Ask Dr. Z

Hi Dr. Z: How would you code this report as tips revision or an embolization, Please advise? Ultrasound evaluation ther right neck demonstrated the right jugular vien to be patent compressable and suitable for venous access. An image was obtained and saved. Under direct ultrasound visualization the right jugular vein was accessed and a 7 French sheath placed. Through this a C2 catheter was negotiated all the way down into the IVC and through the TIPS shunt. Hand injection of a few cc of diluted Visipaque 320 demonstrated good flow through the TIPS shunt. A full venogram venogram was not performed due to the patient renal failure. Next a 14mm Amplatz II plug was deployed in the covered portion of the TIPS stent. After a few minutes, injection of contrast through the sheathdemonstrated no further antegrade flow through the TIPS shunt. The catheter was withdrawn and hemostasis obtained at the puncture site. The patient tolerated the procedure well. A total of 20 cc of Visipaque 320 was used for the procedure. IMPRESSION: TIPS SHUNT OCCLUDED WITH AN AMPLATZ II PLUG.

Would like reassurance on coding an op note. Rt femoral artery entry up to non selective aortogram 36200 came back down bilateral runoff 75716 changed to 75710 left hypogastric (internal iliac) film (cath stopped here) 36246 back up and down the right side arteriogram at the SFA Balloon angioplasty w/o stent at the Popliteal 37224 and Anterior Tibial 37228 arteries Here is what we are thinking. Drop the 36200 because no longer non selective. Change the bilateral S&I angiography from 75716 to 75710 because the right side interventions will include that. Bill for the angioplasties as 37224 & 37228 This seems awfully simple compared to last year. 36246 37224 37228 75710 Are we correct?

I need clarification on the CPT code for this procedure: Re-wire of a left internal jugular temporary dialysis catheter using a 23 cm Palindrome catheter. "Initially we tried to wire through the catheter but the catheter peel-away sheath would not pass over secondary to the angle. Therefore, we needed to rewire over 2 stiff glidewires after placing 12-French sheath. At that point, eventually, even though it required eventually another catheter because the catheter got damaged, we were able to pass over the wire and it looked pretty good with the tip in the superior vena cava, right atrial junction and a good gentle curve of the catheter. The catheter was then flushed with weak heparin and then with 2000 units of heparin in each catheter lumen and secured with 3-0 prolene for the exit site...." A coder chose 36580 -which states replacement. I haven't found information as to coding when it is a rewire. Can you provide clarification? Thanks in advance.

Are there CCI edits with any of the new heart cath codes and 93505 for the Hospital? Those I have seen seem to be for Physician only. Thank you.

Dr.Z, have an case I am unsure of how to code, pulmonary angiogram performed and infusion catheter is placed but dictation states that infusion will not be started but patient will be monitored for worsening condition and infusion started if necessary. Should the infusion 37201 still be charged or reduced in some way or only code for the catheter placement and angiogram? Have not seen this dictated before. Facility is questioning if can code 37202 if saline put in catheter? Thank you so much.

Hi Dr Z. What is the correct cpt code to use for cinefluoroscopy of the aortic valves? We used 76120, but was recommended to use 71023 or 71034. Thank you

Hi Dr. Z, we appreciate your knowledge and expertise, and we can sure use it on the following scenerio. I think we are ok on how to code all the procedures here except for the removal of the HERO. It would stand to reason that if the insertion would be 36558 and 36830-52, then the removal would be 36589 and then a code for a revision/removal/ligation of the AV fistula graft, but I don't see this described here, are we missing something? Did he just simply disconnect the catheter portion from the fistula portion? Thank you so much for your help PREOPERATIVE DIAGNOSES: 1. Chronic kidney disease, stage V, presently dialyzing with dysfunctional right femoral TCC and thus for removal of the same: 2. Thrombosed left jugular HeRO device for removal of same. 3. No further need for IVC filter and thus for removal of same. POSTOPERATIVE DIAGNOSES: 1. Chronic kidney disease, stage V, presently dialyzing with dysfunctional right femoral TCC and thus for removal of the same: 2. Thrombosed left jugular HeRO device for removal of same. 3. No further need for IVC filter and thus for removal of same. NAME OF PROCEDURE: 1. Cutdown exposure of the HeRO catheter at the left jugular insertion site with removal of the HeRO catheter. 2. Removal of IVC filter through the left jugular approach. 3. Replacement of a left jugular tunneled cuffed catheter, 23-cm precurved Palindrome catheter. 4. Removal of right femoral TCC catheter. DESCRIPTION OF PROCEDURE: The patient's left neck and chest were prepped and draped in the usual sterile fashion after adequate satisfactory general endotracheal anesthesia was obtained. The left jugular HeRO catheter insertion site incision was reopened and the HeRO catheter isolated at this location. The catheter entrance tract was encircled with a 3-0 Prolene pursestring suture. The HeRO catheter was then divided and a guidewire passed down into the vena cava through the HeRO catheter followed by complete removal of the HeRO catheter and replacement with a 13-French sheath. The sheath was then replaced with a Cook IVC filter retrieval kit which was passed through the wire and used to remove the IVC filter without any difficulty. The filter retrieval kit was then exchanged once again for a 13-French sheath followed by placement of 22-cm precurved Palindrome catheter which was tunneled subcutaneously and delivered out over the course of the guidewire insertion site. The large dilator and introducer assembly were then passed over the guidewire after removal of the 13-French sheath and positioned in the right heart under fluoroscopic guidance. The guidewire and dilator were then removed and a 23-cm Palindrome catheter passed through the introducer and positioned in the right heart under fluoroscopic guidance. The peel-away introducer was then removed. The pursestring suture was then tied at the catheter insertion site and the catheter insertion incision was closed in layers using 3-0 and 4-0 suture. The catheter was then secured at the exit site to the chest wall using nylon suture. Sterile dressings were then applied. At this point, the patient's right femoral TCC catheter was prepped and draped and then removed. A sterile dressing was applied at the right groin. The procedure was then completed and the patient awakened, extubated and taken to the recovery room in stable condition.

Can you bill for two separate diagnostic mammograms when they are done before and after a ultrasound guided breast biopsy?

Dr. Z, I need some advice on an edit that we are getting with a diagnostic runoff(two position)75625 and 75716 and then going into an athrectomy of the SFA(37225). Since the 37225 includes cath placement, I did not charge the 36200 for the diagnostic cath position thinking that the more selective position in the SFA would override the 36200. Medical Records is receiving an edit because of the missing 36200. Any advice?? Thank you so much for your attention to my question. Henri. Sadler

Dr Z, I am having trouble coming up with a code for a aspiration rheolytic thrombectomy of the pulmonary artery. Would you use code 37184? Thank you

Dr Z Should we still be billing 75774's for additional arteriograms with the new billing codes?

Hi Dr.Z, I have seen your January 2011, as you said the diagnostic angiogram is not included in the 37226, since based on the diagnostic findings, the intervention is decided. 1. Why shouldn't we code the catheterization here, for the diagnostic angiogram. Is it included in 37226 when performed through the same access. 2. When other vascular families were catheterized, ex: Popliteal angioplasty followed by renal artery catheterization, do we need to use 36245 here, since it belongs to seperate family. Thanks for your time in advance! Prabhavathi India

Dr Z, Is guidance bundled in with an EP study? we have heard several different things. Also, If our doc. uses ultrasound guiance and flouroscopy during an icd or PPM placement can we bill 71090-26 and 76998-26? Thank you for your help Traci

Concerning the Peri and Post procedural: Pt has PM implant and then has f/u one week later to have settings adjusted to more appropriate settings. Is this when you would use the Post procedural code? Can you give an example of when you would use Peri/post procedural codes before and after a surgery. Thank you

Nitroglycerin is not separately billable when done during a diagnostic arteriogram correct? I know it's considered part of the angioplasty when done during that, but I wasn't sure if it's included in the arteriogram/selectives without angioplasty. Thanks

My neurointerventionalist wants to charge 76377 x 2 for 2 sets of 3D recons performed during cerebral coil embolization px's. Just because the MUE is "2" on CPT 76377 doesn't in my opinion mean that we can code this twice for the region of the brain that is reconsructed twice. Is there any new published advice on this? I did find a recent AHA Coding Clinic for HCPCS 3rd Qtr 2010 that addresses this..."CPT 76377 would only be reported once when multiple base codes are imaged..." This to me means that the base codes are the cerebral angiography codes and we could only assign 76377 once even if 76377 is performed twice during a neuro embo px. Thanks for your thoughts on this.

If the jugular vein is accessed to place a central line for dialysis and the vein was cannulated; however, a catheter could not be passed. The CVC was successfully passed from the other side. We have been coding CPT 36299. This is being denied by Medicare even after an appeal including op notes and coding guidelines. Why isnt it appropriate to bill CPT 36000 instead?

If the doctor just does angioplasty of the tibioperoneal trunk at its origin, can he bill since he only treated the tibioperoneal trunk and no other vessel in that family? This was not addressed in our webinar, I don't thinl? Thank you,

Hi, Dr. Z! We attended your webinar late last year regarding 2011 Updates for Interventional Radiology, Cardiology, and Endovascular Surgery. In reviewing the handout, I have a question. On page 8 there is a slide: LE Endovascular Revascularization Case 2. Your 2011 coding for that is on page 9. We noticed that you listed 36247-59 which is a catheter code. We are confused because we thought that the catheter codes are now bundled into the procedure codes which were 37227, 37231, 37233. Thanks so much for the help!

Is use of a closure device included if only a cardiac intervention is performed & not a diagnostic cath? Thanks

Dr. Z. I need help...incision was made at the proximal thigh to expose the proximal sfa. After exposure needle was used to puncture the vessel and a quidewire was inserted. This was then followed sheath and dilator. An angiogram was then obtained with a hand injection of contrast through the side arm of the right sfa sheath. This redemonstrated the popliteal artery aneurysm. The measurements were taken and sheath changed to allow passage of the stent graft device. An 8 mm wide x 10 cm long graft was selected and was placed under fluoroscopic control. This was then postdilated using an 8 and 9 mm balloon. A completion angio was performed demonstrated a leak at the distal aspect of the stent graft. Therefore and additional endovascular stent graft was placed with a greater than 1 cm overlap. This stent graft was then ballooned with a 9 mm balloon. The stent graft extension was an 8 mm wide x 5t cm long device. After this was done a completion angio was obtained of the stent graft areas and of the entire right lower extremity. This anggio demonstrates resolution of the leak in the popliteal area. ....the rest is results of the angio and closure. I know there isn't an endo for popliteal but could we use 34805-22; 34825-51; 34812-51, 75952-26; 75953-26 and 36140? One coder thought 37207/37208 which isn't supported by 442.3 popliteal aneurysm. Can you please help??

Dr. Z, Our physician is placing angiogaphic catheters in the mid to distal ureter prior to lithotripsy. She had been placing a nephrostomy at the same time, but the urologist no longer requires this. I had been charging for a nephrostomy tube placement. Should we be using an unlisted procedure code for this? I am also wondering if this is sufficient dictation to charge for 50390 and 74425. Here is a sample dictation: PROCEDURE: PERCUTANEOUS LEFT URETRAL CATHETER PLACEMENT: Using ultrasound/fluoroscopic guidance, aseptic technique and local anesthetic, the interpolar posterior calyx was percutaneously accessed with a 21 gauge micro-needle with some difficulty due to the decompression of the left collecting system in this patient with a double J left ureteral stent in place. Contrast is injected, confirming intraluminal position of the needle. A guidewire was advanced and coiled in the left renal pelvis. Using standard angiographic technique a 6 French vascular sheath was placed. Nephrostogram was obtained demonstrating a 1.6 x 1.2 cm filling defect in the left renal pelvis consistent with a large renal stone. The stone in the lower pole calyx is not radiopaque and it could not be identified on nephrostogram. The left double J ureteral stent in patent. Guidewires were advanced down the left ureter, vascular sheath was removed and replaced with two 4 French straight ureteral catheters which were placed with the tips ending in the mid left ureter. Thanks in advance, I appreciate your website, books and conferences, Without those I would never have been able to pass the CIRCC.

I am curious how to code out the following scenario: 1. Redo left to right ileo-profunda femoris bypass using the 7 mm supported Propaten Gore-Tex graft and 2. Right profunda femoris to mid popliteal reversed right great saphenous vein bypass. Is the profunda femoral artery considered in the femoral artery family in terms of bypass procedures? I was not certain since it branches off the main arterial vessel. Before selecting ileo-femoral and fem-popliteal bypass codes I wanted to assure that these were correct. Thank you, Elke

Hello Dr Z One of our surgeons performed a aspiration thrombectomy of the pulmonary arteries, along with a coronary angiography and other procedures. What code would you use for the aspiration thrombectomy? They also used an angiojet to perform a rheolytic thrombectomy in the right main pulmonary artery after the aspiration thrombectomy. Thank you for your help.

I apologize for my last question: It should have read what is the coding difference between a flow wire/pressure wire (93571-26) and a filter wire. I do not have a code for the filter wire.

Can you please help clarify new CPT code 93452 for left heart cath? I realize that the left ventriculogram is now included in the left heart cath codes (other than congenital caths). On your 2011 Cardiac Cath Coding Quick Reference Sheet, the description states LHC (+/- Lt vgram). I thought that if you don't cross over into the left ventricle then it is not a left heart cath. It would be a coronary angio only which would be 93454. This should be simple but the minus sign is confusing me. Thanks for your help.

Please do NOT include any actual patient medical records with your question. Dr.Z, patient came in for pacemaker insetion and cardioversion with SSS and A-Fib and the order states both pacemaker insertion and cardioversion, can we code both here? Thanks

With the new cardiac catheterization we were wondering how you would code the injection and imaging of the IMA--this is not a graft, but was done to determine the patency of the IMA for possible CABG. Thank you

We routinely do MRI/MRAof the head together as part of our stroke protocol. How do you bill for MRI/MRA head done on same-day? Should we report this service with 70551(MRI head) and 70544-59(MRA head) to receive payment on both MRI and MRA head according to the CCI Edits? Is this appropriate?

Dr Z. I have one question and how it would be coded in 2010 and today. Comprehensive EP Study 93620 & 93527 I receive an edit that the 93527 is a component code of 93620. My understanding was that a transpetal puncture was a part of the comprehensive EP because of placing multiple caths. I do not get an edit with 93620 & the new code 93462. The Cath Lab is stating it was always and still is seperatly reportable. This is the below statment that I received from them. "Transpetal has always been a seperate procedure. Futhermore, when this type of procedure is preformed in EP we are not doing any cath like procedures, we are usually performing an ablation that most likely has a pathway on the left side of the heart. The transpetal procedure although high risk puts the ablation cath in a position that is much easier for the Electrophysiologist to work with. My question was some patients have a patent foramen ovale/PFO (this should close aswe get older - it is a hole in the heart, it actually makes the transpetal easier if you have one) there was a code last year for transpetal 93527 w/o PFO and transspetal w/PFO. Is there just one code now no matter what?"

How would you code a proper hepatic artery to right hepatic artery bypass with a reversed greater saphenous vein?

If an AVF will not mature and superficialization of the vein is performed along with ligation of several branches of the same vein can you code 37607 and 36832?

Hey Dr. Z! In 2011, a DIAGNOSTIC lower extremity angio is codeable (with a modifier) prior to an intervention correct?

Hello Dr.Z, I have a question regarding the new codes for lower extremity revascularization coding (37220-37235). New guidelines, if I am interpreting them correctly, state that selective catheterization would be inclusive in this service code. Is that correct? If my interpretation is correct there would be only one code reported for catheterization, angioplasty/stenting, and imaging unless prior diagnostic imaging was performed. Please confirm this for me. Thank You

Dr. Z, we are seeing an increase in the use of "crosser" catheters for CTO use in peripheral vessels. We now have a plethora of such catheters being brought in by various vendors (Flowcardia Crosser, CTO Frontrunner, Quick-Cross Spectranetics, etc, etc). The physicians and the techs want to code the use of these catheters as angioplasties. Last year we had discussed with ZHealth and we had been advised that these are "glorified" catheters and not to code anything additional for their use. Today I happened to be in the IR Suite and one of the reps was telling the physicians that they recommended the use of unlisted cpt 37799. Have you any updated information on these catheters and their use? What would your recommendation be? Thanks for your insight, we breathe easier knowing we have ZHealth resources to help us!

Hi Dr. Z, Since the Jetstream device is approved for both thrombectomy and atherectomy, if BOTH procedures are performed during the same session, can BOTH procedures be coded along with BOTH C-codes? Thanks in advance!

In the eLearning series for percutaneous biopsies it states "post procedure imagine to verify that there are no post procedure complications (without new symptoms) is included in the biopsy charge." The example listed is difficulty breathing post lung biopsy warrants coding the diagnostic imaging separately. If the patient has no symptoms then we should not be billing for the chest xray? Does this same concept apply for bedside PICC/central line placements with a follow up cxr for verification of tip location?

Dr. Z, If our radiologist places a NG-tube under fluoroscopy the code is 43752, but my question is can we bill for the abdomen x-rays that are done afterwards to confirm placement. Thanks

93542 and EP! Please help! MD attempted av node ablation from the rt. femoral vein and was unsucessful. Went into the LV from the lt. femoral artery. He says 93542, I say I have to ask Dr. Z. Thank you!

Dr.Z, Patient came in for possible left lower extremity intervention. Access from right femoral and accessed right internal iliac (36245) and angiogram performed then crossed bifurcation and selected left internal iliac after angiogram performed a stent insertion. My question can we add 36245-59-Rt along with 37221 75716-59? Thanks

Hi Dr. Z, For a long time we have not billed for any conscious sedation with our Interventional radiology/cardiology procedures. We were told that it was included in the procedure. Is that right? We bill for the medication but not the administration. Thanks,

Dr.Z: I'm confused to when we can code for 75710 when doing diagnostic angiograms? Example:Right Common femoral artery was selected.AP views showed to have normal caliber and branching. The puncture site was appropriate for Angio Seal device deployment. They then continue with the diagnostic angiogram. thank-you for your help.

DR. Z I have asked for a soft tissue biopsy code (20206) for my hospital. I sited the notation in your book page 365. Finance was not convinced we could use this for soft tissue after reading the CPT code description. She asked that I get more documentation regarding this issue. Do you have any documentaion on using this code as a soft tissue biopsy that I can share with her? Thank you,

We have a need for clarification on codes 93922 and 93923. 1) Does the term "when only one arm or one leg is available for study" does this mean the patient only has one? This is in the CPT changes book page 216. 2) For a unilateral study we are not sure if it means the patient only has one limb or if the patient has both limbs and only 1 is to be evaluated. We are not sure when to use 93922 or 93923 with a 52 modifier. 3) 93922 states 1-2 levels and we cannot understand using 93922 when there are 3 levels evaluated. 4) When is it appropriate to code 93923 with the 52 modifier? We are confused....... Perhaps we are making this more complicated than it its. Could you please help us understand this? Thanks in advance for your help.

I have a question about ICD-9 procedure coding in the periphery. Should 00.44 "Procedure on vessel bifurcation" be assigned to the following procedure: Angiography through the sheath was performed and revealed a 95% stenosis in the iliac artery right at the bifurcation of the internal iliac artery. The internal iliac artery also had a severe ostial stenosis. The iliac artery was markedly calcified. A 8 mm x 2 cm Fox plus balloon was then advanced to the target lesion and inflated up to 10 atmospheres. Repeat angiography continued to reveal 50-60% residual stenosis, but good distal flow. There is no evidence of perforation or dissection. The Fox plus balloon was then exchanged for a 8 mm by 27 mm express peripheral stent, which was advanced to the target lesion and deployed at 8.05 mm diameter. Final angiography revealed less than 15% residual stenosis and excellent distal flow. There was no evidence of perforation or dissection. Thanks for all you do to help us! Chris McCoy

This was a left heart cath and selective coronaries - 93458 with aortogram CPT codes charged by the cath lab: 75625, 36245, 75724 Dr Z. I beleive that the G0275 would be the more appropriate code instead of 75625. Then 36245 & 75722. The report only reflects the description of the renals and no other description of the aorta or other arteries/structures G0275, 36245 & 75722 for the right selective placement. Is this correct. Op report description: Aortogram was performed at the level of the renal arteries. She has had renal artery stenting for renovascular hypertension. The angiogram showed a patent left renal artery but there was overlap of the origin of the right renal from the inferior mesenteric artery. In light ofthis, a selective reight renal angiogram was performed. We find about 30% to 40% ostial narrowing within the stent but no significant obstruction.

Dr.Z, For 2011, Femoral & Popliteal is considered as single level as far as territory is considered for angioplasty/stent & atherectomy. What would be the case if both stent & Mechanical thrombectomy in femoral and popliteal arteries for different clinical conditions. Kindly clarify, thanks for your help in advance! Prabha, India

Greetings, I have a angio intervention on the illiac vessel with a stent. I know this is coded as 37221. The diagnostic angio performed at the same time is what I am having trouble with. The cath is placed in the aorta and a runoff is performed with no cath movement. Then,a diagnostic inturp through the tibials bilaterally is documented. How would you code this with the new code 37221? Can you also coded a 36200 as it is through the same femoral access? Thanks,

How should we code the exchange of an externally accessible nephroureteral catheter for an indwelling nephroureteral stent and a nephrostomy? All were done percutaneously through the existing access. My initial opinion was to code unlisted procedure CPT codes 53899 and 76496. After searching the Dr. Z Database, it seems like 50387 might be the better choice - that code doesn't say specifically what the replacement is (1 or 2 tubes), and the drainage remains externally accessible. Am I on the right track?

hello, if a patient has a brachial artery to cephalic vein hemodialysis fistula and the radiologist punctures the cephalic vein at the distal humerus level and advances centrally and performes a fistulogram would this be code 36147? is this punture concidered a fistula puncture or is it a remote access with 75791? please advice as the more i read it the more confused i get.. thank you for your help in advance...LR