Ask Dr. Z

Dr Z, Patient has aorto-bifem graft. MD places catheter in thoracic aorta does thoracic aortagram and abd aortagram. Catheter then placed in main body of graft to evalulate the femoral anastomoses.Then he performs angioplasty of the distal graft 9in the femoral limb). Am I correct this should be coded as PTA of aorta?

Please do NOT include any actual patient medical records with your question. Does procedure 93459 need a modifier 26 added if my physician goes to the hospital and performs this procedure

If our physician is performing a heart cath at the hospital, do we put a 26 modifier on the new heart cath codes eg 93458-26

Dr Z, can I code catheter placements for additional collateral vessels off the primary vessel? For example I coded 36217 for catheterization of the right costocervical trunk, however the physician also advances the catheter deep into two significant collaterals off the costocervical. Would I code that to 36218 for each additional vessel? Thanks

Dr Z: My CV Surgeon performed an atherectomy of mobile posterior ascending atheroma in an open surgical procedure? How would we code for an open ascending aorta atherectomy. Thanks for your help.

What codes replaced 93510-26, 93556-26, 93545, 93555-26, and 93543 in 2011? Thanks!

Dr. Z, Prior to 36147 & 36148 you indicated we could code 36145 up to 3 times, but no more than three times. Do you know if we can code 36148 twice? I have a retrograde puncture followed by an antegrade puncture then stent insertion. Then MD discovered no flow in graft, then another retrograde puncture to perform 36870. I'm wondering if we should code/charge 36148 x 2? Thanks.

Hi Dr Z: I was informed that one of the hospitals across town is billing for an atherectomy procedure when using a Crosser device is used to make a path in a vessel. Should we bill for an atherectomy when the Crosser is used? Thanks

Dr. Zielski, I hope this e-mail find you well. We have a meeting tomorrow to discuss the MAC issue with our physicians. My understanding from your in-service was that the hospital and physician charges should match, otherwise neither the hospital nor the physicians would get paid. My co-worker heard a different thing. She heard that if the bills do not match, the bill from whoever charged more (hospital or MD) would be rejected. Could you please clarify? Thanks in advance, Lucy Seoane BCVI

Question regarding appending laterality modifier to new peripheral intervention codes: Since the implementation of the 2011 CPT codes, the option to select the laterality of the side treated (specifically -LT or -RT for the lower extremity vessel) -- is not available in 3M in the "OPPS" modifier category. MUST select "all modifiers" from the modifier category. After you select and append the modifier for laterality and compute, you receive a 3M message as per below: Modifier -LT (left side) or -RT (right side) may not be appropriate as assigned. However, for CPT's that are not new/did not change from last year; e.g., 36247, you can still select -LT or -RT from the OPPS modifier category. Should we limit our modifier application for peripheral vessel intervention to -59 for the situation of intervention on both legs? THANK YOU.

Paragraph 21 of The NCCI Edits Manual v16.3, Chapter 5 states: 21. CPT code 37202 (transcatheter therapy, infusion other than for thrombolysis, any type...) ... This code should not be reported for infusion into a blood vessel in the catheterization pathway of a blood vessel undergoing a percutaneous or open diagnostic or interventional intravascular procedure since a catheter is already in the blood vessel. ... Does this mean that if the doctor injects nitroglycerin into a vessel and follows that after a while with an angioplasty or stent, the nitroglycerin injection should not be coded as 37202 and 75896? Why is this not mentioned in your book, Vascular and Endovascular Coding Reference? It only says not to code 37202 with diagnostic work up. Thank you very much.

Hi Dr. Z, I just want to be sure of the new peripheral codes. The doctor accesses from the left femoral artery the right iliac, performs a right extremity diagnostic to the foot, then does an atherectomy in the right superficial femoral artery, an atherectomy in the right commom femoral artery, both followed by angioplasty, then closes with an angioseal. I'm reading the rules over and over, as far as I can tell I can only bill 37225, and 75710. The angioseal closure is included, and the right common femoral and right superficial femoral are in the same territory. The selective catheterization is included, I believe the only other code is the diagnostic extremity - am I correct?

Patient had transjugular liver biopsy and TIPS procedure in the same setting. Can I code 36011, 37200, 75970 and 37182? I'm unsure if I can code 36011 since they advanced the catheter into the portal vein to perform the TIPS.

Are the vessels branching off the internal iliac artery, the obturator, the gluteal, etc., considered part of the internal iliac artery for lower extremity revascularization coding? For example, if a balloon angioplasty is done on the right internal iliac and another balloon angioplasty is done on the right oburator in the same session, would 37220 cover both interventions? If not, how would the angioplasty of the right obturator be coded? Thank you.

Hi Dr. Z, we've had some confusion regarding the actual usage of the new 2011 add-on for transseptal heart cath during EP ablation, 93462. I was under the assumption that we could just include 93462 as an add-on to 93651 and diagnostic EP study codes, but our 3M encoder program suggests coding 93452 and 93462 in addition to the codes for the SVT ablation and EP study, which seems unnecessarily duplicative. What would you suggest?

Dr Z, I have a question concerning the new LE revascularization codes when performed with more selective cath placement in the other extremity for angiography. If access is from the left femoral and the IR doc selects the right external iliac and injects for diagnostic angiography of the left leg and ends up only doing intervention on the left iliac (all from the initial access) can the 2nd order selective cath placement on the right side be coded in addition to the diagnostic angiography and the intervention? Thanks so much for your help.

We are receiving denials from Medicare and commercial carriers for pacemaker implants (33208) when billed with 427.81 and 426.0. There is not an LCD in place for this. I have reviewed the info on CMS's site and I cannot figure out the reason for these denials. Can you provide any insight? Thank you for your time.

DR. Z, Can we charge oxygen saturations (82810) with right heart cath (93451)or it is included in the right heart cath, please advice. Thanks

Hi Dr. Z: Is it appropriate to (for HOPPS)attach a -73 or -74 modifier to certain radiology 70,000 codes? I was told by one of our coders that it is only applicable to the surgical range. I did see a couple of responses where you did use it on a 70,000 code. My example is: A CT guided lung biopsy was to be performed, however, upon completion of the initial scan, the mass was no longer present, so I was going to put a modifier -73 on the 77012 code, but I was told that is incorrect. I would have also put the -73 on 32405. Also, can you give me any tips to tell me what the radiologist needs to cover in his report for an exam that is terminated due to extenuating circumstances? Thank you very much.

Greetings Dr. Z, If a patient has an elective cardioverion performed through an existing ICD would it be coded with 92960 external cardioversion or 92961 internal cardioversion? Neither code seems quite right and there does not appear to be an EPS code that covers this scenario. The MD has documented it as an internal cardioversion. What are your thoughts? Merci beaucoup!

DR. Z, The patient came in for AV fistula creation and in the same setting it states 'using ultrasound, the upper extremity was mapped. Based on the findings from the ultrasound decision was made to proceed with a left basilic vein transposition.' Not sure if this is good enough to code 'G0365'along with the creation of AV fistula? Is this ultrasound mapping included in the AV fistula performed in the same setting? Sometimes we see an order stating vein mapping or pre op for AV fistula creation and the procedure is bilateral venogram, please clarify when and what kind of documentation suports 'G0365'? Thanks

I have a question about an AV graft thrombectomy converted to a systemic heparanization with follow up the next day. This was done in January 2010 so the new AV graft codes were used. The AV fistula was accessed and a fistulagram performed. The cephalic vein was thrombosed and basilic vein was small in caliber. tPA was given and the cephalic segment manually massaged. Following this, balloon angioplasty was perfomed throughout the basilic vein and the thrombosed segments of the fistula. Due to adherent thrombus in the fistula and residual clot burden, an additional 4 mg tPA was injected into the fistula. The patient was converted to systemic anticoagulation through the access sheath and will return the following day for re-eval. The patient returns the following day for a follow up fistulagram. There was re-angioplasty of the basilic vein because it was still small in caliber. A Trerotola thrombectomy basket was advanced into the distal AV fistula due to some clot still present. This was cleared. Note that a second sheath was placed within the more proximal fistula and served as a working sheath for today's procedure. Hopefully, I have included the main parts of both reports. The codes I got for the first day are 36147 for the fistulagram and 36870 for the thrombectomy. Should I code the angioplasty of the basilic vein? For the second day, should the codes be 75898, 36148, 35476 and 75978? Can a second thrombectomy be coded since this was an ongoing infusion from the day before? Thanks for any guidance on this one.

Our electrophysiologist performs atrial fib ablations which require two transseptal punctures. Prior to 2011 we were billing 93527 for the first one and 93799 for the second. For 2011 we are wondering if 93462 can be billed with a quantity of two when used in conjunction with 93651?

Dr Z, With so many ways to code abdomen and runoff studies, I'm finding it more difficult because of the wording "pelvis" and rt lower extremity. Heading reads "Right extremity arteriogram possible PTA stent" PVD with wounds. The report reads "pelvic with rt lower extremity angiogram, PTA rt SFA with attempted recanulization of rt SFA" FINDINGS: Aorta/Pelvis:There is mild ectasia of the infrarenal aorta. No aneurysmal disease, dissection or flow limiting stenosis exists.Iliac arteries are unremarkable. Both internal iliacs are patent. Common femoral segments are patent.  Note, on the left supreficial femoral artery is occluded. Then goes on to Right leg findings:....(the rt leg is injected at the external iliac) I feel the intent of the study was rt leg as stated on the very top of the report. In order to evaluate the iliacs you would need to inject at the bifurcation (that's a given). I also feel the "Note" is an incidental. I would greatly appreciate your thoughts on this. Your examples for claudication both have high and low injections which this does not. Injection bifurcation and rt external.

Dr. Z! I am a little confused hoping you can clarify a question I have on the 2011 Endovascular Revasularization Codes. :) The patient had a Atherectomy of Rt external Iliac artery and right profunda. Due to rough surface and some residual stenosis A PTA was done in both vessels. He then did a PTA of the right profunda artery. My 1st thought is; 37225-fem/pop atherectomy +/PTA 36246 - placement for the Iliac 0238T - Iliac atherectomy;status C( no $ attached) this code does not include the cath placment,so that is why 36246 is coded. He does Not get credit for the PTA of profunda? correct? Because the PTA was done on the Iliac after the Atherectomy we can not code the 37220, correct? Wow! I think that is it...Thanks again for your help!!

Please do NOT include any actual patient medical records with your question. For 2011, would the G0269 code still be coded with heart catheterizations for hospital side coding? The CPT coding notes say that closure device placement is inherent to the catheterization and not separately reportable, but we were not sure if that applied to this code. Also, if the patient came back and just had stent or angioplasty(no heart cath)would the G0269 code be used then? Thank you.

Could you please help? I have searched data base and can't find examples of the HeRO catheter embolectomies (only placement 36830-52 and 36558-51). Have two operations that incision is made and fogarty catheter was then used to perform embolectomy of the venous end of the graft and the arerial end of thegraft to removed organized blood clot(only one 36831). Then the HeRO catheter was embolectomized with a fogarty catheter also. Following this good flow was noted throughout the catheter. Venogram of the AV graft was perfromed on the vnous end and arteriogram was performed in the subclavian artery (no charge??) Following this the graft was repaired with suture and incision was closed with sutures and staples. Does the HeRO embolectomy qualify as a seperate 36831-5951 charge? Thanks, Kim.

What type of situations could you use an E&M code and code this represent services provided by the nurses? Example: Patient comes into the hospital (outpatient) for a non-working gastrostomy. The nurse pours coke down the gastrostomy tube to unclog it. The radiologist is not involved as the nurses resolves the problem. Example: Patient comes into the hospital (outpatient) for a non-working PICC. The nurses flushes the PICC and the PICC starts working. No further procedures were done.

Dr. Z, Can I use an E&M like 99211 when a replacing a broken suture holding a gastromy tube in place? Patient was given numbing meds to replace the suture.

Hello, I need help :) The surgeon did a Graft Thrombecomy with revision (36833). He then did a fistula gram (36147) and because of stenosis in the venous outflow did an PTA (35476 & 75978-26). And a segmental incisiion of graft & overlying skin with primary closure??? Separate incision and closure.. Diag: End-stage renal disease, thrombosed graft fistula with recurrent bleeding from the false aneurysm of arterial limb of the graft with skin erosion. After revison/thrombecomy proc; The inflow was then tapered due to the incision..sheath removal of the graft was clamped proxiamally and distally, sheath withdrawn and sheath hole closed with sutures. Clamps released and palpable thrill was present along the graft, hemostasis was obtained. Counts ere correct x2. The wounds were closed in layers with Vicryl & Monocryl for teh skin Dermabond waa applied to seal wounds. This is what I am not sure about: Incision was then made to excise the sutured skin at the site of graft bleeding. The skin was excised as well as the underlying graft. No evidence of infection. The wound was reapproximated with nylon suture. Because this was a separate incision and it was done after the revision was completed, he feels he should get credit for the work. Since the graft was no infected, I am thinking this is still a part of the revision but not 100% sure. Your advice would be so appreciated! Thanks you!

Hello Dr.Z, I have a question in regards to the 2011 Endovascular Revasculatiion Codes. Left percutaneous femoral access was done and angio demostated occulsion. A PTA was done in the Rt SFA, Rt Anterior Tibial and Rt Posterior Tibial would you code as; 37224, 37228,& 37232? Or should it be 37224, 37232 & 37232? Because there is no add on code for the Fem/Pop Territory I am not sure if it is correct to do the 37224 & 37228 together.. Also if the doctor selectively does Angiogram ie: multiple times do we Not bill for any of those? I would also like to verify that 36245-36248 is included in the PTA revasculariztion coding! Thanks for your time and prompt reply..It is greatly appreciate..:) Deb

I just want to clarify what I read in this Q/A in the Jan 2011 newsletter please: Q: In 2010 I would code 93539 to check IMA for suitability for CABG. What would be used in 2011? A: Codes 93455, 93457, 93459, and 93461 describe coronary angiography(the blockages you found)and arterial/venous grafts (even if for evaluation of subsequent use as a graft, such as the IMA before it is a graft) by itself, with RHC, LHC,and RHC w/ LHC. So, it will just be part of the larger code. If this were a congenital case, then consider code 93564 for the IMA evaluation. In this answer, if a LHC is done + imaging the IMA for patency before CABG but the patient has no grafts at all. You would code the ungrafted IMA as if it were already grafted? CPT 93459 Thank you

Please do NOT include any actual patient medical records with your question. Is modifier 52 ever appended to cath codes if documentation does not meet the full description of the CPT code? thank you

Does the new code 93463 include hand injection of intracoronary nitroglycerin? Thank you.

Hello again, I just submitted two questions about coding S&I codes with the new lower extremity revascularization codes. And, I think the answer just clicked for me as I was reading through your information in the 3M References. The S&I codes specific to the intervention are the ones included. For example the 2010 codes 75962 or 75964. But, S&I codes for a diagnostic study, such as 75710 or 75716, are not included and can be coded in addition to the revasc codes. (guess I was going a bit overboard in my own code restructing for 2011!) I hope you see this before going to the trouble of answering my previous submission... Thanks again for the excellent resources!

How would I code coronary angiography and left ventriculography without a left heart cath? I only see 93454 for the coronaries. I am not finding a new code for the left ventriculography. Thank you for your assistance.

Question regarding chest tube and tPA infusion. After a sheathed needle was placed and fluid aspirated, chest tube was placed and 6 mg of tPA was infused into the loculated pleural effusion to facilitate drainage. Can we report code 32561 with chest tube placement? 

Hi there-- In the facility setting as of 2011, I know that we are no longer supposed to bill G0269 in conjunction with diagnositc cardiac catheterization procedures. But is it still ok to bill G0269 if the only procedure performed is a PCI Procedure? (ie. a stent, PTCA, or atherectomy)?

Dr. Z, question regarding AV graft. Performed open thrombectomy and follow up shuntogram found stenosis in both innominate and venous anastomosis performed PTA again found evidence of extravasation at venous anastomosis placed a viabhan stent graft. We are coding with 36831 75791 35460 37207 75978 75960 (since not sure coding both PTA and stent in Venous anastomosis) however this giving an edit that 36831 included in 37207, please advice. Thanks

Now that 49420 has been deleted for 2011, how would you answer the question from December 2005 below? Question: Dr. Z, When a paracentesis is performed with ultrasound guidance and a 6 Fr non locking pigtail paracentesis catheter is left in place would the codes to assign be 49080 and 76942 or 49080 and 75989? Thanks. Answer: Since a catheter was left in place and not removed, this would actually be coded as an insertion of a temporary drainage catheter for dialysis or drainage with code 49420. I would use code 75989 since imaging was performed and a catheter was left in place for drainage. 49080 is for use when drainage is performed but the needle or catheter is removed. Posted December 14, 2005 Thank you!

Hi Dr. Z, Here's the coding scenario: Doctor placed an AV fistula, however not maturing, brought patient back to ligate veins surrounding the fistula because blood was going to the veins instead of fistula. What CPT code can we use? 37609 is ligation of the av fistula but since he did not ligate the fistula, just the veins surrounding it. He was thinking of revision 36832, is this appropriate. Your input is appreciated. Thank you, Ginie

Good morning: I need some clarification on using our 59 modifiers for Diagnostic procedures done at the same time of an Intervention.Since the Diagnostic Cardiac codes that required a 59 mod are bundled into the new CPT codes,should we add the 59 modifier to the New diagnostic CPT when done along with the Intervention? Thank you for your time, Sylvia Roberts

Please do NOT include any actual patient medical records with your question. Hi Dr. Z, If we used 93230 cpt in 2010 for the holter monitor, which code would we use in 2011 to replace 93230? If we used 93224 cpt in 2010 for the holter monitor which code would we use in 2011 to replace 93224? Thank you so much for your help Geri Elliott Norva Medical Billing, Inc. geri@norvamedbill.com

Hello Dr. Z, Could you please tell me how you could the following? I currenly have it as 64622, 64623x3 with 77003 once. Fluoroscopically guided radiofrequnecy ablation of the left S1, S2, S3 and S4 (SI joint). I was told that I can only use the fluoro code once, is that true in this case as when I code it out in 3M it brings it up 4x. Thanks for all your help!

If a dr enters a arteriovenous graft for embolectomy with a scalpel then performes an embolectomy with a catheter into the preexisting HeRO catheter, and then the Fogarty catheter was then passed to the arterial end with similar retrieval of arterial flow with brisk arterial bleeding. Can we charge 36831 for the arterial and 36831-59 for the HeRO catheter embolectomy? Thank you for your help!!

Dr. Z, I am having difficulty understanding the bundling and reporting for code 0238T. 1. In the case of an atherectomy in conjunction with a PTA in the iliac artery territory, would you add code 0238T to the primary code 37220? 2. In the case of an atherectomy in conjunction with a stent in the iliac artery territory, would you add code 0238T to the primary code 37221? Thank you for your time!

when you use a adenosine drip for a coronary pressure measurement, with a wave wire, can you bill 93463? thanks so much!

I am pretty new to vacular coding and when referring to your book most of your examples use the same catheter being moved/advanced from one site to another. What if other catheters are introduced along the way. Do you code each catheter seperately?

In an emergent situation at the patient’s bedside, a physician places a central line and fluoro is not used, however, a chest x-ray is ordered to confirm placement. Can we charge for the chest x-ray?

[Per the NCCI Policy Manual 16.3, “when a central venous catheter is inserted, a chest radiologic examination is usually performed to confirm the position of the catheter and absence of pneumothorax. The chest radiologic examination is integral to the procedure, and a chest radiologic examination (e.g., CPT codes 71010, 71020) should not be reported separately.”]

Dr. Z, Patient came for AV graft pseudoaneurysm repair. Proceeded to mark the aneurysms and then proceeded to cut over the area that marked and then removed the skin. Then cut the part of the aneurysm that was very thinned out and sewed the aneurysm wall with prolene suture. ..36832 At this point imaged the exit of the vein from the artery and 1 cm above, guided by the ultrasound, inserted a needle in the brachial artery base AV fistula and then advanced a guidewire and marked teh thin dilator of the micropuncture kit and inserted it for about 2cm only. Secured it to the skin, and then injected 10ml of 50% contrast 3 times and did an AV fistuogram and venogram and superior vena cavogram. They are normal. The AV fistula had multiple areas of dilated more than usual but it was very goo, did not seem very major, and then there an area about 5 mm that not really stenotic. We coded 36832 for repair but not sure for the fitulogram and how do we code the access part to perform fistulogram. We are not sure whether to code this 36120 75791 or 36147, please explain. Thanks