Ask Dr. Z

Changing a mammography order

When there is a patient scheduled for a screening mammogram but it should be a diagnostic, we call the patient's physician for a corrected order. Are the radiologist allowed to order exams they feel are also needed at that same appointment. such as cyst aspiration or biopsy.

Flolan 93463

Can we use 93463 for the evaluation of pulmonary hyperetnsion reversibility using intravenous Flolan (epoprostenol)during a right and left heart cath?

HERO device

Greetings A physician is placing a HERO graft. He angioplasties a stenosis in the vessel to place the HERO. Can we charge for the angioplasty, or is it part of the Hero placement. Thanks, LW

76937 with 36147 and 36148

I see in your 2012 IR Coding Reference, on page 259, "32. Ultrasound guidance for vascular access (76937) may be reported with AV access procedures if indicated and documented appropriately." 76937 is still a CCI edit with 36147, but if documented properly can we now charge for it with a -59 or do we still need a medical reason such as obesity, scar tissue at access site or failed multiple attempts? I saw in one of your 2011 Q&A answers that something may change with regards to being able to report 76937.

35697

Greetings, Pt. has a gunshot wound to the aorta. It is repaired with sutures (3 5221). Two weeks later the physician takes the Pt. back for a pseudoaneurysm to the aorta at the same location close to the SMA. He repairs the aorta with a bovine patch and dissects the SMA added a harvested piece of saphenous vein and attached this to the SMA then reattached the SMA to the aorta in a different location (35081 with 35531 with a 78 modifier. Not to confident that I have the right codes/ worried if this is a bypass. Am I correct in the choice of codes. I need to give feedback to the physician. LW

33229

We have a patient that received a down grade in their device, due to an increased ejection fraction. They went from a BIV ICD, to a BIV PPM. My question is do we bill the 33229 code, or do I need to bill the removal of an ICD, and the placement of the new BIV PPM generator, since we are dealing with two different types of devices. Thank You

37204 psuedoaneurysm embolization with thrombin

How would i code injection of 400 units of thromdin into aneurysm in the hepatic artery.

AV shunt arm venoplasty

In arteriovenous shunt interventions, can you code the S&I codes for an intervention multiple times in a single zone even though the surgery code can only be coded once? For example, if you angioplasty two different veins in the same upper extremity peripheral zone, can you code them as 35476, 75978, and 75978-59? My understanding is that you would only code 35476 and 75978. A vendor has been telling coders they can code the S&I multiple times so I want to check with you. Thank you in advance for your help.

34111, 34201

Hi Dr. Z, If our doctor is performing an open emrbolectomy of the Brachial artery, Radial artery and the Ulna artery can i use 34111 twice with 34101 or do i just use 34101? Thanks for your help... Please see an example below ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ A linear incision was made of the patients right medial aspect of the elbow and carried down with dissection. the patients bracial artery, radial artery,and ulna artery was identified, respectevily controlled with vessel loop. Than a transverse arteriotomy was made of the brachial artery. A #2 Forgaty catheter was passing through to the proximal brachial artey. There is organized embolus was expressed. Brisk flow was achieved and irrigated with saline and then embolectomy catheter was passing through the radial artery . the radial artery had minimal clots and passing through the ulna artery, the ulnar artery has an organized embolus as well. Both achieved brisk back flow and were flushed with heparinized saline. After satisfaction the transversed arterectomy was closed with interrupted 7-0 prolene stitch and restored right upper arm blood supply, palpable radial and ulnar pulse.

Repair AV graft

Greetings, Pt had removal of infected AV graft 35903. He repairs the artery and vein with a bovine patch. Is this considered revascularization or repair. I'm checking to see if I can bypass edit. LW

Tunneled catheter removal

If a patient has an existing infected tunneled catheter that is still in the correct position and the radiologist removes it, the code used is 36589 and is dictated. If the catheter is pulled so that only the catheter remains under the skin, the cuff is out, and the radiologist has the nurse or technologist remove the catheter, would that change the coding or the dictation?

Non-tunneled catheter exchange 49423

Here's a quick question. Patient with liver cancer and ascites undergoes parcentesis with placement of an indwelling, non-tunneled catheter. The next day the patient returns with leakage around the catheter site. The abdominal catheter is removed and a new catheter placed under fluoroscopic guidance. I believe 49021 would be used for the first admission but what should be assigned for the catheter exchange on the second day? Can 49423 be assigned even thought this is not an abscess or cyst drainage catheter? Thanks again.

Pancreatic transplant 36245, 75726

Patient with status post pancreatic and kidney transplant with dropping hemoglobin. A cobra catheter was used to select the pancreatic artery which came directly off the right common iliac (access was right femoral artery). An angiogram was performed. I coded 36245 and 75726. Is this correct?

33230, 33231, 33240, 33262, 33263, 33264

My question concerns the application of the new ICD codes. When would we use the 33230, 33231 and 33240 cpts codes? Definition states "with existing leads" on each of these codes so would lean to use for generator change procedures. BUT, we have the new ICD rem/replacement codes 33262,33263 and 33264 for "battery change" procedures. "An Insider's View" release covering the 33230, 33231 and 33240 CPT 2012 changes/additions interpretation would lead me to believe would be used in a "staged" procedure where a surgeon placed epicardial leads and patient was sent to Cardiology for generator placement. That would require the use/application of CPT codes 33202-33203 for lead placement which throws us into Inpatient Only codes. Your insight/instructions will be greatly appreaciated.

Exchange of femoral CVC with bilat upper extremity selection via same acces

We did an exchange of existing right femoral CVC with the selectively of both the RT and LT upper extremity veins and  a bilateral venogram was done.  I’m thinking that we can not bill for the selection of the bilateral upper extremity nor the venogram because it is done via the CVC exchange access site and it is encompassed into the exchange code. The physician also accessed the lt ext jugular vein and angioplastied the Lt Brachiocephalic vein (occlusion) and placed tunneled CVC.
Your thoughts,

37191 - 37193 vena cava filters

With the new filter codes, is 36010 now included in that or is that still separately billable?  How about a diagnostic IVC gram and US guidance for access (76937)  the more I read the description the more I’m confusing myself! :)

Thanks!

No temporary pacer 33210 with valvuloplasty 92986

Is the placement of a temporary pacing wire bundled with aortic balloon valvuloplasty (92986)?

35286, 35666, 35700

I have coded 35666 for the bypass and wanted to verify if I could use 35286/59 for the interposition graft placed in the CFA due to atherosclerosis? Thank you! a standard oblique incision was made in the right groin and carried down through the subcutaneous tissue through the previous scar down to the level of the common femoral artery. It was carefully dissected and encircled with a vessel loop, as well as the SFA and profunda femoris artery. The previous bypass grafts were also dissected free. Through a longitudinal incision below the knee, the posterior tibial artery was carefully dissected and encircled with vessel loops. The patient received 5000 units of heparin intravenous systemically. Clamps were placed on the common femoral artery. The grafts were detached from the previous artery. The artery had significant atherosclerotic disease. Therefore, an interposition graft was performed with a femoral interposition graft. We utilized an 8-mm PTFE graft sewn end-to-end and spatulated without difficulty with a running 6-0 Prolene suture flushing proximally and distally prior to completion. Complete inflow was restored. Next, clamps were reapplied to the common femoral artery. A 6-mm ring PTFE Propaten graft was sewn end-to-side to the common femoral artery flushing proximally and distally prior to completion. Complete inflow was restored. The graft was tunneled down subcutaneously to the posterior tibial artery and sewn end-to-side with a running 6-0 Prolene suture flushing proximally and distally prior to completion.

Codes G0448 and C1886

Dr.Z Do you have any info on HCPCS code G0448; Also on new pass-thru C-code 1886. Thank you so much for this wonderful web resource

Left main coronary artery intervention

I have a new Dr who is asking about coding coronary interventions and wanted to be sure we were aware of when we could bill the left main as 2 interventions. I am not aware of this and do not think you can seperate and bill 2 intervention done in the Left Main. Please help!

Dialysis graft aneurysm repair

greetings, A Pt has a old dialysis graft not functional for over a year as it was ligated. It develops a aneurysm. The physician excises the aneurysm and ligates a posterior branch running alongside of the graft. Would this be 35011? Thanks, LW

Doppler prior to tunneled central venous catheter placement

Dr Z WHAT CODE CAN I USE WHEN MY DOCTOR DOES A NECK/JUGALUR VEIN DOPPLER EVALUATION. BEFORE PLACEMENT OF TUNNNELED 5 FRENCH DUAL LUMEN CENTRAL VENOUS CATH.

Renal intervention without a diagnostic study

Dr. Z, wtih the new codes, i have a question regarding renal intervention without diagnostic study, my thought process we may not code catheter placements separate (with the new code 36251 includes both catheter placement and S&I) however some consultants are advising us to use 36245 along with the intervention codes. Can you please clarify. Thanks

Ultrasound show paracentesis as not needed

Our Interventional Radiologist has requested a clarification on the correct way to bill for the following procedure. The patient has an order for a paracentesis. The process when the patient arrives is to do a prescan ultrasound to make sure there is enough fluid. When it is determined that there is not enough fluid to perform the paracentesis the patient is sent home. Is it appropriate to bill for the paracentesis with the modifier of -73 showing it was cancelled before sedation OR would it be billed as a limited ultrasound. If we bill for the limited ultrasound is the outpatient order for the paracentesis sufficienct or should there be a new order for a limited ultrasound by the radiologist? Thank you for your assistance.

Peritoneal catheter tpa injection

In the following example, how would it change if only a fibrin sheath was demonstrated and the tPA was injected but the brush wire was not used. Everything else the same. 2011 case. 1) Patient with a poorly functioning peritoneal dialysis catheter presents for evaluation. In a sterile fashion, the tube is injected with contrast and evaluation of the peritoneal cavity is performed (49400, 74190), demonstrating fibrin sheath around the catheter and multiple adhesions in the abdominal cavity. 8 mg tPA is mixed with saline and injected through the catheter. After thirty minutes, the area is reevaluated, and a wire is placed through the catheter with subsequent disruption of the fibrin sheath (49999, 76496). A repeat injection demonstrates free spill of contrast throughout the peritoneal space.

IVC and SVC filters

Are diagnostic IVCgrams (75825) and US guidance for vascular access (76937) still ok to bill in conjunction with 37191 through 37193? Is 36010 now included? Also, if an SVC filter is placed, is that unlisted (37799) thanks!

Upgrade of ICD to multi with LV lead 33264 and 33225

Please do NOT include any actual patient medical records with your question. Upgrade of a dual chamber defibrillator to a biventricular defibrillator. Remove and replace generator, insertion/addition of left ventricular lead and attachment of generator to previously placed atrial and right ventricular leads. How would you code this utilizing the new 2012 cpt codes? Thank you!

93799 PDA closure

Hi Dr. Z, The only answer I can find on this subject in the Q&A is 6 years old so I need your guidance. A 2 year old patient had a patent ductus arteriosus closed with an Amplatzer closure device. I'm unable to locate a CPT code? Thanks for your help.

Placement of sheath for CT scan

Pertaining to a previous Question below. If the Physician places a sheath or a dilator to be used for CT would you use 36410/76937? Thanks Question: If a patient comes in for a CT scan and requires an IV access to be placed by IR due to "poor venous access", is the 36000 and 76937 seperately reportable? Typically the 36000 is bundled, but due to the poor access and the fact that they are taken to IR for the procedure, does that warrant the charges? The fact that is performed for the sole purpose of administering the contrast, regardless of the reason they have poor access, does that void charging the 36000/76937 seperately? Answer: I would not code additionally unless CVC catheter was placed. An IV, no matter how hard it is, is part of a CT scan. Dr.z

33264

Please do NOT include any actual patient medical records with your question. Dr. Z, I have a question about the new ICD coding. If a patient is having an upgrade from a dual chamber ICD to A Biv ICD with removal of old gererator and insertion of new geenerator,and LV lead insertion only, do I use 33263 and 33225, or 33264 and 33225, or other? Thanks. D

ICD upgrade 33263 vs 33249

Hello Dr Z. Question on new 2012 Rhythm Device Coding. The patient has a ICD (single lead) and presents for a Upgrade to BiV ICD (dual lead)Would it be coded as: Removal of ICD generator (33241) Insert ICD generator, multi(33231) Insert BiV lead (33225) Insert New lead (atrial) (33216) Thanks for your help Melissa

Bilateral piriformis injections

When you perform bilateral Piriformis injections, because it cannot be billed w/50 modifier and the description says 20552 is for 1 or 2 or more muscles, how would you bill when an injection is done one on each side of the body in the same setting? 20552 and then 20552/59 or just 20552?

33207

2012 Pacemaker Procedure Initially a dual chamber generator change. Found fractured lead. So now dual gen change with placement of 1 lead. (Bad lead is capped) We know to use removal code 33233, however there is much confusion after this...... 33208 states insertion of 2 leads, with pacing and sensing in two chambers. 33207 states insertion of 1 lead in ventricle with sensing and pacing in only one chamber. Do we choose these codes by the number of leads inserted or by the number of chambers paced and sensed? Thank you!

Transforaminal injection and epidural 77003

I have a quick question on guidance codes. If there is a transforaminal injection (which includes the guidance code) and then the radiologist does an epidural can we use the 77003 with a 59 modifier? I know there are a lot of changes for guidance for 2012. Thanks for your help

35201

Greetings, Pt. has fem-peroneal bypass graft with spliced saphenous vein originating from the hood of aortobifemoral graft. At the hood connection of the vein a pseudoaneurysm develops. Pt taken back to the OR for repair. After draining partially thrombosed pseudoaneurysm he sutures the hole in the hood would you code this as 35141 or repair of a blood vessel Thanks, LW

37224

Hi Dr. Z, can't wait for this year's seminar! Can we please have several case studies involving AV grafts in the legs? I need help with the following: Graft is accessed at the upper thigh on the arterial side of the graft in an antegrade direction. Contrast was injected and refluxed to the arterial anastomosis. There is narrowing at the arterial anastomosis and irregularity of the arterial side of the graft. There is also mild narrowing on the venous side. It is elected to perform angioplasty of the venous side of the graft and at the arterial anastomosis. A second access is obtained and the arterial anastomsis and the femoral artery slightly above the arterial anastomsis were dilated. A cutting balloon was then used to dilate the venous side of the graft and the portion of the graft at the transverse portion. Thank you in advance.

Repeat stent placement in same coronary artery at a subsequent encounter

If I am understanding the guidelines correctly, a pt. who has a DES and a non-DES stent placed in the Circumflex, only G0290-LC would be used. Later on the same day the pt. has to return to surgery due to stent thrombus and has an addional non-DES placed in the same vessel. How is the 2nd procedure coded? Thank-you for your help. MP GRMC

Removal pacemaker, upgrade to biventricular ICD

93581

The physician performs a percutaneous transcatheter closure of a post-operative ventricular septal defect. Can we use 93581 or must an unlisted code be used? The procedure is the same but the condition is acquired not congenital. Thanks for your help.

AV graft intervention

Please do NOT include any actual patient medical records with your question. Dr. Z, Patient came for dialysis graft complication. Angioplasty done after angioplasty some extravasation was noted at the site of the lesion. This was treated with gore viabahn stent graft, can we charge boht PTA and Stent here? Thanks

33206 with 33233 and 33225, 33229 and 33225

I have two questions in regard to the new generator replacement codes for January 2012. If a patient has a BIV pacemaker and presents for a generator change but ends up having the RA lead replaced. Old lead was capped. What codes should we use? (33206 because a single lead system was newly implanted and 33233 for generator removal?) If a patient presents for an upgrade from a dual chamber pacemaker to a BIV pacemaker and the only new insertion is the LV lead should we use the dual chamber generator change or the multi lead generator change in addition to the insertion of the LV lead code?

36830

Dr. Dunn, How do we code insertion of cryovein graft for dialysis? Thanks Prasanna

Bridging venous lesion across territories

Hello, During an AV fistula intervention the radiologist treats a an occlution from the axillary vein which extends to the innominate with angioplasty and Stent can i code two angioplasty and two Stent deployment. I knowt that the lesion in continues but i am in two different zones. Below i have included an example. Thank and Happy HOLIDAYS !!!!! ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Digital subtraction fistulography was performed from the upper arm venous outflow to the heart. The micropuncture catheter was exchanged over an 035 wire for a 7-French vascular sheath. The axillary and subclavian veins were angioplastied with an 8-mm and 10-mm balloons after the lesion have been crossed with a 035 Glidewire and catheter. Upon crossing the occlusion contrast was injected through the catheter to confirm intravenous position. The subclavian vein/innominate venous junction was angioplastied with 8 and 12-mm balloons. As flow through this occlusion could not be reestablished, the occluded segment from the axillary vein to the innominate vein was stented with a 10 mm x 6 cm Zilver stent and a 12 mm x 4 cm Zilver stent, the larger of the two stents extending through the smaller 10-mm stent and into the innominate vein.

Two physicians to do diagnostic angiogram and intervention

Hi Dr Z. I have a question about a physician coming in to do the intervention after the diagnostic exam. If a patient does not leave the table is it considered a different encounter or is it a continuation? Do you give new imaging and selection components for the new doctor? Thanks!

37201, Trellis, bilateral venous

I researched the Q&A list. I have a question on a patient that had thrombus, extending from the IVC (inluding pt's IVC filter) into bilateral femoral veins and left popliteal vein. The MD did mechanical thrombectomy and thrombolysis, bilateral iliac and femoral vein angioplasty, and right common iliac venous stent. My questions are: 1)do we code for only the thrombectomy, only the thrombolysis, or both? The MD dictation states: "approximately 3mg of TPA was pulse injected via the Berenstein catheter into the thrombus within and just below the IVC filter and allowed to dwell there for the duration of the procedure (which was approx 2.5 hrs). 8Fr Trellis catheters (30cm treatment lengths) were inserted bilaterally and positioned within the vena cava just inferior to the IVC filter and extending to the left common femoral vein and the proximal right superficial femoral vein. The Trellis was activated for total 12min and 5mg TPA pulse sprayed through each catheter. Suction aspiration was performed from both catheters for approximately 60-80cc each side. Both catheters were then repositioned distally extending to the mid-SFV on the left and distal-SFV on the right (just above the sheath). The Trellis was run again for another 12min and instilling 4mg TPA on the left and 3mg TPA on the right. Aspiration was performed for an additional 60cc each side and with the Trellis motor cannula removed. Aspiration flow this time was brisk on both sides." 2)how many angioplasties are allowed? Prior to the section of the procedure quoted above, the MD states: "Balloon angioplasty was performed of both femoral and iliac veins, beginning above the sheaths and continuing to the IVC filter with a 6mm x 20cm Dorado. This was done to disrupt the fibrin crosslinking of the thrombus (given its subacute age) and allow better penetration of thrombolytic." Do we code for 4 angioplasties,or is this treated like a pre dilation and considered part of the thrombectomy or thrombolysis? Then after the completion of the thrombectomy/thrombolysis procedure, the MD also did 1 angioplasty in the right iliac for residual 70% stenosis for which I planned to code. Thank you very much for your help.

35606

Please do NOT include any actual patient medical records with your question. Hi, How would you code a R common carotid artery to left subclavian artery bypass with reimplantation of the left common carotid artery into the previously placed bypass graft? I am coding 35606 for the carotid-subclavian bypass, but I am not sure how to code the reimplantation portion of the procedure. Thanks for your help.

76000

Our cardiologist performed a valve fluoroscopy with IV administration of Perflutren lipid microsphere 1.1 mg/ml. Is the code for this 76120 or just 76000? Thank you. Procedure: Valve fluoroscopy FINDINGS: 1) Valve fluoroscopy was performed to evaluate transcatheter aortic valve. The valve prosthesis was circular and symmetrical. There was no evidence of stent strut fractures. 2) Normal transcatheter aortic valve.

Staged coronary interventions

If a cardiologist performs a left heart cath with coronary stent placement on Monday 12/19/11 and brings the same patient back on a different date 12/21/11 and deploys another stent in a different vessel family; Can we only bill for the coronary stent placement for the second encounter on the 21st or is there a modifier that can be used like: stage procedure modifier codes 58 or 78? Thanks, Sarah C.

Attempted coronary angioplasty with balloons

After performing left heart cath patient was found to have 95% stenosis in mid LAD. Cardiologist attempted intervention several times with different balloon sizes but lesion could not be crossed. Our question is from a facility prospective. Considering modifiers can't be used in inpatient setting how should we bill for this? Do we just get to bill for the Left heart?

Reporting 77778 with 37204

Hi Dr. Z, I was reading the NCCI Manual Revision 1/1/2012 and in Chapter 9 70000-79999 the Rad Onc section F #'s 5 and 6. It states that 77778 should not be reported with 37204. But, if a rad oncologist is present and infuses the brachytherapy, he can charge a lesser code. Please check this out and let me know what you think, and what that lesser code should be. At my hospital, the nuc med radiologist infuses the brachytherapy. Thanks! Judy A.