Ask Dr. Z

Can you please tell me what the documentation requirements are for code 76998 so it can be charged? We have a case where the physician did a D&C using ultrasound guidance. The provider clearly documented the use of the ultrasound in the operative note as well as the findings, yet there was no permanent film taken. Does an intraoperative ultrasound require permanent images?

When performing common and internal carotid angiography from the common carotid, how can you determine whether it is intra-or extra cranial? For example: would this be reported with code 36222 or code 36223? "The catheter was then removed over the wire, and an Biomet catheter advanced over the wire and pulled back to engage the left common carotid artery. The wire was removed. Carotid angiography was performed, given the patient had an occluded right carotid artery and moderate disease in the left internal carotid artery. 1. There is diffuse atherosclerotic plaque disease in the common carotid artery of 30% to 40%. There is calcification present. The internal carotid artery is patent with 40% plaque disease present."

If just aortic pressures are taken (during a catheterization without mention of where the catheter ended up/placed), would that constitute charging/coding a left heart catheterization?

Occasionally, a neurosurgeon will order a shunt survey on a previous placed shunt. At my hospital, the radiologist just has the technologist x-ray the skull, c-spine, chest, and abdomen to view the entire shunt. We do not inject contrast. Currently we have a bundled charge that includes each of these codes (and charge a lesser dollar amount). Should we use CPT code 78645 instead?

What code should we use when a TriVex system is used to resect varicosities? Should this be reported with code 37799, 37765, or 37785?

Could you please describe in detail what is included in a complete abdominal aortogram? I frequently code abdominal aortograms with bilateral leg run-offs with findings of the abdominal aorta and renal arteries only. Am I to add modifier -52 to code 75625 because the mesentary arteries weren't mentioned? Or are the findings for aorta and renals sufficient for a complete abdominal aortogam?

My physician performed a cutdown thrombectomy on PTFE dialysis graft arterial and venous anastomosis. Then he angioplastied the venous stenosis (severe recoil) and then placed a stent. The problem is, when he closes the graft he patch angioplastied, does this make it a revision of a dialysis graft? I know if we code this to a revision then the angioplasty and stent code are bunded. So do I code this as either: A) 36833/75791-2659, or B) 36831/75791-2659, 35460-51/75978-26, 37207-51/75960-26?

If both the right and left subclavian veins are angioplastied (patient has SVC syndrome), is this coded as one venous PTA (35476/75978) or two? The CPT mentions that you can only code for one central vein lesion no matter how many are lesions are treated. But, it also goes on to mention (page 206 in the 2013 professional edition) that regardless of the distinct lesions treated within this segment. What do they mean by the words "this segment"? Does it matter if the catheter has been advanced beyond the SVC to the contralateral side of the body? I can report codes 36011/75791 instead of code 36147, but I wanted confirmation on if this is truly just one PTA. Thank you.

I have a simple question that probably you can address. I have a case that I am auditing that involves an embolization of an AV fistula brain. I am recommending code 61624, but my question is regarding the catheter access. The radiologist punctures the arterial side and the venous side for proper embolization. I know to only code the embolization code once, but can I code the catheter placement for both vascular systems (36215 series and 36011 series), as he accessed the femoral artery and femoral vein? This case would follow CPT coding guidelines of 2012.

During an AAA (34803 75952) repair two docking limbs from bilateral cutdowns (34812-50), the left docking limb did not deploy within the gate of the modular device. A brachial artery access was obtained, and na aorta-uni-iliac graft was placed on the left side. Would you consider this placement of the aorta-uni-iliac graft to be a part of the AAA graft since it was used to correct a problem in placement of the AAA graft? Also if it is not considered part of the AAA, would you use extension cuff (34825/75953) since code 34805 is mutually exclusive with code 34803?

I am coding a case of a dissecting aneurysm of the supraclinoid left internal carotid. The physician used a Y-stenting technique without the use of coils to divert flow and "occlude" the aneurysm. One stent was placed in the supraclinoid ICA and A1 segment. The M1 segment was selected through an open cell of the previously deployed stent, and a second stent was deployed in the supraclinoid ICA and M1 segment, bridging the aneurysm. This created aneurysm occlusion through flow diversion. Would this be coded as an intracranial embolization with code 61624, or should I use an unlisted code? I have read that this is a new technique used for wide-necked aneurysms, aneurysms where the emanating branches are incorporated in the sac, or it's a giant aneurysm causing mass effect.

Code 37197 is for percutaneous retrieval of vascular foreign body. If physician has to use cut down during the process to retrieve, would code 37197 apply (modifier -22 perhaps)? Scenario is stent retrieval, but stent had partially deployed, so small cutdown had to be made. 2nd scenario, stent same as above but physician retrieved during cut down only. Is this unlisted?  (No surgical repair to vessel at all.) Thank you much!

Follow-Up Information Provided Upon Request: No surgical repairs to vessel at all.

For code 76937, I thought I had read before that during a case this could only be billed once due to the code description. It mentions "evaluation of potential access SITES". For some reason I remember someone telling me that or reading it somewhere, and I just wanted to double check.

I thought that in your book you referenced Medicare guidelines regarding diagnostic test (75710) done the same day as an intervention. But I can't seem to find it. I need to show one of my doctors that it does indeed come from Medicare and not something I made up.

My doctor is reporting code 35646 for performing aortoiliac occlusion, but he also wants to bill code 35697 for reimplantation of the IMA to the right limb of the bypass. This is an add-on code, and I cannot find any guidelines that state what the primary code should be. Can you please help?

I have included a report for transcutaneous oxygen monitoring. "Indication: Left Heal Ulcer Interpretation: Probes calibrated to 45 degress c and all 4 electrodes calibrated to 158 mmHg. 1. The control electrode was placed on the second interspace, left anterior chest wall. After 15 minutes of room air it read at 46 mmHg, and after 10 minutes of 100% oxygen 144 mmHg. 2. The second electrode was placed at the left medial ankle. After 15 minutes of room air it read at 46 mmHg, and after 10 minutes of 100% oxygen it read at 204 mmHg. 3. The third electrode was placed at the left foot dorsum between the first and second metatarsal. At 15 minutes on room air it read at 56 mmHg, and after 10 minutes on oxygen, it read at 138 mmHg. 4. The fourth electrode was placed at the left foot dorsum between the fourth and fifth metatarsals. After 15 minutes on room air it read at 69 mmHg, and after 10 minutes of 100% oxygen it read at 141 mmHg. Conclusion: Based on these readings, patient has adequate tissue perfusion at the areas tested with adequate response to oxygen. Oxygenation should be adequate for tissue healing at the areas tested."

Would you tell me how to code this service? 93922-26-52 physician? 93922-TC-52 outpatient hospital? I have to render an opinion to providers and management that believe TCOM can be billed with code 93922 or 93923 and no reduced modification. No ABIs are performed. Please help me with an explanation that includes references and your expert opinion.

I know I have read somewhere in your vast array of knowledge that the catheter must be in the aorta to do a true aortogram and not just the the access site of the common femoral.  I have looked and been unable to find and was hoping someone would know it right off.

This patient had renal artery embolization for a large renal metastatic mass. There are two left renal arteries. The vascular surgeon does an angiogram and embolization of the left UPPER pole renal artery in a third order branch, as well as an angiogram and embolization of the left LOWER pole renal artery in a second order branch. Does this represent one surgical site? And therefore only one 36253, 37204, 75898 set of codes? In your Interventional Radiology Coding Reference, I see that the right and left kidneys represent two surgical sites. But I don't know about two arteries on the same side. And would code 75894 only be reported once for follow-up? Thank you very much.

Our NIC department is charging codes 93505, 76932, 93308, and 93321 for echo-guided endomyocardial biopsy. Please advise if codes 93308 and 93321 should be charged with code 76932 since code 76932 includes echocardiographic guidance? Also, if codes 93308 and 93321 can be reported with code 76932, is there enough documentation in the report to support these codes?

Procedure: The right neck was prepped and draped in a sterile fashion and anesthetized with 1% Lidocaine. Using Seldinger techinque by the central approach with ultrasound access, the right internal jugular vein was then punctured. Through this, a 6 French sheath was inserted. A 6 French bioptome was inserted and advanced to the right ventricle. A total of five specimens were then obtained from various places in the right ventricular apex and septum. The bioptome and sheath were removed, and adequate hemostasis was obtained. The patient was monitored for the next half an hour. The five specimens were sent down to pathology for analysis. Transthoracic echocardiography for endomyocardial biopsy monitoring study completion: There were no apparent complications. 2D measurements Left ventricle LV internal dimension, ED, chordal level, PLAX 50 mm LV internal dimension, ES, chordal level, PLAX 34 mm Fractional shortening, chordal level, PLAX 32 % Ejection fraction 68.6 % Cardiac Anatomy Left ventricle: The cavity size was normal. Wall thickness was normal. Systolic function was normal. Doppler Tissue Imaging: Doppler tissue imaging of the posterior wall demonstrates an E wave velocity of .28-.29 m/sec. Study Conclusions Left ventricle: The cavity size was normal. Wall thickness was normal. Systolic function was normal. Doppler tissue imaging of the posterior wall demonstrates an E wave velocity of .28-.29 m/sec. This is suggestive of the absence of rejection.

How many times can code 37202/75896 be reported for treatment of intracranial vasospasm? Is this code reported per vessel, per vascular distrubtion, or per operative field? For example, if vasopressin is administered in the RICA, LICA, and LVERT for treatment of vasospasm in each of these vessels, how many units of 37202 and 75896 would be reported?

Patient had a port-a-cath in left jugular. During chemotherapy, he complained of severe pain and so presented for catheter check. Fluoroscopy indicated that the catheter was dislodged from the port and was within the right atrium and ventricle. This was removed with the use of fluoroscopy and an ensnare. Then incision was made over the port, and it was removed. I am not sure how to code this, so I would appreciate your help.

We have a question regarding FNA of thyroid nodules. We have a physician who mentions in his report that he is doing a capillary and suction technique, but never mentions FNA. When we say we need documentation for FNA versus core, his reply is "capillary and suction technique" is FNA. Can we assume and code these as FNA? Please advise.

Is code 75989 reported per site drained or by modality used for the procedure? For example, a single pelvic abscess is visualized with ultrasound and then accessed under fluoroscopy with a Yueh needle and drained. An APD catheter is placed after the Yueh is removed. I'm thinking one abscess - one access under fluoroscopy - 1 drainage = 49021, 75989.

You have addressed sclerotherapy several times, and I am still confused (sorry...but please help). "Procedure: Ultrasound guidance for needle placement. Procedure: Sclerotherapy, multiple veins. General endotracheal anesthesia. US Guidance with documentation. 25 guage needle into AVM. Right foot contrast was injected. Venogram was performed. Foam sclerosant 1% injected. Venous malformation opacifies." No mention of varicies, but I don't see that code 36471 is for varicose veins only... just specifically legs. Would you code the above as 36299, 76496, and 76397? Or simply 36471 (multiple veins)? Also, would you only use code 37799 if scleroablation with alcohol?

It is my understanding that you cannot bill a stent or angioplasty when done for maceration of a thrombus unless there is an underlying stenosis. Would this apply to ANY stent or angioplasty regardless of where it's done (i.e., pulmonary artery)? Thank you for your help.

I have LARIAT reps arguing with me about whether the LARIAT procedure is investigational or not. I think maybe the DEVICE is no longer investigational (although the ZHealth book says it is – it must have JUST been approved).  Do you have any insight on the procedure that has occurred since your book was published?

Could you please tell me if I can charge for our radiologist's following procedure?  And if so, what is your suggestion?  "Non-imaging access of an Ommaya port along the midline of the vertex subcutaneously of the skull.  He withdrew 5 cc of spinal fluid then infused methotrexate at 1 cc/min."

I submitted a question a few minutes ago. Actually, the patient had Dextro-transposition of great arteries since birth. "Procedure abstract: The right coronary artery was engaged, and selective angiogram was performed on the right coronary artery. Administered some 2.5 mg of verapamil and 100 mcg of interarterial nitroglycerin. Selective angiograms were performed of the left coronary artery. Catheter advanced into the systemic ventricle across the aortic valve, and an AP ventriculogram was performed."  What would you recommend as the best code for this procedure?

How do we code for imaging of left axillary-bifemoral bypass? It was through the left brachial approach. They did an angio of the arm first to evaluate the anastomosis and axillary artery. Advanced the catheter into the bypass graft and evaluated the graft. Further advanced the catheter "into the descending graft proximal to the left groin" and evaluated both lower extremities. Should we use cath code 36215? And angio codes 75710 (for left arm evaluation) and 75716 (for bilateral leg angio)? Thank you so much!

I have a question about abscessogram with drainage placement. Patient's drainage catheter was removed in prior surgery. Now after three days sinogram was done, and it showed continuted fistulous connection with the J pouch, so a drainage catheter was placed. Since there is no existing catheter, I do not think we can bill code 49424 for abscessogram... but can we bill codes 20501 and 76080 with codes 49021 and 75989 for this case?

Patient presented to the ER after biliary drain fell out. Initially the tract was recanalized with a Kumpe catheter and a Benston wire. Following a diagnostic study, the tract was dilated, and a new 8.5 Dawson Mueller external biliary drain was replaced. Can we report this with codes 47500/74320 and 47510/75980?  Or report this as a replacement with code 47525? If we code this as a replacement, how do we capture the diagnostic study?

I have a question about the new external carotid artery code. We performed a bilateral nasal embolization for epistaxis. On the left side, we did a common carotid injection, followed by superselective ECA injections and embolization. On the right side, an ECA injection was done, followed by superselective ECA injections and further embolization. I know on the left we charge codes 36222 and 36227, but what about the right side? Since code 36227 is an add-on code I know we can't charge it by itself, but I don't know what else to do. Your help with this is very appreciated!!!

I need some additional information regarding the new TAVR Category III code 0318T.  What is the exact definition of this code?  When and how do you choose from using the "T" code vs. code 33365 for a transaortic approach?  I have come across some information that leads me to believe that the "T" code is more appropriate for an "invasive" total open chest, whereas code 33365 is more for the "minimal" incision and access through the ribs.  Can you please provide some clarification?

Please advise on how to handle these two scenarios:  1) Hospital charged codes 93653, 93621, and 93613, and they edit out.  2) We charged codes 93656 and 93609, and they edit out.  Please advise on what we are doing wrong.

MD states he places catheter in aorta does abdominal arteriogram then goes on to tell what he sees in the lower extremities but does not move the catheter. Then he moves catheter to birfurcation and goes from the right to the left external iliac and does an arteriogram which show coral-reef plaque. What is the correct way to bill?

In regards to dialysis access management, my IR practice has a question. If I perform a declot/or fistula gram/graftogram with venous angioplasty on a patient today and schedule them for a follow-up "maintenance" venous angioplasty at the venous anastomosis/site of stenosis in 30 to 60 days after the this procedure, because I am concerned about a recoil stenosis, can we still bill and collect? Are there any issues with reimbursement (technical or professional) for the procedure being denied? Is there a specific history we have to put down to get paid for these "scheduled" venous angioplasties?

Would you code a distal external iliac artery to proximal tibial artery bypass with reverse greater saphenous vein with 37799? I haven't been able to find any info for the external iliac, only femoral to tibial. I wondered, since it is a "distal" external iliac if code 35566 might be considered instead of the unlisted code? Thanks for your help.

Is a biliary brush biopsy coded as 47552 or 47553? Please explain what the difference is between these two codes.  Also, what code would be used for a percutaneous aspiration biopsy via the biliary tract? Thank you.

For example, 93458 done, and femoral angio performed with the intent of placing a closure device. Decision made not to place the device. How should this scenario be coded? Also, same scenario and closure device was placed how should that be coded? Within our cath lab we have debated this round and round and I would like the clearest guideline. 

Id really appreciate your help with codes for this procedure. Patient with a postoperative gastric fistula. Contrast study of the fistulous tract showed gastric fistula at the ampula. The drainage catheter was removed and a short Berenstein catheter was advanced is positioned at the gastric fistula. A microcatheter was then advanced to the fistula. Transcatheter embolization was then performed using 2cc on nBCA adhesive along the length of the fistulous tract as the catheters were withdrawn. I'll assign 20501 and 76080 for the study, but I can't find a code for the embolization of the fistula tract? Thank you!

For a fibrin sheath disruption during a CVC exchange, I know the appropriate codes are 36595/75901 with -52 modifier, if via same access site. My question has to do with billing 77001 at the same time. Is it appropriate to code the fluoro along with an S&I code or would they be inappropriate together since both are radiological guidance procedures via the same anatomotical site? Thank you!

When charging for 76937 does the radiologist need to document that the images were saved even though we did save them. We are documenting that the vessels are patent as well. I read someone else that it wasn't necessary to document that it was saved.

Hi, I have researched your Q&A and found that it is appropriate to bill 36015 when selective catheter placement in a PDA via the aorta is done. However, I am not sure what to do with a catheter placement in a PDA via the pulmonary artery with angiography. Can you please review the attached documentation an let me know if I can bill for the catheter placement into the PDA and which angiography code I should use, 76496, 75774, or perhaps since the aorta was described can I use 93567? A RHC & LHC was also done. Thanks so much for the help!! 1. Cameras are in the straight AP and lateral position. There is a Berman catheter placed across a femoral venous sheath with the tip into the right ventricle. With injection of contrast, the right ventricle is dilated and heavily trabeculated with preserved systolic function. There is no evidence of significant tricuspid regurgitation. The patient is status post hybrid Norwood procedure. The PDA stent appears to be widely open. There is good retrograde flow into the native ascending aorta. The distal right pulmonary artery appears to be normal in size. 2. Cameras are still in the same position. The Berman catheter is now placed across the main pulmonary artery with the tip into the distal PDA stent. With injection of contrast while the balloon, at tip of the catheter, is inflated, there is good flow into the native ascending aorta. The distal left pulmonary artery also appears to be of normal size. 3. The Berman catheter is now pulled back to the proximal portion of the PDA stent. With the balloon inflated, there is flow into both branch pulmonary arteries that appear to be filling very faintly. The narrowing at the proximal pulmonary artery is at the level of the previously placed band.

Dr. Z, one of our auditors had this question for you. thanks! Summary of Op Report: The pocket was opened and a BIV ICD was removed and replaced with a biventricular pacemaker. The three existing leads had good sensing, pacing parameters and impedences and were retained and attached to the new biventricular pacemaker. The pacemaker was programmed the same way as before and the wound was closed. This claim underwent a coding audit where the auditor recommended removing CPT 33229 and replacing it with 33221. My understanding of 33221 is that it is for insertion only pacemaker pulse generator for those patients who do not already have a pacemaker; while 33229 includes both the removal of existing pacemaker as well as insertion of new pacemaker. Please advise. Thanks

I have a question in regards to code 36011. Can you use this code to represent an innominate/brachiocephalic vein. The physician states that he performed the following: "Innominate vein injection: demonstrated no venovenous collaterals and a normal superior systemic venous system."

We come across a case where patient admitted for lumbar puncutre/fluoroscopic guidance under day surgery status after the procedure patient taken to the recovery later developed severe headaches so broght back to the IR suite blood patch under fluoro guidance performed. Are these considered one session so code 77003 only once as session means same encounter? Suppose if these procedures performed in OBS setting first day lumbar puncture and second day blood patch both under fluoro guidance how do we charge 77003? Please explain. Thanks

I have a question about a perm cath exchange. An existing right IJ perm cath needs to be exchanged due to infection. After looking with ultrasound, it was determined there was no other appropriate access available. So, existing perm was removed, a new tunnel was created (keeping the existing access to the right IJ), and a new perm cath was inserted. Should this be charged as an exchange (36581) or as a new perm placement (36558)? You help clarifying this would be greatly appreciated!

Can you bill for 76937 with Heart Caths,Interventional Cardiac procedures etc... CPT 2012- page 384 states " Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent real-time ultrasound visualization of vascular needle entry, with permanent recording and reporting (list separately in addition to code for primary procedure)

Hello, I have a case that i have not come across before and would like your help and/or feedback if possible. I am coming up with 37799, 76496 and maybe 36299 for the contrast injection. Thank you for all your help.... PROCEDURES 1. Ultrasound guidance 2. Flouroscopic confirmation 3. Left neck/ upper extremity LYMPHATIC MALFORMATION access, drainage and doxycycline direct injection venogram and sclerotherapy RESULTS: 15-20 cc of yellow drainage from multilocular/multiseptated LYMPHATIC MALFORMATION. Placed 4 F system and instilled doxycycline sclerotherapy of 180 mg/18cc with 4 cc contrast. No complications. Dressed. Will return in 1-2 weeks for follow up and perhaps more sessions.

Am I suppposed to use code 37211 (arterial thrombolysis, initial day) for the following scenario? "Penumbra cath advanced to the left MCA.  Two mg of tPA IA injected in this branch, over three minutes. Follow-up angiography done, and due to persistent thrombus, additional 2 mg tPA was given over three to four minutes. Follow-up angiography done, and Perclose placed."  LCDs are not updated for new codes yet.