Ask Dr. Z

Professional coding team inquiry for G mastitis steroid injection with aspiration, US guided. Interpretation is 96372, 10160, 76942. Would 19000, 76942, 96372 be more appropriate based on GL?

"After obtaining informed consent through PARQ conference, the area was reidentified at the right breast 3:00 7 cm from the nipple measuring about 2.5 x 0.8 x 0.9 cm. The second site with echogenic central debris at 1:00 8 cm from the nipple measures about 3 x 1.1 x 2.6 cm. A Team Timeout was performed. The breast was cleansed and draped in sterile fashion. 1% lidocaine was utilized for local anesthesia. A 22 gauge needle was advanced to the both areas under direct ultrasound guidance and aspiration performed. A total of 6 mL of viscous fluid was removed and discarded. A total of 160 mg of Methylprednisone mixed with Ropivacaine was administered into the cavities and surrounding tissues. The needle was removed, gentle pressure applied for hemostasis, and a sterile dressing placed. Estimated Blood Loss: <5mL Complications: None."

He has had prior placement of CRT-D device which is at ERI status. Biventricular pacing percentages were at 97% and is presented today for generator change. He has preerosive changes on his device and leads. He has had a well-functioning CRT-D device with an abandoned prior RV lead. His abandon lead was originally placed in the submuscular pocket, we then changed out the device pacing through the prior LV lead. Through the device the leads were interrogated, the patient was in underlying atrial fibrillation with fibrillatory waves at 1 mV. Lead impedance was 390 and stable. The RV lead showed no sensed R waves at VVI 30 pacing threshold of 0.75 V at 0.5 ms and an impedance of 430 ohms. The LV lead showed a threshold of 1.5 V at 1 ms impedance of 600 ohms and high-voltage impedance was 55 ohms. Bradycardia parameters were set DDIR with a lower rate limit of 70 VT monitor was set at 160 VF zone at 200. Standard outputs were programmed with the device. No immediate complications of the procedure. 

33263? 33264? or 33249?

Are the robotic surgeries always coded as VATS (32663), or can they be coded to open (32480)?

A skin block was performed. A peri-prostatic block was performed by placing a spinal needle on each side towards the prostate base and injecting 10ml of 1% xylocaine for a total of 20ml. Under ultrasound guidance 3 gold markers were inserted into the prostate (right apex, mid-gland, and left mid-gland) placed at the appropriate depth and avoiding the urethra. A long spinal needle was then used to hydro-dissect the perirectal space with sterile normal saline. Separation was confirmed in both the transverse and sagittal planes. The needle was aspirated slightly to ensure the needle was not intravascular. While keeping the needle in place, the hydrogel applicator was attached. The hydrogel was then injected over 5 seconds. The placement of the hydrogel was evaluated and the ultrasound probe was removed. After 15 minutes of observation the patient was released. Would you code 55874 with 55876 and 76942 or is the ultrasound guidance included in 55876 because you used 55874?

When performing angioplasty of the right posterior tibial, common plantar and lateral plantar arteries, are all arteries included in CPT 37228 or is it appropriate to add 37232 x 2 as well? Thank you.

Does this documentation support CPT 78582 with 78800?

Comparison: There are no prior studies available for comparison.

Procedure:

Ventilation study: Dynamic planar scintigraphic images of the lungs were obtained in the posterior projection while the patient was breathing a mixture of 9.5 mCi Xenon-133 and air, through a breathing apparatus. Images were obtained during initial breath hold, rebreathing to equilibrium and during wash-out phase, over a 3-minute period.

Perfusion study: Following the intravenous administration of 5.4 mCi technetium 99m MAA, static planar images of the lungs were obtained in the anterior, posterior, RAO, LAO, LPO, right lateral, and left lateral projections.

Findings: The ventilation study demonstrates heterogeneous distribution of inhaled radiotracer centrally, with mid to upper lung persistent radiotracer on washout images suggesting air trapping. There are small subsegmental defects at the left lung hilus region, without peripheral wedge-shaped large perfusion defect.

Impression: Mid Lung Air trapping

Our vascular surgeon performed repair of brachial artery transection, and we are not sure what code to report. We are only coming up with 35206. What are your thoughts?

"Small bulldog clamps were placed on the proximal and distal ends for control. The proximal and distal ends of brachial artery were cut back with scissors, then it was repaired with end-to-end anastomosis using two running 7-0 Prolene sutures. Once anastomosis was completed, the bulldog clamps were removed."

I have a physician who is doing a pulse volume recording only.

"Study: Right lower extremity pulse volume recording. Indication: Gangrenous changes of prior foot amputation. Interpretation: Pulse volume recordings were obtained at the right high thigh, low thigh, calf, and ankle level. This showed decreased amplitudes at all levels. Impression: Pulsatile recordings of the right lower extremity are suggestive of more proximal disease."

Would this be reported with code 92923 or 92922? If neither, what should I be coding?

Patient's LAD distribution is subtended by TWO different grafts. Drug-eluting stent is placed in the distal 1st Diagonal via access thru the saphenous vein graft. Via separate approach, a DES is placed in the native mid-LAD via the left internal mammary artery graft (LIMA). May we code C9604-LD, C9604-LD-XS for these two interventions because the two grafts are completely separate from each other with separate ostia?

Do you have recommendations for how the X-modifiers should be used with IR and CV? For example, would selective catheter codes get XS for separate structure? Would a true diagnostic angiogram get XU when done with an intervention? If you are switching from 59 to the X-modifiers and code IR and CV, what would be the correct way to use these? Thank you!

What advice can you offer for this encounter? Patient was originally scheduled for an AV shunt imaging for maturation. Only an US scan ended up being performed. "US exam of the left upper extremity in the area of the surgically created fistula was performed. A patent radial artery was identified. The anastomosis was identified, however, no flow was noted within the outflow vein. A segment of approximately 1 1/2 to 2 cm of the juxta anastomotic vein was thrombosed/occluded. There is reconstitution of the outflow vein via collaterals. Given that the juxta anastomotic outflow vein was very small and already occluded no intervention was done at this time." Since no attempt at access was performed, I don't think it is appropriate to report an aborted 36901. This is an extremity, but 76882 doesn't seem appropriate since this is vascular. Not a Duplex study. This doesn't seem to fit 93922. Thank you for your help.

Is it appropriate to bill 76380 in conjunction with cerebral angiography codes 36224, 36226 based on this documentation:

PROCEDURES:

1. Selective bilateral internal carotid artery cerebral angiograms.

2. Selective left vertebral artery cerebral angiogram.

3. Ultrasound-guided access and catheterization of right common femoral

artery.

4. Cone beam CT imaging performed in each vessel

IMPRESSION: Successful three-vessel cerebral angiography with cone beam CT

performed during each vessel injection of the Jefferson preoperative protocol.

No vascular abnormalities evident.

If atherectomy and PTA of the radial artery and the palmer arch are done, do we report two atherectomies? I currently have 0237T, 37246, and 36216 (brachial access). Is the palmer intervention separately reportable?

When the doctor documents the patient has a complex thyroid mass with cystic and solid portions; then he does an US guided aspiration of the cystic portion and core biopsy of the solid portion.

Do we bill the solid core biopsy only as this is one mass (one surgical field)? Or can both aspiration and core be billed? My radiologist is insisting we bill both. Need clarification please.

Thank you

Good morning,

MR Neurogram is an unlisted cpt code 76498. My doctor's are asking if there are alternative codes that could be used instead of the unlisted code? Like a MRI code of each of the locations the neurograms are being done on. Would MRI Codes be compliant?

Thank you

Can you bill 33210 and 33975 together, if not why and is there another temporary pacemaker code.

surgeon does a external iliac to profunda interposition bypass graft end-to-end. Then he does a bypass graft from the interposition bypass graft to the SFA. How is this coded?

Please advise re the correct CPT coding for the following case.

Embolectomy of the distal right external iliac artery with fresh thrombus removed from the RCFA and the profunda.

Femoral endarterectomy and patch profundaplasty using bovine pericardium to restore in-line flow to the profunda. Angiogram of entire right lower extremity performed via micropuncture through CFA patch graft, demonstrating patent distal RCF and profunda arteries, occluded right SFA, slow reconstitution of the popliteal with peroneal and posterior tibial arteries serving as run-off. No flow seen beyond the ankle. Injection of tPA down the PT under US guidance.

Hello! Pro-fee coding question here.

Patient came in for right iliac-to right profunda bypass. After placing the bypass graft there were complications nd the patient was bleeding and they believed the aortic clamp had damaged the distal aortic wall. To control the bleeding they placed an aortic-uni-iliac endograft and then they placed a left fem-to-right profunda bypass graft and ligated the iliac-profunda bypass.

We're looking at 35703 for aortic repair of the dissection, 35661 for the fem-fem bypass, but is there anything we can pick up for the iliac-profunda graft placement that they completed and then ligated just distal of the iliac anastomosis? 35665-52? Add a 22 to something else? or nothing at all?

Dr. Z-- is there a CPT code for lumbar drain replacement? Many drain replacements have their own CPT code. Procedure report below without PHI. Thank you!

Contrast was injected into the existing lumbar drain, which was confirmed to be in the epidural space, and this drain was removed.

A 22 gauge LP needle was inserted into the lumbar region above as a guide. A 14 gauge LP needle was inserted into the lumbar region at the L2-L3 interspace.  There was return of CSF fluid and a lumbar tube with a wire was insert was threaded through the LP needle and into the subarachnoid space. The needle was then remove followed by the wire and dressing was then applied over the lumbar drain

If one APP assists with the harvest and CABG and a second APP assists with the MAZE procedure can the second APP also code with AS modifier? If so since the MAZE CPT code 33259 is an add-on code, should they also code the CABG codes since they assisted with the MAZE procedure?

Can the interventional radiologist in the outpatient hospital prior to performing the intervention, order e.g. MRI and may read it too? It may also be read by anyone of the radiologist in the group practice (outpatient hospital radiology) or (office/global radiology imaging). Is this in compliance with the Stark Law's in-office ancillary services exception?

When the Radiologist places 2 separate orders, 1 for 76700 abdomen complete. Another for 76705 abdomen limited, and done 2 hours apart. Same ICD-10.

Can these two be reported together based on separate orders, or is CPT 76705 consider inclusive to 76700. And not allowed in this context.

The patient had a LAAO closure device deployed but there is a gap between the device and the appendage wall. There have been literature showing that ablating the appendage wall around the device will shrink the tissue around the device.

Do you think this would qualify as a AF Ablation?

This pt had a CAGB 33533 and thru a separate incision, had a thrombus removed from the LT atrial appendage. The physician billed 33315. I was just wondering if 33310 is more appropriate because with 33315 aren’t we charging for CPB twice? Here is the op note portion of 33315: I began the operation by lifting the heart, exposing the left atrial appendage. This was opened. The clot was removed and passed off the table as a specimen. The opening was oversewn with a 5-0 Prolene suture in 2 layers.

Thank you.

When the Radiologist places 2 separate orders, one for CPT 73502 hip w/pelvis 2-3v. Another for CPT 72170 pelvis 1-2v. Both for the same ICD-10.

Done 2 hours apart.

Do we code both codes? Or do we combine into one CPT, confusion lies in the separate orders.

If the Radiologist places 3 separate orders for CPTs 72070 thoracic 2v, 72072 thoracic 3v, 72074 thoracic 4v.

For the same ICD-10 code. Done minutes apart.

Do we allow codes with modifier 59? Or combine these services into one code of 72074?

If the Radiologist orders two separate orders for hand x-rays, one for CPT 73120 hand 2v, and another for 73130 hand min 3v. Done 7 minutes apart for the same ICD-10 code.

Do we combine these services into one code of CPT 73130? OR do we allow both codes, since two separate orders were placed?

Can you please help with this one? Dissection was carried down to the sternum, which the entire length was a severe nonunion. The oscillating sternal saw was used to complete a re-do sternotomy. The xiphoid process was removed d/t very protuberant and causing pain. We then developed bilateral pectoralis major advancement flaps by developing a plane beneath the LT and RT pectoralis major muscles. Each muscle was lifted off the sternum and mobilized toward the midline. Ostectomy was performed to freshen the edges of the sternum. I used the KLS plating system. Reduction clamps were used to bring sternum together and for allowing placement of plates and were removed. The flaps were then closed over the midline using #1 PDS suture. Drains were placed and layered closure was performed. Would this be coed as 21750 and 14000 vs 15734 x 2? we are unsure on the muscle advancement flap codes. Thank you.

Hello Dr. Z,

How would you code a cloacagram where scopes were utilized? Would 52000 & 74775 be sufficient or is an unlisted more appropriate? The abdomen and perineum were prepped and draped in the usual sterile fashion. Endoscope was placed in the mucous fistula. A balloon catheter was then placed in the mucous fistula and the balloon inflated.

Cystoscope was performed and a balloon catheter with a marking catheter inserted within the lumen was placed into common channel. Contrast was injected into both catheters under fluoroscopy. BB was placed at perineum. Contrast included isovue and gadolinium. Catheters were capped. Rotational fluoroscopy was performed.

Urethra length was short and common channel length was approximately 3.25cm

Thanks Dr. Z!

The skin site over the targeted lesions was prepped and draped. Lidocaine with infiltrated into the deeper tissues around the lesion. under direct sonographic guidance, aspiration was performed using a 22 gauge spinal needle. Lesion completely collapsed upon aspiration and approx. 2 cc of yellowish fluid was removed. A ring shaped biopsy marking clip was placed at the former site of the cyst.

Compression was held until hemostasis was achieved. The specimen was sent t the lab for analysis.

Post procedure digital CC and lateral mammograms were obtained which show resolution of the mammographic finding and the biopsy marking clip in the expected location

Impression: successful ultrasound-guided aspiration of 2cm cyst in the 4-5:00 position of the left breast.

Since this is a breast aspiration, would that clip placement be considered unlisted? I got codes 19000, 76942, 77065 but unsure of the clip placement. Thank you- DM

Radiofrequency lesions were created with a temperature of 80 degrees Celsius for 80 seconds at the following stated levels. First, the right L5 dorsal ramus was targeted. The right sacral ala was identified using fluoroscopy. The skin over this area was anesthetized with 2 cc 1% lidocaine using a 26-guage 1-1/2 inch needle. Then, a 20-gauge 150 mm Stryker Venom needle with a 10-mm active curved tip was advanced to the sacral ala. Next, the right L4 medial branch was targeted at the junction of the transverse process and superior articulating process of the L5 vertebral body. Next, the right L3 medial branch was targeted at the junction of the transverse process and superior articulating process of the L4 vertebral body. Would the recommended coding be 64635-RT, 64636-RT or 64635-RT, 64636-RT (modifier 59), 64625-RT, or 64635-RT, 64636-RT x 2? There is no mention of the sacral nerves being specifically targeted. Seems like 3 levels (L5-S1, L4-L5, and L3-L4) were RFA’d- any guidance would be much appreciated for coding this.

Please help. What is your direction on billing for an US and then US guidance of same body area/same DOS? What if US guidance is included in procedure? If the US guidance code is bundled into the US body area code, which to bill?How would you code this one? CEUS of b/l legs and then US guidance used for aspiration of b/l infective myositis...76978 & 76979 and 10160 X2, or code also 76942? The CEUS codes are not bundled into 76942. What is the direction with respect to billing for an US of same body area as Procedure using US guidance.....even if US guidance is included in procedure and not billed separately. When bundled; e.g. 76942 into 76705, can we billl the 76705 instead of 76942?

Can you please help us decide what this pain injection charge should be? The report is suggesting 20600, which we are questioning. "A 22 gauge Quincke needle was placed at the posterior medial aspect of the right lateral L6-S1 articulation from a posterior approach with discussion of the lowermost disc as L6-S1. 0.3 ml Isovue-300, 0.4 ml ropivacaine 0.5% and 20 mg triamcinolone were injected at this site. The needle was removed. There were no apparent immediate complications of the procedure. Follow-up was planned with the referring service. The patient was able to walk following the procedure. Patient denied the possibility of pregnancy with last menstrual period approximately 3 weeks prior to the procedure and with serum hCG level less than 2."

Are the New C codes C7516-C7553 only for ASC or also apply to OP Facility?

According to CPT guidelines CF, SFA and popliteal are considered one terriority for intervention. Does this same rule apply to IVUS performed in all three vessels?

Are there only certain brands of "covered" stents that qualify for use of CPT codes 34707 and 34708 if the proper indication is met? I have looked and have not been able to find a list anywhere, so I was guessing it's just the fact it is referred to as "covered." Our facility uses the Bard LifeStream covered stent, so I'm specifically inquiring about that brand. Thanks!

Hi Dr. Z,

A CT guided core needle biopsy of nodule immediately in front of the left kidney was performed. Technically successful and uneventful CT guided core needle biopsy of the left anterior pararenal nodule. Would this be coded 49180 or 52000,77012.

Thank you.

Hello Dr. Z,

Skin and subcutaneous tissues were anesthetized using 1% lidocaine. Surgical incision was made overlying the area of previous surgical incision from port removal. Port pocket was irrigated and hemostatic. Port pocket was then packed with iodoform gauze.

Looking into 10060 with 52 modifier. Since anesthesia was administered, would E & M code be an option?

Kindly advise. Thank you for your valuable input.

Sincerely,

VJ

Are codes 47554, 47535 correct for the follow procedures?

1. Cholecystostomy tube cholangiogram.

2. Over-the-wire cholecystogram and cholangiogram.

2. Cholecystoscopy.

3. Laser lithotripsy - video guided.

4. Cholecystostomy tube exchange and conversion to transcholecystic internal/external biliary drain.

5. Post tube cholangiogram.

I coded 75625,75716 and 75774 from this part of the OP report

A flush catheter is placed into the aorta at the T12-L1 junction and a complete AP abdominal aortogram taken.Normal arteries are not visualized in keeping with his end-stage renal disease. Infrarenal aorta is atherosclerotic but not aneurysmal. A removable type IVC filter is noted. Catheter is brought down to the L4-L5 iliac bifurcation and a pelvic angiogram taken.This demonstrates patency of bilateral common Iliac arteries, external iliac arteries and internal iliac arteries. External iliac arteries are ectatic.Catheter is then brought down to the level of the right common femoral artery and a selective right lower extremity angiogram taken.This demonstrates patency of the common femoral profunda femoris and proximal SFA. The knee prosthesis is occluding the popliteal artery on the right. Additional selective catheterization is then performed with A 014 quick cross catheter.

Hi, I am seeking clarification on the scenario of retrograde right common carotid origin stenting (with endarterectomy of right internal carotid artery just distal to the bulb). Due to anatomical considerations, I see that the distal left common carotid/left common carotid origin would be intrathoracic. However, with the right common carotid origin being behind the sternoclavicular joint, as this is the junction between the neck and the thorax, I am uncertain if this would be considered intrathoracic or cervical. Could you please verify if stent code assignment for the scenario of retrograde right common carotid origin/right proximal common carotid stenting done concurrently with right internal carotid endarterectomy would be 37217, or 37215/6? Thanks

Hi Dr. Z. Besides 93458, can we bill 92920-74 (hospital) for the attempted intervention? The doctor spent 35 minutes on the attempt, no balloons, just wires and microcatheter. “I used a 6 French EBU 3.75 guide catheter and selectively engaged the left main. I then attempted to cross into the 1st diagonal (culprit vessel) which is a small caliber that is less than 2 mm in diameter with a 95% stenosis and reduced TIMI 2 flow. The 1st diagonal branch has an extremely angulated takeoff. Essentially it goes backward 180° and then turns another 180° in an S shaped with extreme acute angulation that makes wiring essentially impossible. I could not wire with a run-through. I attempted wiring with a different wire she is a choice PT floppy wire crossed into the proximal diagonal but with an S shaped that prevented it from further advancing across the lesion (any time I would advance it it would flop back into the LAD). After a prolonged attempt I elected not to proceed ...” Thanks in advance!

I am confused if code 93356 or 93356-26 can be billed on a professional claim? I work for Cardiologist that is owned by hospital. Is this a facility charge?

His documentation is frequently confusing ...Would you code 93656/93655? Also, I'm struggling identifying additional mechanisms and afib remaining after ablation. any advice is appreciated. Using the intracardiac echocardiography, a single

transseptal sheath was inserted in the left atrium. The mean right atrial

pressure was measured at 8 mmHg and the mean left atrial pressure was

measured at 10 mmHg. The Biosense/Carto mapping system was utilized

during this procedure. After obtaining the left atrial map, RF pulses

delivered to the left and right carinas until pulmonary vein isolation was

accomplished. After completion of the PVI, LA roof line was created.

The LA posterior wall was then isolated by using pacing/capturing technic.

The esophageal temperature was closely watched and high-flow irrigation

was done whenever temperature rise was noted. The catheter was then

removed from the LA and positioned in the RA . RF touch-up lesions were

performed in the SVC and CTI.

50 year patient. Malfunctioning tunneled CVC was removed, after angioplasty of the right IJ with 12 x 40 mm balloon, there was resolution of stenosis to less than 10% residual stenosis. After angioplasty of the SVC with 12 x 60 mm balloon, there was resolution of stenosis. A 23 cm DuraMax catheter was placed over a guidewire with its tip in the atriocaval junction in good position. The catheter was functioning with good blood return and flushed without difficulty.

What would be the correct code(s) for this removal of tunneled CVC, angioplasty of IJ and SVC, and new tunneled catheter on over the same guidewire?

DX: CAD With NSTEMI New Onset Atrial Fib

Procedures: CABG X3, PVI, Left Atrial Appendage Clip Application, Rigid Sternal Fixation

Here is a Portion of the OP note. Coded as 33256.

Is 33256 the correct code for the following excerpt during a CABG Procedure

Thank you

OP Note: Following Arrest, we performed Pulmonary Vein Isolation. The heart as retracted to the right, the ligament of Marshal was incised and the left superior and inferior pulmonary veins were encircled. A medtronic cryoprobe was utilized to ablate the pulmonary veins for 2 minutes. Once the probe defrosted it was removed. The heart was then retracted to the left and the right superior and inferior pulmonary veins were encircled. The cryoprobe was again utilized to ablate pulmonary veins for 2 mins. Following this a 45mm atriclip was applied to the atrial appendage.

Can we code placement of a central line separately to 36556 in addition to 99152 when the physician is using the line for administration of sedation meds in a patient with no IV access? The physician is performing lower extremity arterial interventions.

Male w/infected LT knee was in operative suite when I was called. Had exposure on anterior surface of LT knee & incision in below-knee area on medial aspect of proximal LT calf. Ortho surgeon had been evacuating the area of infection when he noticed bleeding behind the tibia. When I arrived patient had a tourniquet insufflated to 300 mmHg. We let this down & noticed bleeding posterior to proximal LT tibia. I extended incision about a half a CM proximally. Upon doing this, was noted patient had significant venous pressure. By extending incision I was able to see into the depth of the wound better. All bleeding appeared venous in nature. I took Gelfoam soaked in thrombin & packed the area. Tourniquet reinsufflated to 300 mmHg. We left this in position for 10 minutes. Tourniquet released, no evidence of active arterial bleed. Good Doppler signal over DP, no signal over PT. No active pulsatile bleed from knee incision. Gelfoam & thrombin left in position. Ortho surgeon closed incision. Should I code only an E/M for my vascular surgeon's work?

Should 33509 be coded if it is harvested and not used due to calcification and small vessel?