Ask Dr. Z

Can you code for opening a vessel that was occluded when plaque shifted frm the inital vessel being revacularized (e.g., stent in the LAD plaque shifted and occluded the diagonal branch)? The diagonal branch was ballooned opened. I've never heard that you couldn't code for it. Could you please confirm?

Is it wrong to add anatomical modifiers (-LD, -LC, -RC) to code 93571 or 93572 (FFR)?

Successful angioplasty opening of left SFA CTO in retrograde ipsilateral fashion (via left popliteal artery) followed by antegrade angioplasty and stenting of the left SFA in contralateral fashion (via right femoral artery) due to dissection and suboptimal results. Is it appropriate to report code 37226 with 37224-59 due to additional access sites?

"Patient presents with a large, over 8 cm, infrarenal abdominal aneurysm with significant tortuosity of the left proximal common iliac artery. After access of the appropriate vessel, the device was then positioned just below the left renal artery. The gate was then exposed and appeared to have been lateral into the right. Attempts for quite a long time to cannulate the right gate were unsuccessful. He now elected to convert the stent to a uni-stent and place a crossover fem-fem bypass. The 36 x 82 mm convertor was advanced through and positioned. With this he deployed the right iliac extension limbs. The 16 x 74 mm limb was placed; angiogram indicated an endoleak into the aorta...  A second stent was placed using the 16 x 90 mm limb."  We are unsure of how to properly code for the Zenith graft, as it was converted to a uni-iliac stent with a convertor. Do we assume to code for the type of stent (bifurcated two docking limbs) with code 34803 and extension limb? Or the procedure (uni-iliac stent) with code 34805, although we don’t know how to capture the converter stent?

We've just done our first fenestrated repair of an aortic dissection, and we are needing help with coding it. Can you help us? Here is what was done: 1) Successful balloon-assisted juxtarenal and infrarenal aortic fenestration. 2) Unchanged SMA occlusion. Patent celiac axis, IMA, and bilateral renal arteries. 3) Occlusion of right common iliac artery successfully treated with bare metal stent.

The following case was coded with 35476, 36870, 75978, 36147. We were asked to add codes 37212 and 75791 by our HIMS dept. Not sure if this would be appropriate. "The graft was accessed with a micropuncture needle in an antegrade fashion. A fistulogram was then performed from the right atrium to the level of the fistula. Two improve visualization of the central stenosis a Kumpe catheter was advanced to the subclavian vein and subsequent venography performed. Fistulogram demonstrated a large thrombus within the fistula distal to the venous anastomosis. Thrombolysis was performed and this thrombus was laced with 6 mg of TPA. After a short waiting period a catheter and wire were advanced beyond the thrombus. Another 6 mg of TPA were used to lace the venous outflow thrombus. Mechanical thrombectomy was performed through the outflow vein and the fistula thrombus. The above described conduit and venous outflow stenosis was negotiated with a glide wire. Subsequent balloon angioplasty was carried out without significant residual. Brisk flow was acheived."

If a patient that had a previous ablation for a-fib by pulmonary vein isolation, and comes back for another ablation to treat a fib, but pulmonary vein isolation is not repeated, do we then use code 93653 for this ablation rather than 93656?

Can we use AV graft codes for Hero graft thrombectomy and angioplasty (i.e., 35476, 36870, 36147, 36148)? "Thrombosed left HeRO catheter. Left AV graft, percutaneous thrombectomy and ultrasound-guided cannulation,placement of sheath x 2 arterial end,venous end, shuntogram. Left AV graft, percutaneous balloon angioplasty Using ultrasound guidance,the left HeRO AV graft was cannulated using a micropuncture needle, switched to a 6-French sheath planing toward the venous end. Wire and catheter advanced along the thrombosed graft and stem part into the vena cava. The AngioJet device was used to thrombectomize the graft itself. This was followed by balloon angioplasty using a 7 mm x 4 cm balloon. The outflow was patent. A sheath was introduced in a similar fashion towards the arterial end and wire was placed into the proximal brachial artery where an over the wire Fogarty was used to thrombectomize the proximal portion. Completion angiogram was performed through the brachial artery revealing a patent graft and flow into the distal arm."

Contrast was injected into the trans-stomal catheter whose pigtail is in the renal pelvis. A wire was advanced through the trans-stomal catheter and an exchange for a new 10 French x 50 cm Cook Amplatz universal drain with its upper end in the renal pelvis and the stomal end projecting about 15 cm outside the stoma. Would this be reported with codes 50688 and 75984?

How do you report portal vein reconstruction with vein? "The mass was then excised along with this portion of vein, which included the level of the SMV up to the level of the junction of the splenic vein and portal vein. When the specimen was completely resected, we then turned our attention to our interposition graft. The length was not amenable to primary repair, so using our IJ vein graft, we performed first anastomosis from the level of the graft to the superior mesenteric vein using an end-to-end technique using 5-0 Prolene. When this was completed, we moved the clamp up to the level to include the graft and then cut the graft to length for the proximal anastomosis to the splenic and portal vein. This was performed in somewhat of a spatulated manner to incorporate both the large venotomy at this site."

Have you heard of Aorfix and Heli-FX? Our surgeon used both of these devices, and I am not very sure how to bill it. What codes can you recommend for these devices? I researched about the Aorfix, and it looks like it could be 34802. I am not very sure about the the Heli-FX though.

If patient has a right heart catheterization only, and they also go retro to the aorta and do an angio (but do not do a left heart catheteriation), do you code the add-on catheterization code 93567? Or, do you code catheter placement and S&I in the aorta?

I'd appreciate your insight on the more complex AAA coding scenarios (using CAT III codes 0078T, 0079T for fenestrated modular bifurcated prosthesis). However, for the aorto-uniiliac prosthesis (34805) with renal snorkel stents, should the conventional stent codes, 37205/06 be used (with cath codes 36245 and stent RS&I)? Op note attached. "PREOPERATIVE DIAGNOSIS: Abdominal aortic aneurysm. Left internal iliac artery aneurysm. Bilateral common iliac artery aneurysm, complex anatomy. POSTOPERATIVE DIAGNOSIS: Abdominal aortic aneurysm. Left internal iliac artery aneurysm. Bilateral common iliac artery aneurysm, complex anatomy. OPERATION PERFORMED: Complex endovascular aneurysm repair with an aorto UNI right iliac Medtronic Endurant device with coil embolization, left internal iliac artery aneurysm. Plug Medtronic occluder device, left common iliac artery, with additional coils placed. Right-to-left femoral-femoral bypass, bilateral renal artery covered stents in a "snorkel" technique and intravascular ultrasound."

This patient has a non-resolving peritoneal fluid collection from previous surgery. They already have an existing abscess tube for drainage. The IR physician injected 2 ml of absolute alcohol along with 2 ml of air. The patient was rotated through 360 degrees and lavaged the anterior of the cavity over the next hour and discharged in good condition. The procedure was performed without fluoroscopy, but spot films taken document instillation of sclerosant alcohol. Code 49084 seems too involved. The coders' desk reference for px's book states this code involves a sm incision, catheter placement, then fluids infused and subsequently aspirated for diagnostics after which the catheter is removed and the incision closed. Code 49400 is only listed as air or contraast being injected and then what about the lavage of the fluid for an hour. There is the 49999 unlisted code or maybe 49084 with a 52??? How should this be coded?

One of our electrophysiology cardiologists performed left atrial appendage ligation using Lariat device. The reimbursement consultant from Sentreheart recommended using code 33999 or 93799 with a possible crosswalk to codes 92987 and 33203. The procedure was performed through epicardial access with left appendage contrast injection. A TEE was also perfomed by another cardiologist by the same practice. Please advise the best possible way to bill this service, what the RVU value should be, and probable allowed amount for this service. As of 9/9/13, the Medicare carrier for IL is NGS.

If a patient has an appendiceal abscess and a drain is placed in the peri-appendiceal area, would this still be coded 44901 per indication? Or would it be 49021 since drain not placed in appendix?

I have a client who insists on coding 61070/75809 to check the catheter on a morphine pump he inserted for back pain. I know this is for checking a ventriculoperitoneal shunt, but one for a morphine pump for epidural infusion?

"Terumo guidewire was used to selectively catheterize the left subclavian vein. A venogram was performed demonstrating the takeoff of the external jugular vein. The external jugular vein was selectively catheterized. A run in the AP and lateral projection demonstrated multiple abnormal engorged venous pouches with venous outflow restriction. An SL 10 microcatheter and Precision Master microwire were used to selectively catheterize the distal pouch. At this juncture the entire distal bulb and pouch were obliterated with a series of Cashmere and Presidio coils. Control venogram revealed complete obliteration near the external auditory meatus and mastoid air cells. The patient woke up with complete cessation of pulsatile tinnitus." Would I use 61626, 75894, 75898, 36012, 36012, 75860, 75820?

When a CVC is placed, is it necessary for the physician to document where the catheter tip terminates (i.e., sublcavian, brachiocephalic, etc.)? Our physicians document location: right femoral, ultrasound guidance used, successful placement, but not where the tip is. Our coding staff state that if the site the cath tip is terminated is not documented they must code to CPT 36000. Any guidance would be appreciated.

When performing IVUS during a venous procedure (either diagnostic or intervention), do you code per vessel evaluated (37250, 75945, 37251, 7594)? Does catheter placement/movement have to be documented to code for more than one vessel? Example: "Following unilateral extremity venography, I introduced an IVUS catheter and carefully surveyed inferior vena cava in its entirety as well as the iliac and femoral veins on the right. I found no occlusive lesion."

Can catheter selectivity be determined in the hepatic arteries when only liver segments are mentioned (i.e., report states, "selective catheterization of segment II hepatic artery... selective catheterization of segment V-VIII hepatic artery... selective catheterization of segment IV hepatic artery")? If so, what are the rules for that?

"Patient had right-sided carotid cavernous fistula and upon imaging before embolizing the right they discovered that a left carotid cavernous fistula was present, so they came back two days later to embolize the left. They performed a bilateral cerebral angiography from the common carotids prior to the embolization, which was performed from the left cavernous sinus via femoral vein access. After embolizing, the physician came back and performed cerebral angiography as a follow-up from the bilateral internal carotids, the bilateral external carotids, and the left vertebral." So my question is, can I code the extrernal carotids as angiography?  Or do I have to consider those a follow-up? Also since the catheter went further and since we code to the highest catheter placement, I am unsure if I should code the highest order and use the internal carotid code 36224 instead of the common carotid code 36223... or should it be 75898?

Vascular surgeon does common femoral to superficial femoral artry bypass using 8 mm PTFE graft. CPT 35661 fem/fem graft per the coders' desk reference states right to left femoral bypass. Should I use unlisted code 37799 in this case? Or could I use code 35661 for the same extremity? Thank you for your advice.

One of our doctors does a number of direct puncture embolization procedures under fluoroscopic and ultrasound guidance. I'm using code 37799, unlisted vascular surgery procedure, with codes 77002 and 76942 for the guidance. Is it appropriate to code both ultrasound and fluoroscopy with the unlisted procedure code?

We are unsure of how to code Amplatzer plug deployed into ductus venosus: "Following sterile preparation and draping and infiltration of local anesthesia, a 21 gauge micropuncture needle was inserted into the right internal jugular vein. A 0.018 wire was introduced. A 4 French transitional dilator was used to exchange the 0.018 wire for a 0.035 Bentson wire. Over this wire, a 4 French Kumpe catheter was introduced. The catheter and wire were guided through the right atrium into the inferior vena cava. The ductus venosus was successfully catheterized. Hand injections of contrast were made, which demonstrated a markedly enlarged main portal vein and left portal vein and a small, but patent right portal vein. The catheter was removed, and over the wire, a 4 French delivery sheath was introduced. Through this sheath we introduced and deployed an Amplatzer 2 plug, 4 mm in diameter by 6 mm in length. Final radiographs appear to show the occlusion device in good position within the ductus venosus. Ultrasound images of the deployment device were also obtained and are retained within the patient record."

My facility performed a venogram of the sagittal sinus from internal jugular vein. Pullback pressures were then measured from the anterior superior sagittal sinus through the left internal jugular vein. I have codes 36012 and 75870, but I am wondering about the pressure measurements. The report contains many detailed pressure readings. Would 93770 be a valid code for this?

If there is clearly defined and appropriate documentation to support additional ablation areas after the PVI (93656) and still treating for a-fib, can we report code 93657 multiple times for each additional linear or focal? Again I want to reiterate that we have the documentation to support the additional areas treated.

Is it okay to report codes 93653, 93621, 93623, and 93642 together even though code 93621 is a add-on procedure without a base code?

Help! My doctors feel that this should definitely qualify for code 93655, but I do not agree. If this does not meet the criteria for code 93655, can you please offer some advice on how to educate my doctors? This paragraph is during PVI procedure. "The patient has typical atrial flutter, which was documented on a pre-admission ECG. The ECG showed flutter waves negative in leads II, III, aVF, and positive in V1. The flutter had a CL of 220 msec. During the procedure today, conduction along the cavotricuspid isthmus was assessed and found to be intact, measuring 82 msec in the medial direction and 80 msec in the lateral direction. Ablation was performed along the cavotricuspid isthmus. Bidirectional block was achieved and was confirmed by pacing and recording lateral and medial to the ablation line. Post ablation of the medial trans-isthmus conduction time was 124 msec and the lateral 120 msec." If it does qualify, can you explain why since it was not spontaneous or induced during the procedure?

I have a question on coding for an acute hospital facility on an outpatient case. Patient has a total chronic occlusion of the RC treated with three drug-eluted stents. Patient also has a bypass of the RC that is not addressed, which is also occluded. He also has angioplasty of two branches of the RC; posterolateral and post descending. The two branches were not totally occluded. My question is, when using C9607-RC for the facility, do we use code 92944 or 92921 for the angioplasties in the branches of the total occluded RC? I am thinking of reporting codes 92921-RC and 92921-59RC because the branches are not totally occluded. The CPT says code 92921 or 92944 may be used as add-ons to code 92943.

"Example: Standard Seldinger technique under US bilateral CFA were accessed with different sheaths. Perclose suture mediated devices were deployed in both CFA and additional 3rd device also deployed in right CFA due to dense calcification even though vessels of decent size. 18 French sheaths placed bilaterally. Abdominal aortogram was obtained. Following review Gore excluded graft is deployed; this is a modular bifurcated graft. Following deployment in the infrarenal location, tapered catheter & Glidewire used to cannulate the gate. Bell bottom device used from the left side, which was placed through the cannulated gate with 3 cm iliac overlap. The proximal end of graft anchored with 30 mm compliant balloon. Right iliac limb is fully eployed with 14 mm balloon. Overlapping left iliaclimb and gate were anchored in place with compliant 30 mm balloon that slowly inflated. Same balloon used to anchor the left iliac vein. Hemostasis was obtained using percutaneous suture mediated device. Hemostasis obtained with no evidence for bleeding with no immediate complications." Is this reported with codes 34803, 36140-RT, and 75952-26LT?

What CPT code would you use for a excision of a superficial temporal artery aneurysm? It looks like one end was clamped and the other end was sutured.

Can you clarify what, if anything, would be appropriate to bill for the following circumstance? "The physician went into the right femoral artery performed a left heart catheterization and stent x 2 in the RCA (overlapping), and prior to getting the patient off the cath table to physician noted the patient had an ST-elevation. He proceeded on with cannulating the left groin to the RCA where the stents were placed and by a guided projection taken showed TIMI III through the RCA with thrombus formation in the nmiddle of the stent. He then placed a balloon, which he had to inflate x 3. After removal of balloon, the thrombus had resolved." What code(s) would the physician be able to bill for the post angioplasty for the thrombus formation? Can we bill anything?

From the NCCI Manual on the topic:

13. Abdominal ultrasound examinations (CPT codes 76700-76775) and abdominal duplex examinations (CPT codes 93975, 93976) are generally performed for different clinical scenarios although there are some instances where both types of procedures are medically reasonable and necessary. In the latter case, the abdominal ultrasound procedure CPT code should be reported with an NCCI-associated modifier.

When the vascular lab performs 93975 and the ultrasound department performs 76775 (kidneys) both for hypertension, can you code both? The vascular physician's read only the vascular and so the kidneys have to be scanned in US so the radiologist can read.

My physician stented the right coronary and the left circumflex when the patient presented with an MI. Can I bill code 92941 for each vessel, or do I bill codes 92941 and 92928 (for the second intervention)? Thank you so much!

 A patient has the following injuries from a MVA, and the surgeon wants to code this as two blood vessel repairs direct. He completes the procedures below. The injury to the aorta was disection of the plaque. Would that be an endarterectomy and not a repair? "Findings: 1) Distal abdominal aortic traumatic injury. 2) Injury of the proximal common iliac vein, at the venous confluence the inferior vena cava.  Procedures 1) Endarterectomy and bovine patch repair of the lower half of the infrarenal abdominal aorta. 2) Primary venorrhaphy of the venous confluence."

Initial Question:

What code do you recommend for bone mass measurement study performed on a DEXA unit? I have a reference that states, "BMM refers to a procedure that is performed with either a bone densitometer (other than single photon or dual photon absorptiometry) or a bone sonometer system that has been cleared for marketing for BMM by the FDA."

Follow-Up Comment:

Thank you. I was told that the equipment to be used is DEXA, and not the same as DXA (as stated in the code description).

"An 18 gauge Caldwell needle was advanced into the peritoneum. Appropriate needle location was documented with cont. sonographic and a paracentesis was performed. The patient's skin was cleaned and dressed. The pt. tolerated the procedure well and was discharged in stable condition. At this time, the Denver Shunt along the left lateral chest wall was accessed with a Huber needle. Manual aspiration demonstrated free flow of ascities. 6 mg tPA was then infused through the upper port of the Denver shunt. Post tPA infusion with contrast under fluoroscopy demonstrated patency of the Denver shunt. The Huber needle was then removed." I planned to report codes 49427, 75809, and 37211, but wanted your opinion regarding my code selection.

Can a doctor image or see the aorta on an angio with the pigtail in the proximal iliac? Not very sure if being a pigtail makes a difference. Does the pigtail need to be within the aorta for the doctor to see the aorta? I have a doctor who doesn't explicitly state that the pigtail was in the aorta when he did an aortoiliac angio (he was treating an ilaic aneurysm). I have read here before that the aortogram could be done with the catheter (or even sheath) in the proximal iliac, but I am not sure if "pigtail cath" makes a difference.

Would you consider the following a reference to determine the age of an “infant”? CPT 99381 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger than 1 year). If hip and lower extremity can be imaged on one film and the patient is 15 months old, would you code CPTs for hip and LE for tech component opps?

I have a left heart catheterization with aortic root, along with a abd-aortic run-off. The physician describes the non-selective renals, then repositioning for the non-selective bilateral ilio-femoral run-off. The bilateral lower extremity angiographies are described in complete detail all the way down to the ankles. My initial thought was 93458, 93567, G0278, and G0275. But he gave such a full and complete seperate report of the lower extremities starting at the iliacs that I felt that maybe I need to drop the G0278 and replace it with 75716-59. What is your opinion?

My IR physician are performing a new sclerotherapy procedure. A drainage catheter is placed into the lymphatic cavity (ie, axillary or thigh lymphocele) under ultrasound guidance, sclerosant agent is infused, and drainage is secured. Patient returns in a few days or week later. Next visit the contrast is injected in the drainage catheter for evaluation. Lymphocele has become infected in setting of obstructed catheter. Drainage catheter exchanged for new. Sclerosant therapy was infused into the collection and drained. How would this case scenario be coded?

When a CABG is performed and harvesting of the saphenous vein graft is performed via endoscopic approach, is the harvesting separately billable (33508)? The CPT code descriptions 33510-33516 include harvesting of saphenous vein graft (ligation is assumed).  Code 33508 does not state whether saphenous vein is included in CABG with this approach or is separately reportable. Please advise.

Is it appropriate to bill code 01520 when Tumescent is used as an anesthesia for endovenous ablation therapy? Or is the "anesthesia" included in code 36475?

Typically, when our physicians perform CPT 93623, it is done during the EP study but before the ablation. We're seeing a case where it's documented as "post ablation testing" and IV isoproterenol was admininistered following the ablation. Is code 93623 billable in this circumstance?

I am having a rough time understanding operative site when coding for percutaneously embolized aneurysms. How many operarative sites are there in the brain? Is it one because we only have one brain, two for left and right side, or can we code per aneurysm? I keep getting different opinions on this and need to get this clarified.

Our patient underwent tunneled intraperitoneal catheter placement for management of malignant ascites three weeks ago. He came back with poor drainage and pain while connected to vacuum bottle. He underwent initial tube peritoneal check and then, due to fibrin sheath, tube was removed and new tube was placed in same subcutaneous tract but different intraperitoneal location. Can you help us with this procedure coding?

I'm thinking I would code this 36147, 37221, 37223. Ultrasound was used to obtain access into the graft. Contrast injected showing severe stenosis involving the external iliac and common iliac veins. This was angioplastied with residual stenosis. Patient has had multiple angioplasties, so I decided to stent lesion. Stent deployed in the common iliac vein into the proximal external iliac vein. Contrast shows residual stenosis involving the distal external iliac vein so I decided to deploy another stent, which extended the stent down to the level of the distal external iliac vein. Attention then directed toward pseudoaneurysm, which was in the venous limb of graft. Stent deployed across pseudoaneurysm to cover it and was pulse dilated. Since the external iliac is part of the peripheral zone, and the common iliac is part of the central zone I think I can code the stenting of both. I'm fairly new to vascular coding and appreciate your input!

Is there a place (like a website) where you can find out what all is included in a procedure? For instance, are IVs and a Foley included in a heart cath? Is a central line insertion included in a AAA? Should you charge if an art line is put in during a procedure?

"Procedure done was flush aortogram and bilateral lower extremity bolus chase angiograms. StarClose left common femoral artery: Ultrasound-guided needle access used to access the LF common femoral artery. A Storq guidewire was passed up into aorta, over which a 6 French brite tip was passed. Through the sheath and over the wire, a 4 French universal flush cath was passed to the suprarenal level of the abdominal aorta. Universal flush cath was passed to the suprarenal level of the abdominal aorta. Flush aortogram was done using 20 ml bolus for a total of 20 ml, after which the universal flush cath was withdrawan to the bifurcation of the aorta to the iliac arteries. Bolus chase angiogram of both lower extremities was done simultaneously using total of 70 ml boluses all the was down to the foot. StarClose placed in the LF common femoral artery."  Would the code used for this procedure be 36140 or 36200? I'm having a hard time trying to figure out if cath entered the iliac artery from the right side also.  Will I need to use G0269?