Ask Dr. Z

Is it appropriate to report code 62362-52 for repositioning of pain pump since a new pocket was created? Or is our only option unlisted code 64999?  "The patient was taken to the operating room and placed supine on the operating room table. After adequate anesthesia was induced the patient's abdomen was prepped and draped in standard surgical fashion. Her old incision was opened in the left midabdomen. A pocket was then formed above the level of the fascia inferiorly. Dissection then was carried over superior and medial to the location of the current placed on. This was dissected free circumferentially from the soft tissue and fascia until free. There was a small fascial defect was repaired using 0 Polysorb in figure-of-eight fashion. The pump was then re\re located left midabdomen the same incision. Secured on all 4 corners with oh Surgilon. The wound is then closed in two layers using running 2-0 Polysorb and 4-0 Polysorb on the skin. Steri-Strips were placed as a dressing the patient returned to the recovery room in satisfactory condition."

"An incision was made paralleling the old scar, and the pacemaker was isolated. The pacemaker was explanted, and multiple attempts with multiple screwdrivers were made to detach the atrial and ventricular leads. The screws were stripped, and the patient is pacemaker-dependent. Attempts were made to access the left subclavian vein, but the lead would not pass at the junction of the subclavian vein and superior vena cava due to an occluded vein. The pacemaker was placed back in the pocket temporarily. A new pacemaker pocket was created on the right side. The pacemaker was implanted, and the ventricular lead was advanced to the level of the right ventricular and sutured in place. The atrial port was plugged. Attention was turned back to the left side. The leads were removed by pulling the leads apart from the headers, and the leads were capped. The pacemaker was explanted, and the pocket was irrigated." Would I bill code 33228 or 33227 since the final result was a single lead system as well as code 33222 for a pocket revision?

I am having trouble coding a primary AAA procedure, which had additional bilateral iliac stents, iCAST stent of right internal iliac, embolization. I will send dictation if needed. The history is 7.6 cm AAA and “very short common iliac arteries bilaterally”. Are the iliacs coded as extensions of the AAA procedure (34802/75952) or as primary iliac stent grafts (34900/75954)? I am leaning toward extensions of the AAA procedure, but the physician also uses a second main body device in the right iliac with failed contralateral limb in right internal iliac. Then an iCAST stent graft is used in the right internal iliac artery. Is this an extension or 37205/75960? There is a third catheter placement from the left brachial artery (additional to the bilateral aorta 36200-50). The catheter goes to the left internal iliac artery (embolization) and then is moved to the right internal iliac artery (iCAST stent). Is this reported with codes 36246 and 36246-59? The MD does angios of both internal iliac arteries (evaluation for left embolization and "identification of right int iliac branches"). Is this included in code 75952, or are additional codes used (75774)?

Is there any coding guidance for Y90 embolization procedures? Also, are there requirements or restrictions regarding physicians who are authorized to performed the radiopharmaceutical therapy or interstitial radiation source application?

Fluoroscopically-guided cannulation of right C6-C7 neural foramen through transforaminal approach for injection of local anesthetic and steroid.  What is the appropriate CPT code for this?

When the interventional radiologist assists the surgeon in the OR, should we report S&I codes if documentation supports coding? The cardiovascular center wants to charge code 76000 as a way of tracking the number of procedures the interventional radiologists assist in the OR. What is protocol for this scenario?

CT-guided core biopsy of a splenic mass. Is this reported with code 49180 or 38999? We would use code 77012 for the guidance portion.

Our physicians order a nuclear stress test, and a pharmaceutical or treadmill stress is performed first. In the documentation the stress test is terminated either with accompanying symptoms (e.g., chest pain or SOB) or no accompanying symptoms. The nuclear imaging is then performed. The codes they include are 78452, 93016, and 93018. Are codes 93016 and 93018 still appropriate since the stress was terminated? Do we append modifier -53 if the termination was per protocol, but with accompanying symptoms, which would put the patient at risk if the stress was continued? If the patient has no symptoms documented during the stress protocol, should codes 93016 and 93018 be billed at all?

My office just started doing vein ablations in our clinic, and I'm having trouble figuring out what I should be billing for. For the ablation itself, the first vessel we bill code 36475, and if a second vessel is done I bill code 36476. The part I'm confused on is the guide wire. I know when the hospital was doing the procedures they bill out for the guide wire using HCPCS code C1769; however, the physicians are not able to bill that code out. What code would you suggest using for the guide wire?

If a physican places a stent at the time of an AAA graft, but he specifically states it is for stenosis, do you use code 37221 or 34825? It is placed inside the distal portion of the graft down to the external iliac stent that was placed at a previous session.

MD selects the right innominate artery and describes the right common carotid and the right vertebral. Can both codes 36222 and 36225 be submitted from the one catheter placement?

If an embolization was performed either in the cerebral (61624) or extracranial (61626) vasculature, and a diagnostic angiogram was NOT performed (let’s say it was done the day prior or somewhere else), you code for the embolization and the selective catheter placements for each vessel selectively catheterized in order to drop the coils, correct? For example, a meningioma off the IMA, and we embolize three arteries in order to block blood flow... would be coded as 61626, 36217, 36218 x 2, right?

I'm trying to discern between using codes 61624 and 61626. The patient has a sigmoid sinus dural AV fistula, which was embolized in two sessions. The arterial feeder is off the right occipital artery. The venous portion is the sigmoid sinus. Initial treatment/embolization of the fistula was performed solely via the right occipital artery feeder. The follow-up treatment involved embolization of the occipital artery feeder and sigmoid sinus. The fistula connects the extracranial vascular system to the intracranial vascular system, it seems. Would code 61624 be appropriate for both procedures regardless of the site of embolization (occipital artery feeder only vs. occipital artery feeder and sigmoid sinus)?

An angled Glidewire was then passed through the short sheath to the level of the aortic arch and exchanged for a vertebral catheter, which was guided into the right subclavian artery, and the vertebral catheter was exchanged for a 6 French shuttle select sheath passed over a stiff Supracore wire. Innominate right subclavian and right common carotid angiography was performed and allowed us to localize the site of triple lumen catheter placement as the proximal to mid right subclavian artery. Using balloon occlusion using a 6 x 20 mm balloon, we had the anesthesia service remove the triple lumen catheter from the neck. We then elected to treat this by deploying a 6 x 16 mm iCAST covered stent because there was a fair amount of bleeding coming from the right neck, and angiography performed at this point revealed what appeared to be bleeding pseudoaneurysm. The balloon occlusion portion is stumping me. I don't think I should use code 35475.  Thoughts?

I code for both the primary and assistant surgeons. The primary surgeon from the first procedure was the assistant for the second and visa versa. How do you code one procedure that turns into two, that stretches from 7:45 am to after 4:30 pm on a patient that exceeded 400 lb? They did a bilateral femoral artery cutdown, with attempted deployment of aortobiiliac unibody graft. They added a micropuncture to the left brachial artery for additional access. In addition to the patient’s size he also had severe tortuosity of both iliac arteries with at least two 90 degree bends. They had difficulty unsheathing the right limb, and after many attempts to unsheathe the limb and a broken wire, they decided to move to the OR where they performed an open AA aneurysmorrhaphy with aortobiiliac bypass. After thoughtful research I feel that the following is correct, but I would like a second opinion. Surgery 1: 34812-50, 36200-RT, 36200-59LT, 34804-53, 75952-26. Surgery 2: 35102-2278. One of my concerns is that code 35102 will be bundled into code 34804 due to NCCI edits.

There is a "0" edit in NCCI for codes 0205T and 92978. If we do spectroscopy (0205T) and/or IVUS with the same catheter, how do we code this?

 When doing intercostal angios for the purpose of a retroperitoneal hemorrhage, do you use code 75705 or 75726?

I work for an acute care hospital facility. Patient arrives in process of having an STEMI. The physician describes multiple "culprit" lesions and doesn't identify only one as the cause of the MI. Is it correct to code more than one intervention utilizing the acute MI codes such as C9604, C9606, and 92941 if the physician decribes several culprit lesions?

The interventional radiologist orginally punctured the right common femoral and then catheterized and imaged the left hypogastric. He then selectively catheterized and imaged the left superior gluteal, left inferior gluteal, and the left iliofemoral arteries. I have the following codes so far: 36247, 36248 x 2, 75736, and 75774 x 3. He then catheterized the left circumflex iliac artery and the left inferior epigastric artery and did diagnostic imaging in both. I am not sure how to code these two in addition to the codes above. All of the imaging was done to check for bleeding. Patient is post trauma with internal hemorrhage.

In an earlier Q&A, you recommend code 92941 for treatment of an MI with angioplasty, atherectomy, OR stent placement... or all of these. If a drug eluting stent is used, code C9606 applies for hospitals. Would code C9606 be the correct code to report if the patient had ONLY a drug eluting stent placed in the LAD?

How would you code the procedures listed? I couldn't fit the entire report. PROCEDURES PERFORMED: 1. EP study with right atrial CF, His bundle RV pacing and recording. 2. 3D mapping with Carto 3 system. 3. Double transseptal puncture. 4. Intracardiac echo. 5. Pulmonary vein isolation. 6. Cavotricuspid isthmus ablation. 7. Left atrial roofline, anterior line, septal anterior line, mitral isthmus line, and intracoronary sinus linear ablation were all performed to treat that annular flutter and to reinforce documented previous lines from the procedure in 2006. 8. Mapping and ablation of a micro reentrant focal arrhythmia from the anterior wall of the left atrium. 9. Intracardiac adenosine push. 10. Fluoroscopy.

I've heard from several people (who listened to a webinar today) say that collateral vein embolization does not require deleting code 36147 and replacing with 36011 and 75791 in addition to embolization codes. And that code 75791 would never be used in an IR case - only in OR if a patient was received there with an existing access. Your thoughts?

What do you suggest for nodal basin ultrasound exams? Our facility is doing these along with breast ultrasound. Are these include in breast ultrasound? Per our facility they are doing these for supra and infra clavicular nodes. Please advise.

Following an open thrombectomy of upper extremity AVF (36831), a fistulogram was obtained (75791). Stenosis was found in cephalic vein (a distance away from the anastomosis), and angioplasty was done (35460 75978). Would it be correct to code the fistulogram since it was done post procedure? Per the doctor the stenosis could not be viewed until after the removal of the thrombus, which resulted in the angioplasty.

We are using Doppler in suspicious breast lesions to assess the presence or absence of blood flow suggesting cancer versus a cyst. Are we able to charge for this separately, or would this be considered part of the breast ultrasound? If so, which code would be appropriate? Same situation regarding liver scan looking for tumor where direction of portal venous flow is documented?

What would be the correct coding when changing out ICD generator, capping atrial lead, capping the charging part of RV lead thus leaving the pacing part of RV lead and inserting single pacer generator?

If a physician documents "recent non-ST evelvation myocardial infarction" as the indication, but the patient is not brought to the cath lab acutely, would code 92941 be appropriate for DES/BMS placement? Or would code 92928 be better? Several of our physician are documenting non-ST elevation myocardial infarction for indication for the procedure, but patients are not being brought to the cath lab for several days. I have been using codes 92928, 92920, 92937, etc., because the description reads "during acute MI". Is my thinking correct?

There seems to be some confusion with me and my co-workers on how to code for nephrouteretal stent exchange to a percutanoues nephrostomy. Can you please tell me what is appropriate to report for a nephroureteral stent to PNC exchange? Do we code for a PNC exchange (50398/75984), or do we code for a PNC placement (50392/74475 with a 52 -modifier)?

The patient presents with an acute MI, and the doctor states, "It is unclear if the circumflex or the RCA is the culprit lesion."  The physician subsequently stents both (each vessel having about 90% stenosis. Should I report both using code C9606 (hospital coding)? Or report C9606 only once along with code C9600 (if so, which vessel gets assigned code C9606)?

What is the correct coding for MR enterography? We are getting pushback from a major payer, and I was wondering if there is any guidance out there. "Report includes GI tract, abdomen, and pelvis. "Technique: Axial, coronal, and sagittal T2 HASTE; axial T2 fat-sat; coronal pre and post-contrast VIBE; axial post-contrast VIBE."

My question is, can you report codes 37204/75894 and unlisted code 37799 on this particular case since there was a direct puncture embolization and a transcatheter embolization of the same malformation? Or would they be included in one another? Could you advise us on which direction you would take with this one that would be great. "Medical History: Hepatic arteriovenous confirmation Procedure: 1. Right common femoral arteriogram. 2. Celiac arteriogram. 3. Left gastric arteriogram. 4. Hepatic AVM embolization in 2 areas. 5. Starclose. Medications: Per anesthesia. Contrast: 100 cc Visipaque. Fluoro time: 27.2 minutes. Complications: None immediate. Technique: After the risks, benefits, and alternatives to the procedure explained, written informed consent was obtained. The patient's placed in supine position on the angiographic table and time out performed. The right groin and right abdomen were prepped and draped in sterile fashion and skin site anesthetized with Xylocaine 1% without..."

I have run across a couple of situations (post-discharge) where the order and the radiological exam do not match exactly. For instance, a patient came in through the ED with pain that radiated from her abdomen down to left leg with history of pelvic fx last year. Pelvic x-ray was negative and lumbar x-ray w L3 fx indeterm age. So, the physician ordered MRI. The computerized order was for “MRI Lower Extremity Joint Left WO Contrast” (CPT 73721). It doesn’t look like the physician was actually looking for joint pathology. So, based on medical necessity, and the MRI report makes no mention of joints (mentions no fem neck fx or pelvic fx, etc.), it looks like the order should have been for non-joint (as in 73718 or 72195). Ideally, this order should have been corrected at the time of service. As this issue has been found after the procedure was provided and the patient was discharged, what is the best way to compliantly handle this situation? Code 73721 has been denied for medical necessity, and I would like to re-bill this with code3 73718, as this appears to be what the order should have been.

I could not find a CPT code for this px. Is code 76000 sufficient? "Transnasal sphenopalatine block. Clinical history: 35-year-old female with chronic headaches, referred for a Sphenocath procedure. The patient's nostrils were first anesthetized with 2% lidocaine via an atomizer. A Sphenocath catheter was then inserted in the left nostril with the patient in supine position with the head tilted back and in Trendelenburg. 1.5 mL of a mixture of Visipaque and 4% lidocaine was injected in the right nostril with the spheno-catheter in appropriate position. Fluoroscopy confirmed that the mixture of contrast and lidocaine accumulated in the sphenoethmoid recess. The catheter was removed and placed in the right nostril. The procedure was repeated as above. Conclusion: Successful injection of transnasal lidocaine and contrast into the sphenoethmoid recess. Fluoroscopy time 1.1 minutes Air Kerma 1 Dose area product of 0.21 cm square."

Can code 37250 be reported in conjunction with code 37215? Or is it considered included?

Original Question: What would be the proper coding for a stent graft revision and bilateral renal stenting?

Follow-Up Info Provided: The original stent graft was an Endurant II stent graft, and the physician placed an Express SD renal stent into both renal arteries.  It was a percutaneous approach for the renal stenting.

We had a patient who needed a pacemaker in place for anticipated surgery, but could not have a permanent pacemaker due to infection. So a permanent lead was placed in the right ventricle through the jugular vein and attached to a new single chamber permanent pacemaker externalized. What can I charge in this case?

"Patient with large bilateral Saddle embolus. Access via RCFA. Catheter was used to select the main pulmonary artery. Angiogram was performed, confirming thrombus present in all lobes. 5 mgs of tPA was administered intra-arterial on the left. Right common artery was then selected. Angiogram was performed, confirming thrombus present in the right upper and middle lobes. 5 mgs of tPA was administered on right. Catheter was removed. IVC filter was then placed, and IVC-gram done before and after filter placement. Bilateral selective renal venogram was done." Per your seminars I am saying that we can't bill a procedure for the injections of the tPA. Is this correct? If a procedure can be billed, what CPT code would be used?

Patient with a stent graft in the proximal to mid descending thoracic aorta who is 8 months out s/p. Now with enlargement of not stented area (thoracoabdominal aneurysm repair). Physician performed the repair with stenting thoracic and abdominal aorta with total of four stents starting from abdominal aorta bifurcation and last one overlaps the previous stent in thoracic aorta. Is this correct to code aneurysm repair in the thoracic aorta (36200, 33881, 75957) with proximal extension (33883, 75958) and abdominal aorta aneurysm repair (34800, 75952) separately? Does the way the physician builds the grafts in thoracic aorta (proximally or telescopic way) affect coding (e.g. in this case the main body first in distal thoracic with one extension proximally to overlap with previous stent)?

Do I need a modifier on code 93458 for the initial diagnostic exam with the C-codes for the PTCA?

I have always used these together, per your instructions, for catheter checks. "Patient had a non-functioning port. Port is accessed and contrast injected. After which, a thrombolytic is injected." The new coding system that we are using is giving me an edit that states they are mutually exclusive. Has something changed?

When a right hypogastric artery embolization is performed along with a stent and angioplasty in the right external iliac artery, may we also code the catheter placement for the embolization? Or is it included in the external iliac intervention?

Physician harvested saphenous vein endoscopically (33508). Vein is no good, so same procedure is performed on the opposite leg. Can he bill code 33508 two times?

A physician is doing a dual chamber pacemaker exchange and finds the RA lead has fractured and the RV lead has dislodged. He removes the device, removes the RA lead, places a new RA lead, repositions the RV lead, and then replaces the device. We were told to report codes 33206, 33235, 33233, and 33215. I see that code 33215 is an NCCI edit to code 33206. Can they be charged together?

We are debating over two sets of codes for this situation. The patient presented for a generator replacement of a dual chamber ICD. They discovered the old RV lead was defective, so they capped the old RV lead, inserted a new RV lead and a new dual chamber ICD, and lead and device testing were performed. The department reported code 33241 for removal of pacing ICD generator only, 33249 for insertion/replacement of ICD system with single or dual leads, and 93641 for DFT testing at time of implant. The coding department chose code 33263 for removal and replacement of ICD generator and dual lead system, 33216 for insertion of a single transvenous electrode, and 93641 for DFT testing at time of implant. Which set is correct and why?

In your Diagnostic Radiology Coding Reference book, page 212, item 10, it states it is appropriate to report code 76645 when ultrasound is used to externally mark the breast for subsequent biopsy or aspiration. Does this concept apply to all biopsy/aspiration procedures (e.g., thyroid biopsy)? If yes, do we need to append a -52 modifier to the limited scan CPT since it is not a complete scan?

Is code 38382 appropriate for percutaneous embolization of thoracic duct, or should I use an unlisted code? The procedure is described as follows:

Abdominal percutaneous approach. After reconfirming the intraductal location of the catheter, 6 fibered platinum embolization coils were deployed from the distal chest down to the cisterna chyli in the proximal abdomen. Subsequently, a 2:1 Ethiodol and N-butyl cyanoacrylate glue mixture with tantalum powder was injected through the catheter to complete the embolization of the distal thoracic duct and cisterna chyli. The catheter was removed while aspirating to minimize extravasation. Final spot radiographs of the chest and abdomen were then obtained to document the position of the embolic implants. Findings: Coil embolization of the thoracic from the distal chest down to the cisterna chyli. Distal thoracic duct and cisterna chyli sealed with N-butyl cyanoacry liquid embolic glue.

How would I code the following stent placement?

A 5 French terminal angled glide catheter was advanced over a Glidewire through the right femoral sheath into the right internal jugular vein. Right internal jugular venogram was performed. This confirms the placement within the normal-appearing jugular vein. The 5 French angled glide catheter was then advanced through the femoral arterial sheath into the right internal carotid artery. Cerebral angiogram was not performed. This shows a normal appearance of the internal carotid artery as well as the anterior and middle cerebral arteries. The parenchymal phase is normal. The venous phase is normal aside from the severe stenosis of the right transverse sinus. The microcatheter was exchanged over an exchange length Synchro 2 microwire. A Precise stent 9 mm x 30 mm was advanced over the wire into the internal jugular vein. By advancing the guide catheter into the sigmoid and transverse emesis, the stent was delivered across the stenosis and deployed.

My physician did a select catheterization placement in the bilateral common carotid, bilateral internal carotid, bilateral external carotid, bilateral vertebral, and bilateral thyrocervical trunk. Would it be correct to report code 75774 x 2 for the thyrocervical trunk catheter selections?

I have coded a sacroplasty with 0201T and 72291 for S1-S2 cement augmentation. Medicare is telling me that this code is invalid (0201T). I have referred to your book, and this is what you have suggested. Could you shed any light you have on this please?

If a patient has a superior vena cavagram and then a tunneled dialysis catheter without port, can you report both codes 75827 and 36558?