vein bypass, balloon angioplasty of right anterior tibial vessel, selective angiography of right lower extremity with third order catheter placement, and replacement of infusion cath for another 24 hours.

Patient comes to cath lab, and Ekos catheter is inserted into LLE. The next day he comes back, and the Ekos is removed, repeat angio, clot suctioned through catheter, Fogarty used, and PTA performed. For the second day, I want to charge code 37214, but I am unsure what "continued treatment on subsequent day (37213)" includes. Does this include the second day angiogram, or is that chargable separately? I am also charging codes 37187 and 35476/75978.  For code 37187, is the criteria for a mechanical thrombectomy different in the coronary than in a vein? Suction/Fogarty in a coronary is non-mechanical, but a slide from your 2013 AAPC seminar would indicate that suction/Fogarty would be a mechanical thrombectomy.