Ask Dr. Z

How would I code a left heart cath, coronary angio, LV angio, aortic root, and abdominal angiogram? Please provide modifiers also. Thanks for your help

Dr. Z, a facility wants to charge 76001 for a tech and a fluoro machine being in the OR for more than an hour even though the documented time for use of the fluoro is less than an hour. There is a physician in the room for more than an hour but the fluoro machine is not being used for the whole time. What is the correct way for the facility to code for the fluoro when the OR procedure does not involve an S&I code and the documented time is less than time in the room. Thank you.

Hi Dr. Z, We have a case here that we have not seen before and would like for you to take a look at it. We would appreciate your feedback on this one. When an AV shuntogram in the upper extremity is done from a lower extremity access location, the imaging code is 75791. The confusion comes in deciding the catheter tip location/coding. If the MD accesses a lower extremity VEIN, to the AV fistula, THROUGH the fistula, and INTO the radial or brachial ARTERY, is the code 36012 or third order vessel (artery) - 36217? Thanks in advance, Stephanie

Dr. Z, A question has come up about charging for a CT Abdomen Multiphase. We are charging a 74170 CT Abdomen w+w/o contrast,but should we be charging a 74178 CT Abdomen+Pelvis w+w/o because the pelvis is included in the study? For renal multiphase, we scan the 1)abdomen+pelvis w/o 2)abdomen with contrast(arterial phase)3)abdomen with contrast(venous phase) 4)delay abdomen+pelvis(delay phase). We scan the pelvis with all multiphase-liver,pancreas,renal,except for adrenals. My physician thinks we are under charging because no pelvis charge in 74170. I think we should have a CT Abdomen+Pelvis Multiphase charge-74178 for liver, renal,pancreas and a CT Abdomen Multiphase charge-74170 for adrenals. The radiologists dictate the pelvis on these cases as well as the abdomen. I just got the Diagnostic Radiology E-book, it is really helpful!! Thank you, R Mercer

Dr's I'm totally in the dark on how to complete the coding this one. The patient has a malfunctioning upper arm brachiocephalic fistula with in-stent stenosis of the proximal cephalic vein and recurrent stenosis of the distal cephalic vein. Selective catheterization of the fistula with fistulagram was performed and then Silver Hawk atherectomy of recurrent stenosis within the cephalic venous stent, proximal vein followed by balloon angioplasty of the recurrent stenosis, distal cephalic vein. I coded 35476/75978/36147 for the balloon angioplasty of the distal cephalic vein, but frankly I am at a loss for how to code the atherectomy of the proximal cephalic portion of the fistula. 0237T atherectomy of brachiocephalic trunk doesn't seem correct. Would I use an unlisted code? Any advice would be greatly appreciated.

Dr, Z, Patient has AV fistula with a complication for dialysis. With two AV graft punctures and intervetion was performed using both accesses. Additonally a large accessory vein was seen arising from the venous outflow from the arteriovenous anastomosis. Using a catheter the accessory vein was selectively cathterized and was subsequently embolized using multiple coils. My question is can we assign 36217 36148 and 36299 for the accssory vein access? I understand we can't use more than two punctures for the AV fistula however this was an accessory vein so not sure of this, please advice. Thanks

Dr. Z; I am torn on this report with the proper code assignment. In all honesty I am not sure that code G0275 is correct on this account and the Cath lab assigned 75625. I am in total disagreement with assignement of 75625 also I am not sure that G0275 is supported by this limited documentation. I am only giving infomration related to the abdominal aortography section of the report. Procedures Preformed: Left heart cath with ventriculography, selective imaging of the coronaries. Abominal aortography. Indications: Angia/MI: stable angina. Coronary artery diesase: suspected and abnormal stress test. Cardiac: arrhythmia. History: The patient has hypertension and medication-treated dyslipidemia. Coronary Bypass abdominal Aortography: A catheter was placed and contrast was injected. Aorta: There was medium-sizwed, localized(saccular) aneurysm formation. Infrarenal location. The root exhibited normal size. Thanks in advance for your help.

How would a physician code for ligation of a lumbar artery and an inferior mesenteric artery on an endovascular AAA repair patient with a type 2 endoleak? Would the vascular surgeon use an unlisted code 37799 or is there a more appropriate code? Thanks!

Regarding peritoneal drain placement. On neonates. I am including the op as there is much disagreement with these. Procedure Placement of Peritoneal Drain Indication Perforated Viscus, free air. Procedure performed:parental procedural consent obtained, Fentanyl, The abdomen was prepped and draped, Lidocaine was injected for local anesthesia. The peritoneal effluent was not sampled for culture, The abdomen was irrigatred with warm normal saline, a penrose drain was inserted and secrued for the continued drainage, The patient tolerated the procedure well. 49420 was the code used in the past. Now with the deletion ub 2011 the MD's want to use 49020. I don't feel the dictation supports that code. My other concern is the diag. NECC is not documented, if it were and the dictation was better I can see the use of 49020. ACS suggested 49080. Thank you very much for any assistance.

Hi Dr. Z. I saw the errata regarding the tibio-peroneal trunk for vascular interventions: CODING INSTRUCTIONS 18. The tibial/peroneal territory includes three vessels that are separately coded: the anterior tibial, posterior tibial, and peroneal arteries. The tibial/peroneal trunk is considered part of any distal vessel intervention in the posterior tibial and peroneal arteries (similar to the left main coronary artery). The tibial/peroneal trunk is considered a separate vessel from the anterior tibial artery. The dorsalis pedis is considered part of the anterior tibial artery, and the medial malleolar artery is considered part of the posterior tibial artery. However, the SIR 2011 updates state this: 3 Tibial/peroneal territory: subdivided into anterior tibial, posterior tibial and peroneal a 37228–37235 b Report the initial vessel treated as the primary code for the highest level of service provided within the tibial-peroneal territory with addon codes for additional vessels treated (not additional lesions or procedures in the same vessel) c The tibioperoneal trunk is not considered a separate vessel So now I am confused. The CPT books says: “The common tibio-peroneal trunk is considered part of the tibial/peroneal territory but is not considered a separate, fourth segment of vessel in the tibio-peroneal family for CPT reporting of endovascular lower extremity interventions. For instance, if lesions in the common tibio-peroneal trunk are treated in conjunction with lesion sin the posterior tibial artery, a single code would be reported for treatment of this segment.” Is this where you are getting the information in your errata....and counting the tibioperoneal trunk lesion as a separate vessel from an anterior tibial vessel lesion? I just want to be sure where it came from as my staff are going to want to know given the SIR advice. Thanks again. I know if anyone has the answer it is going to be you!

Dr does arteriogram, tries percutaneous thrombectomy which did not resolve the problem.He then does open thrombectomy of a femoral-anterio tibia bypass. When he does an arteriogram he discovers a pseudonaneurysm of the anterior tibia beyond the anastomosis. He then angioplasties and stents the pseudoaneursym which fixes the problem. Since we now have the new endovascular codes we are not to use for pseudoaneurysm correct? How would we code this? The doctor used 36247 75710 75774 37230 and 34201. I know this isn't right according to his note the thrombus was not beyond the anastomosis. I want to code 36247 75710 75774 and 35875 but I don't know how to code the pseudoaneurysm treatment. Thank you,

I have searched the Q&A database and cannot find an answer in either that or the CCI Edits. Recently our medicare carrier has been denying procedure code 75625 billed with 2659 modifiers as this was performed at the hospital along with some other codes. They are denying this code against a visit code of 99204 which makes absolutely no sense at all. I see no edits on your site or in my recent CCI edits that we receive quarterly. I called Medicare and the person I spoke with said that it could not be billed with a visit code. Just wondering if you know anything of this. I could understand if it was being denied against another radiology code but not a visit. I just don't know what to do about this, as they are paying the same code when done at our free standing cath lab with no problem. Two differences are, at our facility we do not add the professional component modifier and I am not billing the visit code. Thanks Jene Central Florida Heart Center

 Dr. Z, Patient came in for gastrotomy tube. The previous gastrotomy tube fell out, the patient draped and prepped then a 5 French Dilator was inserted into the tract of the previous gastrostomy tube and contrast was injected which opacified the lumen of stomach. A guidewire was introduced into the stomach and the tract was dilated using a 10 mm angioplasty balloon. Subsequently a 20 French gastrostomy tube was inserted over the guidewire with the tip in the stomach. The ballon of the gastrostomy tube was inflated with 8 cc of saline. Can we charge this wtih 49450? Thanks

Please advise the propert way to get reimbursement from Medicare or private insurance when billing for insertion and removal of impella device VAD using and unlisted procedure code 33999 not getting any luck

Dear Dr. Z, When is it appropriate to use 50690. Is it used only for direct injection into the ileal conduit for ileal conduit loopogram? We are having trouble distinguishing when to use 50684 vs 50690. The patient often has a ureteral stent or nephroureteral catheter with external drainage. Thank you for any clarification. mlb

When is it appropriate to add a 25 modifier to an E&M cpt code the same day as a stress test?

I hope this isn't a really dumb question...but when doing the lower extremities with the new revascularization codes, I know you can do the 75625/75716/75710 for true diagnostic studies done prior to the intervention...what about 75774 for the vessels selected after that? since the selective code is included in the new codes I was wondering if the s&i (75774) for the additional vessels was also. thanks!

Hi Dr Z, There was a pt that had a elective replacement of their defibrillator to a dual chamber pacemaker using fluoroscopy. Code 71090 and 33241, but for the implant of a dual chamber pacemaker from a ICD, would you use code 33213 or 33208 and treat it as a new implant since they are not really replacing a pacemaker? Thank you

How do you code a left heart catherization with abdominal aortogram with bilateral runoff?

Can you charge extra for oxygen saturation when performed with a right and left heart catherization?

Dr. Z, I have listened to 2 webcasts on the new peripheral intervention codes and I am confused with the information given on the hierarchy. They have both said the same thing and the last one stated that the "Hierarchy differs from the numeric order, decreasing from most intensive to the least intensive: stent and atherectomy, atherectomy, stent, pta". My understanding from cardiac intervention coding is that the hieracrchy decreasing from highest to lowest would be stent and atherectomy, stent, atherectomy and pta. Am I mistaken on this? I value your perspective and appreciate any direction you can give on this. Thanks for your time.

If the physician does a pulmonary valve balloon valvuloplasty, but prior to the balloon he advances a Spectranetics laser catheter to the level of the valve and applies the laser, is that separately billable? I found the 0205T code but i'm not sure if that would work?? thanks!

Dr Z, Could you please take a look at the below case and tell me how you would code it. Would 33215 be appropriate? Thanks, Terri Derrick INDICATION FOR PROCEDURE: Increased shock impedance on a newly implanted ICD. PROCEDURE: ICD lead revision. ANESTHESIA: IV Versed and fentanyl. DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was taken to the cardiac catheterization laboratory in a fasting state. The patient's left shoulder was prepped and draped in the usual sterile fashion. 1% lidocaine was infiltrated into the skin surrounding the patient's fresh but closed ICD generator pocket incision. Three layers of sutures were ligated and removed, opening the pocket. The generator and leads were removed from the pocket. Noninvasive interrogation device confirmed a high shock impedance of greater than 125 ohms. Gentle traction on the proximal shocking coil plug freed the plug from header. The plug was reinserted into header and re-secured with set screws. The leads and generator were repositioned in the pocket. Noninvasive testing documented excellent impedances and pacing thresholds. The pocket was re-irrigated with antibiotic solution. The skin was closed in three layers. MEASURED DATA: Again, prior to the procedure, the patient’s shock impedance was greater 125 ohms. At the end of the procedure the patient’s shock impedance was 44 ohms. ESTIMATED BLOOD LOSS: 5 mL. COMPLICATIONS: None. CONCLUSIONS: 1. Loose plug/header connection. 2. Successful revision.

When a physician does an interpretation of an EKG and has listed "right atrial enlargment" and "Right ventricular hypertrophy", would you code that as 794.31, abnormal findings? In many instances, an ECHO is done the same day and there is no right atrial enlargement or right ventricular hypertrophy noted on the ECHO. Thanks for your guidance!

I have another question for you this morning...if extension pieces are placed after an endograft and two pieces are placed in the same vessel...one overlapping the other to make it longer, would you consider that one 34825? I didn't think 34826 would be appropriate since it was within the same vessel...It was mentioned that 34825 x2?? your thoughts? thanks!

The physician removed remaining pieces of an IVC filter...one piece in the pulmonary artery and one piece in the heaptic vein...it sounds like the same snare was used to remove both...is that one 75961/37203 or two? i'm thinking one but I wanted to double check. same access site. i'll attach the report to see what you think, thanks! Following informed consent and confirmation of the correct patient identity and planned procedure, the right groin was prepped and draped in the usual sterile fashion. Puncture of the right common femoral vein was performed using single wall technique. A 7FR sheath was placed. A Van Aman catheter was advanced through the right heart into the left pulmonary artery. Contrast was injected through the tube and DSA imaging of the left pulmonary artery was performed in multiple projections. Over a Rosen wire, a long 7Fr sheath was placed into the left main pulmonary artery. Through this, a 5Fr glide JB1 was advanced selectively into the third order branch containing the filter fragmnet. Contrast was injected while DSA imaging was performed. Using a 10mm snare, the fragment was captured and then removed through the sheath. Contrast was injected through the sheath while DSA imaging was performed. The sheath was pulled back into the IVC. Through the sheath, a 5Fr Simmons 2 was used to select and inject the right hepatic vein. DSA imaging was performed. Over a glidewire, the sheath was advanced distally into the right hepatic vein. Through the sheath, the JB1 was advanced into the fourth order branch of the right hepatic vein containing the filter fragment. Contrast was injected while DSA imaging was performed. Using the 10mm snare, the filter fragment was captured and then removed. Contrast was injected through the sheath while DSA imaging of the right hepatic vein was performed as follow-up to the removal.

Interposition grafts..can you please help? Pt is s/p fempop bypass same a.m. From the groin incision, dissection was carried down to the graft. Graftomy was created and thrombectomy was performed proximally and distally with suboptimal inflow. Distally, the catheter couldn't be passed beyond the distal anastomosis. 35875? The distal incision was opened and dissected down to the graft. This was isolated and a graftotomy was then created and thrombectomy was perfromed. This was very difficult to negotiate and the catheter could only be dilated to 2 mm vessel with suboptimal backbleeding. Following this an angio was perfromed with a needle inserted into the graft. This showed residual thrombus at the origin of the bypass graft. Distally, there was still stenosis vs thrombus in the residual portion of the popliteal artery with what appeared to be occlusion of the most distal portion of the poopliteal artery. Thrombectomy was carried out proximally to reestablish flow. Distally it required reopening by and dissecting out the tibioperoneal trunk as well as the anterior tibial artery. Loops were placed-an arteriotomy was created to facilitate exposure. There was a lrge thrombus in the distal popliteal which was removed. Following this a revision was perfromed with an interposition graft. This was positioned distally to the end of the distal graft (fem-pop). The residual portion of the graft that essentially avulsed from the proximal popliteal artery was excised. The proximal popliteal artery was ligated. Flow was then reestablished to the distal popliteal artery and the tibioperoneal trunk. On removal of the ligaloops there was injury to the peroneal artery that couldn't successfully be repaired and dissection was carried out distally to expose the proximal portion of the peroneal artery and the interposition graft was revised to extened to the popliteal artery proximal to this on. This was ligated and the anterior tibial artery was ligated. 35876-59? Dr says 35571/34201. Is this 35876/35875-59? Could you please give your expert opinion?? Thanks!

Per new CPT coding rules If pt has fem pop intervention and a Fem Pop graft intervention. would you still consider this to be one vessel for Native and graft? I am including the report. Thank you for your consideration. ************************************************************** 1. Left common femoral artery retrograde access. 2. Aortoiliac angiography. 3. Right lower extremity runoff. 4. Atherectomy of the right distal common femoral artery as well as the right profunda femoris artery, followed by balloon angioplasty. 5. Atherectomy using Jetstream device of the femoral-popliteal graft, followed by balloon angioplasty and stent placement in the proximal as well as distal portions of the graft with the stent extending into the right popliteal artery. 6. Monitoring of conscious sedation by a trained observer for 3 hours. 7. Complex peripheral intervention with greater than 30 minutes per vessel segment, requiring multiple catheter and wire exchanges and extra thought process. INDICATIONS FOR THE PROCEDURE: The patient is a 59-year-old male who has a history of intermittent claudication. For this, he had recently undergone balloon angioplasty for in-stent restenosis of the right external iliac stent. He did not experience significant relief of his claudication symptoms and requested further intervention to the right leg. He has a known history of femoral-popliteal graft in 2007, which is known to be occluded. Prior to the procedure, I discussed the risks, benefits, alternatives, and complications of the procedure with the patient, including somewhat high risk of complications due to his high-risk anatomy, and he was in agreement to proceed. ANESTHESIA: Moderate sedation administered with a trained independent observer in attendance to monitor the level of consciousness and physiological status for a total of 3 hours. Please see procedure log for all drug administration and monitoring data and further information. Conscious sedation with local anesthesia. DESCRIPTION OF PROCEDURE AND FINDINGS: The planned procedures were explained to the patient in detail including all pros, cons, risks, benefits and all possible complications including and not limited to death, myocardial infarction, retroperitoneal bleed, CVA, hemorrhage, limb loss, renal failure, the need for renal dialysis, blood transfusions, emergency surgery, emergency endovascular angiography with treatment of unanticipated vascular disease or vascular complications, use of antibiotics, consultations with other physicians and use of all accepted surgical/medical modalities for the benefit of the patient. The patient understands and verbalizes and agrees to proceed with the planned procedures. All exclusion criteria have been met to be able to do this procedure as an outpatient procedure. TECHNIQUE: Left common femoral artery access was obtained using a 4-French sheath. Office Procedure A 4-French UF catheter was passed into the contralateral left external iliac artery after obtaining aortoiliac angiography. After this, right lower extremity runoff was obtained. We then exchanged for a 7-French Terumo 65 cm Destination sheath over an Amplatz wire. The patient was heparinized. A slime wire and a 4-French IMA catheter were used to advance the catheter into the profunda femoris artery. We measured the pressure in the profunda femoris artery, and this was 40 mmHg without much pulsatility, indicative of the severe stenosis at the ostium of the profunda femoris as well as the distal common femoral artery. We exchanged out for a Platinum Plus 0.014-inch wire and performed SilverHawk atherectomy with an LS device using 4-quadrant atherectomy in the distal common femoral artery as well as the profunda femoris artery. This achieved excellent results with good flow down the profunda femoris artery. There was some residual stenosis which was treated using a 6 x 40 LP 0.018 balloon, inflated up to 2 atmospheres. Stenosis in the common femoral artery and the profunda femoris artery was reduced to less than 30%. After this, we used a 4- French angled CXI catheter and a slime wire to cross the occluded portion of the femoralpopliteal graft. We were eventually able to get through with a stiff shaft glidewire. The glidewire was advanced to the distal anastomosis. However, we were subintimal in the very distal popliteal artery. This eventually required an Outback catheter to perform reentry to the popliteal artery. We then attempted to pass a 5 x 80 balloon. However, we were unable to pass this through the site of reentry. We exchanged out for a coronary 3 x 30 balloon, which were able to cross and inflate it. We performed multiple inflations with this balloon. After this, there was still significant amount of thrombus visualized in the entire grafted segment. We switched for a Jetstream device and performed atherectomy with a 2.1 mm Pathway Jetstream catheter. This was performed after exchanging through a Platinum Plus wire. TPA was added to the infusion, and multiple runs were performed with the blades up and blades down to achieve adequate lumen. There was still slow flow due to resultant stenoses in the distal graft segment as well as the popliteal vessel and the proximal graft segment as well. We ballooned these areas with a 7 x 40 balloon. We then attempted to deploy a 6 x 80 IDEV Supera stent in the popliteal vessel extending into the grafted segment. However, the stent was under-deployed in the site of reentry as well as in the proximal grafted segment. Therefore, the stent was removed. We then exchanged out for an 8 x 80 self-expanding stent. We had to perform predilation again using a 6 x 40 Cook balloon. The stent was successfully deployed in the distal popliteal segment extending into the distal portion of the graft. We also put another 8 x 80 overlapping with a second 7 x 80 stent in the proximal portion of the graft. After this, the under-expanded areas within the stent were post dilated using a 7 x 40 mm balloon. There was still persistent under-expansion in the overlapped segment in the proximal graft. This was treated using a 7 x 40 V-access balloon, which achieved adequate expansion. Final angiographic runoff showed that we had excellent patency of the common femoral artery as well as profunda femoris artery and brisk flow down the femoral-popliteal graft into the popliteal vessel. There was preserved flow down to the trifurcation into the foot. There was some decreased flow in the very distal dorsalis pedis, which petered down. DETAILED FINDINGS OF DIAGNOSTIC ANGIOGRAPHY: 1. Aortoiliac angiography: The distal abdominal aorta as well as bilateral, common, and external iliac arteries are patent with mild-to-moderate disease. The previous site of angioplasty is widely patent. 2. Right lower extremity runoff: The right common femoral artery has a distal 90% stenosis, followed by 90% stenosis in the ostium of the profunda. The entire SFA, including the femoral-popliteal graft, is occluded with reconstitution of the popliteal by collaterals. There is preserved 3-vessel runoff to the foot. SUMMARY: 1. Atherectomy of the right common femoral artery into the profunda femoris artery, followed by balloon angioplasty with achievement of excellent results. There was some diffuse 30% to 40% disease in the common femoral artery proximal to this. 2. Atherectomy with the Jetstream device of the femoral-popliteal graft, followed by angioplasty and stent placement with restoration of brisk flow down the graft. 3. Three-vessel runoff to the foot with occlusion of the very distal dorsalis pedis vessel.

Hello Dr Z. Please help. Procedure: Fistulagram, venoplasty of the right cephalic vein and right innominate vein and selective cephalic vein venogram. Description of procedure: The right AV fistula was accessed.....and a fistulagram was then performed.(36147)...a bard balloon was then passed....and I performed a venoplasty of the right innominate vein.(35476,75978) Once that was completed, I then used a 6x6 balloon to undergo venoplasty of the cephalic vein.(35476,75978) Once that was completed, a diagnostic selective cephalic vein venogram was performed.(75820,36005) S&I: Fistulagram reveals a patent fistula however the distal runoff reveals greater then 95% stenosis of the cephalic vein at the shoulder level, as well as a greater then 95% stenosis of the innominate vein. Post venoplasty reveals a less than 10% residual stenosis. Question: Is this coding correct? I'm not sure you can charge for both venoplasties Thanks for all your help, Melissa

Dr Z. can you help understand when I would use the new CPT code of 93567 vs 75650 during a cardiac cath. My understanding is that 93567 is used to look at the insertion of the coronary arteries and/or the valves for disease. My understanding is more for when we are looking at the insertion and the artiereis that come off the arch etc. I have a patient that had coronary angiograph and then an arch study for severe claudication of the upper extremity with absent pulses. The report describes the S & I findings of the innominate artery, subclavian artery, the right and left commoon carotid artery. I feel this fits the description of 75650 vs 93567. Thanks for all your great guidance in advance.

I'm submitting this question for a neurointerventional coder: 37184 - primary mechanical thrombectomy... says each add't vessel in the same family would be 37185.. would doing it in the cervical internal then the M1 branch and the M2 branch... I would say it would only be billed 1 time... your thoughts ? if the vertebral was done and the internal then the primary and add on ....

Dr. Z..Please help. Endovascular repair. States caths, angios already in there then: following this, the device, 30 x 18 x 170 device was then placed via the right groin. It was advanced up to approximately the first lumbar vertebra, as well as the pigtail catheter. Then using a series of injections using 10 cc I was able to deploy the proximal portion of this endovascular prosthesis. It was deployed to the point that the figure of eight markers were seen on the gate. This was ballooned and inflated and pulled down into the prosthesis which appeared to be in good position. Next the retrograde injection was performed. The markers were counted out. It was felt that we could complete this procedure with a 14 x 16 x 105 prosthesis. This was deployed without difficulty. Next, the deployment on the right side was then completed. At this point the entire graft and distal fixation point were then angioplastied. Is this a 34802 or a 34803 or 34802 with a 34825 with the 75952 and/or 75953.

Dr. Z, Patient came in with bony lesion iliac for bone biopsy. After administering anesthesia bone biopsy needle was advaced into the iliac bone. Satisfactory position was confirmed with CT. Approximately 3cc of bloody fluid was aspirated too. Multiple core biopsies were performed thorugh the 13-gauge cannula. Samples sent for both culture and cytology. Not sure what else we can charge for the aspiration along with bone biopsy? Please advice. Thanks

During a left heart cath, the patient goes into cardiac arrest and CPR is initiated. Vasoactive medications(atropine, epinephrine and dopamine) are administered via infusion. The facility is wanting to charge 93463 for the infusion of these medications. I believe it is part of the CPR resuscitation procedure and not reported separately as it is my understanding that 93463 is used as a diagnostic tool for assessing hemodynamic measurements before, during and after the administration of the medications. Any assistance you can provide in clarifying this would be greatly appreciated. Thanks so much.

I know this sounds like a very simple question, but i'm looking for documentation to have on hand for this question. if a peritoneal drainage is done (75989/49021) but the drainage catheter is removed at the end of the procedure, is 49021 still the correct code? there are multiple opinions flying around about this one!:) thanks!

Dr. Z -- Regarding new CPT 93462: Is it appropriate to charge/code 93462 TWICE when performed during an A-FIB ABLATION -- if documentation states, "Atrial septum visualized for transseptal puncture" and subsequently states, "Double transseptal technique with two 8-French sheaths placed in the right femoral vein."? If you do not think it is appropriate to charge twice based on the above documentation, can you think of any situation where it would be appropriate to charge/code 93462 more than once during an a-fib ablation? MANY THANKS FOR YOUR HELP.

We are unclear about how to report the non-selective catheterization codes with the lower extremity therapeutic procedures when the catheter is not placed selectively. Our case is: LT access, catheter placed in aorta (high and low) for aortogram and runoff. Bilateral common iliac stensosis that needs stenting. RT access created and kissing angioplasty and stent placements to the bilateral common iliacs done each from there own access side (RT and LT). The catheters never cross over the aorta. So for 2010 - this would be coded 36200 and 36200-59 for the catheter placements. Do we drop 36200 for 2011 lower extremity procedures when the catheter never goes selective or no because they are not selective codes (36245-36248)? I guess another example is if the MD did the same scenerio above but only did the angioplasty/stent on the ipsilateral side after the aortogram and runoff - would you drop 36200 for going into the aorto for the aortogram? Thanks so much!

A two month old has developed a gallop rhythm & found on echo to have dilated left ventricle w/decreased function and severe mitral regurgitation. Pt suspected of having ALCAPA. LHC with coronary angiography confirmed ALCAPA. With a patient so young experiencing symptoms, would this still be coded as non-congenital with 93458? We have billed the ECHO as a congential ECHO. If it can be coded as a congenital cath, what code would you recommend? 93531-52 and 93563?? Thanks so much for your help!

in 2010 proc code for aortography was 93544 for 2011 is the replacement code 93567? Thank you

Here is a brief synopsis: the patient is having prolonged post-transplant hospital course with persistent pericardial effusion and persistent mild respiratory distress. The patient presents to cath lab for fluorscopic evaluation of the diaphragm as well as her routine post-transplant RHC and biopsy. The eval of the diaphragm is a fluoroscopically saved image which demonstrated that the left hemidiagphragm is paretic with evidence of paradoxial motion of the diaphragm. The existing pericardial drain and 350 ml of straw-colored fluid was removed. Oximetries & hemodynamics of the RH were done pre and post pericardial drainage. Endomyocardial biopies were done X5. I wanted to bill 93451-26-59, 93505-26, 33010, and 76000-26. However,76000-26 hits an edit with 93505 as bundled and no modifier is allowed. Is there another code I should be using or is the evuluation of the diaphragm non-billable? Thanks so much for your help with this scenario!!!

Dr. Z, If a patient recieved an epidural injection along with a facet injection, can I add a modifier 59 to 77003 (fluoro guidance for the epidural)? Patient has right lower back pain radiating to the right lateral thigh. Impingment of right L3 and L4 nerve roots seen on recent MRI. Patient also has moderate central canal stenosis and facet arthrosis per the CT done 9 days earlier. Thanks for any help you can give me. Michelle

Hi Dr. Z, Hope you can help. Patient new to our system with Nephroureterostomy tube. We converted patient to a Ureteral Stent exiting out of stoma into bag with Nephrostomy Tube placed at end of case to be removed at later date if Ureteral Stent is draining into bag ok. Nephrostogram demostrated well positioned nephroureterostomy tube with distal portion in neobladder. Wire placed through Nephroureterostomy tube with wire tip into bag and tube removed. 26cm Uretereal Stent placed from posterior approach over wire and deployed in kidney and stoma, Nephrostomy tube placed and capped. I am thinking: 50394/74425 for nephrostogram, 50393/74480 for stent insert and 50398-59/75984 for nephrostomy tube change. Do you think this is OK for a Nephroureterostomy tube changed to a Ureterostomy stent and nephrostomy tube? thanks, Paige Harris

Trying to code a left heart cath /lima angiogram and aortic angio as 93459 is this correct or advise if there is any add on codes

Dr Z, I have been searching through your database online. I couldnt find it on here and online theres a lot of conflicting information. When billing 33240, 33241, and 93641-26 our new system is appending a 51 to the 33241 and the 93641-26. It is also appending a 51 if we do a diagnostic heart cath and an intervention. Can you please advise on what we should be doing? Thanks Traci Alwell

Dr. Z, please help with the coding on this case. I have submitted to Medicare and the entire case was denied for medical necessity and for the 36299 cpt codes. Attempted retrograde venography and angioplasty. A 39 yr old female with multiple medical issues now presents with facial swelling as well as questionable IVC clots. The patient has had prior filter placement. DESCRIPTION OF PROCEDURE/FINDINGS: After obtaining informed consent, preparation of the patient,using normal sterile technique, attempts to access the right common femoral vein proved impossible due to the patient's contracted nature. Access into the groin is impossible. Attention was then turned to the upper neck,where ultrasound was used to map the upper extremity veins. There is occlusion of the internal jugular veins bilaterally, as well as questionable occlusion of the right subclavian vein. The right external jugular vein was patent. Under direct ultrasound visualization, access into the vein was achieved.A run was done showing looped collateral to the thyroid vein, draining centrally but not towards the superior vena cava. This vein however, blew almost instantaneously. A film was taken of the ultrasound access and placed in the permanent file. Similar attempts were also made on the left side to the external jugular vein, and or collateral. Again access was achieved with a needle and runs done again, demonstrating looped collaterals without central flow. At this time, due to the patient's uncomfortableness and non compliance, the procedure was terminated. IMPRESSION: Attempted central venous angioplasty as described above. Impossible due to the patient's contracted status as well as noncompliance with sedation. If clinically warranted, general anesthesia would be required for this procedure. I coded 36299 and 36299-59 for the non-selective direct puncture and injection of the jugulars. I used the Also 75860 and 75860-59 for the imaging of the jugular and collaterals. I referred to the Head & Neck Venous coding section of your 2010 book pg 148 where these seem to be the recommended codes for non-selective direct puncture access of the jugulars. I coded 76937 only once since he did not fully describe the procedure on the left side. All codes were denied and determination stated that the report does not clearly identify or indicate the unlisted procedure. The determination also states that the report also does not show what procedure or what part of the procedure the unlisted code is being billed. Dr. Z, are there any recommendations you can make to help us appeal this decision? Where did we go wrong? Thank you so much for your help.

Please do NOT include any actual patient medical records with your question. When a pericardiocentesis is done (33010) and Ultrasonic Guidance (76930) is utilized, does 76930 get a modifier 59? Thank you, Maria (CCA)

Dr Z: My surgeon performed an atherectomy of the distal right popliteal artery. At the same session, he performed an atherectomy of the proximal portion of a right femoral-tibial bypass vein graft near its origin from the common femoral artery. Do we only bill 37225 once since we are in the femoral/popliteal area on both the vein graft and native artery and on the same side or can we bill 37225 and 37225-59 with the vein graft being considered a separate vessel? Thanks for your help.

I note in the CPT book the description of the new angioplasty/stent codes (37220-37235)state unilateral. Should the modifiers LT or RT be appended to these codes? For example if a left SFA angioplasty and stent were done, should this be coded as 37226LT? or just 37226.

Will the hospital be reimbursed if an EP physician performs multiple diagnostic testing such as a Tilt table study (93660), an EP study (93620), and an Ablation (93651) before deciding to do an implant (33208)? Should the implant be done on a different day of service? Thanks,

Dr. Z, How would I code the following report? I'm not sure if 36596/75902 is correct. History‎: ‎Recent abdominal Pleurx drain placement, now no longer draining‎. ‎Please check tube‎.‎ Technique‎/‎findings‎: ‎Limited ultrasound of the abdomen revealed the Pleurx catheter within anechoic fluid within the peritoneal ‎ cavity of the patient's pannus‎. ‎Limited ultrasound of the remaining abdomen reveals no significant ascites‎. ‎Fluoroscopy of ‎ the drain revealed no kink‎. ‎Aspiration of the Pleurx catheter yielded nothing‎. ‎Contrast injection of ‎10 ‎mL of Isovue ‎200 ‎was ‎ performed under fluoroscopic guidance into the Pleurx drain, confirming contrast extravasation out of the side ports into the ‎ peritoneal cavity‎. ‎A stiff glide wire was inserted vigorously through the Pleurx catheter out multiple sideholes under ‎ fluoroscopic guidance‎. ‎Aspiration of the Pleurx catheter still yielded nothing‎. ‎Next, TPA ‎4 ‎mg was administered into the ‎ Pleurx drain and the drain was capped‎.‎ Impression‎:‎ 1‎. ‎Persistent occlusion of the abdominal Pleurx drain‎. ‎Following TPA infusion, repeat attempt at aspiration will be performed ‎ in ‎2 ‎hours‎. ‎If this attempts still yielded nothing, the abdominal Pleurx drain will likely not function and may be scheduled to ‎ be removed‎.‎ Thank you... my email address is shirley.sweet@vtmednet.org