Ask Dr. Z

Co-surgery with urologist. Summary of vascular report: "I completely excised the tumor, leaving a very small rim of tumor in the cava. Once the left kidney was off the field, I was then able to place clamps in the renal vein, in the cava above and below the tumor, and finally was able to excise the rim of cava that was invaded with tumor. We were able to completely resect the tumor from the cava. We attempted a primary repair, but it was evident that a mismatch in size occurred. For this reason, I decided to patch the cava using bovine pericardium. A bovine pericardial patch was then shaped, cut, and anastomosed to the defect using 3-0 Prolene sutures, and with the aid of loupe magnification. Prior to completing the repair, we back-bled and flushed inflow and outflow sources, copiously irrigated the cava, and finally completed the repair." How should the repair (MD calls it a reconstruction) be reported: 35281 or 34502?

Can we add a 75774 to an aortogram when catheter movement does not advance into a smaller vessel, but is just moving within the aorta (e.g., to get a better look at something visualized in the initial study)? Left femoral access into supraceliac aorta (36200) with findings seen there as well as in iliacs, SMA, IMA, and right renal (75625). Cath advanced into terminal aorta to more closely evaluate right renal. Can we add a 75774 here?

My IR providers feel that if a patient has a GJ tube that migrates into the stomach and they fix it, it is considered a conversion and not a replacement. They are stating that because it is in the stomach it is acting as a G-tube rather than a GJ tube and therefore it is a conversion. Would this be a conversion or a replacement?

Can you please help? My provider states Shockwave 0715T is a form of atherectomy. I am having a hard time understanding this because Shockwave is an add-on code to 92920, 92924, 92928, 92933, 92941, 92943, and 92975. It seems to me that if it was a form or part of an atherectomy that they would have just added Shockwave to the 92924 or 92933 description. Also what code should this be compared with since there is not a Medicare fee schedule? Is it most similar to 92975?

Multi-faceted question for different scenarios; however, all have the same end question regarding the -74 modifier. Report lower level code or what you intended to do?

• Diagnostic coronary and physician is attempting to stent a coronary lesion. He states he easily crosses the lesion with a guidewire but is not able to cross with a balloon or stent. Do we charge 92920-74 or 92928-74?

• Physician is performing staged staged PCI but cannot cross the lesion with the wire. Physician spent considerable amount of time on the effort (greater than 10 minutes). 92920-74 or 92928-74?

• Diagnostic coronary and a lesion is found in the LAD. 10 minutes are spent attempting to cross the lesion without success and determine it is CTO. 92920-74 or 92943-74?

Auditors prefer we use the higher code but would appreciate your guidance. The only thing I found in Q&A was in regards to an aborted cardiac cath and the advice is "report the lower level procedure".

What is the HCPCS level II code for breast clip? Medicare is asking the device code. Localization of breast was done with clip placement during mammo prior to breast excisional biopsy. Codes 19281-XE and 19125 were coded. This is hospital coding.

"46-year-old male with history of RLE venous insufficiency with swelling, VV, and associated inflammatory change presenting for further superficial venous ablation. Limited US of the RLE was performed. Patient was then prepped and draped in usual sterile fashion utilizing chlorhexidene solution. A timeout was then performed identifying the correct patient, site, and procedure. 2% lidocaine was infiltrated for local anesthesia. A 25 gauge butterfly needle was then advanced into a superficial venous branch along the medial aspect of the lower calf. 6 mL of Varithena was then instilled with pressure held above/below the targeted venous segment for ~10 minutes.

Findings: 1) Limited US shows residual infragenicular GSV as well as two enlarged/incompetent venous tributaries extending along the anterior shin/medial aspect of the ankle (image stored). 2) Intraprocedural US images show sclerosant within all targeted venous structures (image stored)."

Physician confirmed that one truncal and two tributary veins txed. Is this all just a 36465-RT, or can the 36471-RT also be coded?

The physician inserts an MAC catheter and then advances a Swan. He does a full RHC and then sutures the Swan in place. Is it okay to charge for both RHC (93451) and non-tunneled CV catheter (36556) via the same access (i.e. RIJ access)?

A case was planned for an EVAR to treat an asymptomatic with AAA. During the procedure the AAA ruptured. Does the reason for the AAA rupture affect how it's coded 34706 instead of 34705? It is not entirely clear as to why the AAA ruptured. Does that matter?

"The physician deployed the main body of the graft without incident. The physician had difficulty cannulating the contralateral gate because of the patient anatomy. Multiple catheters, guidewires,  and two access with different sheaths were performed trying to complete the procedure. Another physician was called in, because a snare wire kept going outside the aneurysm, and a picture was shot through the sheath that showed the aneurysm had ruptured. The patient became hypotensive and did lose pulse and CPT was initiation return of spontaneous circulation was obtained, the ipsilateral and contralateral limbs were deployed, no evidence of endoleak. After closure the patient was transferred to ICU as she had coded 2 times during femoral artery repair."

"Left superficial femoral artery proximal, mid, and distal scattered 40 to 70% fibrocalcific stenoses. Right superficial femoral artery proximal, mid, and distal scattered 40 to 60% stenoses. Atherectomy of the left proximal, mid, and distal superficial femoral artery with a Hawk 1 atherectomy device; embolic protection with a EV 3 spider X 6.0 mm filter. Drug-coated balloon angioplasty to the left mid and distal superficial femoral artery with a Medtronic Inpact 6.0 x 150 mm, and proximal superficial femoral artery with a Medtronic Inpact 6.0 x 120 mm, in overlapping fashion. Ultrasound-guided access of right common femoral artery."

Can we report codes 37225, 75716-26, 76967-26?

Since the codes for Shockwave lithotripsy are for coronary arteries or lower extremity arteries, how would a facility code Shockwave lithotripsy and angioplasty to the left subclavian artery? Would we use an unlisted code to cover both procedures, 37246 with an unlisted, or would the angioplasty code (37246) be sufficient?

For a Medicare patient, the doctor orders, for example, complete joint ultrasounds of the bilateral hands/shoulders/elbows and also the knees and the ankles. Can each be billed with the appropriate modifier? I see in the book it says the MUE is 2 but the MAI is 3? Is that two sides per extremity? Each upper and lower?

How should the Alterra prestent with transcatheter pulmonary valve replacement/implant be coded? Would CPT code 33477 be all inclusive, or should this be reported with two different CPT codes?

20225 vs. 62267?

"The skin opposite the left T11 pedicle was anesthetized with 1% Lidocaine. A small dermatotomy incision was made. Additional local anesthetic applied to the posterior pedicular cortex using a 22-gauge spinal needle. Using a 13 gauge/10 cm long Stryker faceted tip bone biopsy needle, osteotomy was performed and the needle was positioned within the mid 3rd segment of the vertebral body. Utilizing two 18 gauge/20 cm long Franseen needles, biopsy material was retrieved from the endplate/adjacent disc. Material was placed in brain broth. Additional sample placed in a sterile specimen cup containing small amount of normal saline. Attempt a core biopsy through the introducer needle was performed. This retrieved very little in the way of tissue. A new 13 gauge Stryker faceted tip bone biopsy needle was utilized with a slightly more inferior transpedicular approach. This yielded an excellent core biopsy along the superior endplate of L1. Final Impression: Fluoroscopically-guided left T11 transpedicular bone biopsy of superior T11 endplate and adjacent T10-T11 disc."

Can you please help me figure out this case. How can I capture the work for the pediatric interventionist who is helping another provider during difficult cases of balloon angioplasty (92990) or pulmonary artery stent? Is it possible to report the service the main code with modifier -80 or -82?

What is the appropriate way of coding the Norwood procedure?

According to online resources (e.g. https://kidshealth.org/en/pare...), a Norwood procedure consists of:

1) Building a new, larger aorta

2) Creating a shunt (Blaylock-Taussig-Thomas shunt or Sano shunt) (e.g. 33750/33608)

3) PDA closure (e.g. 33820/33822/33824)

4) Making the ASD bigger (e.g. 33736)

Are the components of the Norwood procedure separately billable with 33619? (There are no NCCI edits when the components are billed with 33619.)

I came across only one resource that states the Sano shunt is not separately billable with the Norwood. See below.

https://www.sts.org/sites/defa...

If the patient has a pulmonary vein ablation followed by a posterior and anterior wall ablation with proper documentation supporting, would that be 93656 and 93657 x 2?

"Patient has complex prepatellar bursal effusion with overlying cellulitis. Under direct sonographic control, a 5G Yueh catheter was advanced into a large pocket of complex fluid and connected to a three-way stopcock. Local aspiration was performed, yielding approximately 20 mL of mixed purulent and sanguinous fluid (but amongst three different syringes). Relevant images were permanently stored into PACS. Small drainage bag was then connected to the three-way stopcock and appropriate sterile dressing was applied."

If it was just an aspiration I would code 20611, but what would be the code for the drain placement? Is 10030 appropriate? 

If catheter was placed in the arch but imaging was only performed of the arch, innominate, and subclavian (not of the extracranial, vertebral or intracranial arteries), would you report code 36221 or 75605?

The patient underwent liver radioembolization using Y90 microspheres. The patient received one dose of 51.7 mCi to the right lobe segment 6/7 and a second dose of 26.5 mCi to the right lobe segment 6/7. The provider charged for C2616 x2. The provider stated that each vial is sealed and accounts for one administration only, and sometimes two doses are needed to deliver the proper radiation to the target area. Should the microspheres be reported as C2616 x2, or should only one unit be reported since they were delivered to the same target? The MUE for C2616 is 1 per day.

We are getting conflicting answers as to what to code for an upgrade from a dual PPM to biventricular. Physician took out generator and replaced with new generator and added an RV lead. One of our coders suggested 33228 (dual generator change) and 33225 (insert biventricular lead). I was thinking 33213 (insert PPM generator with existing dual leads) and 33225. Can you please help us?

Can both billed together? 37241 and 37183

TIPS revision 12 mm balloon angioplasty of the TIPS was done with balloon sweep of thrombus (thrombectomy). Post intervention venogram demonstrated patency of the TIPS with an area of residual thrombus/occlusion at the superior portion. The portosystemic gradient measured approximately 25 mmHg. Subsequently, the superior portion of the TIPS was extended with 11 mm VBX stent Which was post-dilated to 12 mm.

EMBOLIZATION AND SCLEROTHERAPY: Through the retrograde groin accesses, the following interventions were done:

1.  Deployment of multiple detachable coils to occlude the renal venous communication to the shunt.

2.  Exchange to long 10 French sheath and subsequent deployment of 2 cm Amplatzer plug within the shunt in vicinity of the caval/lumbar communication

It looks as though the IR physician is doing the fluoroscopy for the neurosurgeon. Can this even be billed? These are different surgeons/groups/NPIs, etc. I'm billing for the physician portion. I'm not sure what to do with this.

"TECHNIQUE: Intraoperative fluoroscopy was provided. Eighteen images. Fluoroscopy time: 3.6 minutes, total estimated skin dose: 96.4 mGy. FINDINGS: Images show scoliotic curvature of the spine with T11 and L3 fracture deformities. Imaging showing needle placement via the pedicles at the T11 and L3 level are provided. Balloon inflation and bone cement injection are then noted. Bone cement is seen throughout the T11 vertebral body with extension into the pedicles. At the L3 level there is extension of bone cement into the L3/4 disc space. Atherosclerotic calcification is noted. IMPRESSION: Intraoperative fluoroscopy was provided. Please refer to the operative report."

Can we report code 61626 x2 for bilateral IMA embolization performed for bilateral TMJ ankylosis prior to bilateral TMJ replacement?

Our coding group is having discussions on post-op pain block reporting for the facility. Over the years, CPT Assistant and Coding Clinic for HCPCS have given advice, and we want to be sure we are interpreting current guidance correctly.

Per CPT Assistant, January 2021, CPT code 64999 should be used for a continuous fascia iliaca pain block. Is code 64450 still correct for a single-shot fascia iliaca pain block (per CPT Assistant, September 2015)?

We have pre-operative ultrasound-guided popliteal blocks from a popliteal fossa approach done by the anesthesia team for post-op pain for foot/ankle surgeries. We have been reporting these with 64450. If this type of block is a continuous infusion, is code 64450 still correct for this circumstance, or should we report 64446 or 64999 instead?

Should this be reported with 37215-78-52 or 37246-GZ?

"Poor expansion of the right internal carotid stent was likely an embolic event. After extensive workup and anticoagulation and antiplatelet regimen instituted, the consensus opinion was had, and repeat TCAR with ballooning of this poorly expanded stent would be immediately helpful as well as for long-range stent durability and patency. Left common femoral vein access had been obtained with ultrasound guidance, and this was upsized to 8 French silk sheath. We then initiated passive flow reversal checking for excellent flow, then clamped the common carotid artery proximal to the sheath to allow for active flow reversal. We performed angiography in two views, and stent was then decompressed and inadequately expanded, used first-day #5 and then a 6 x 40 mm balloon for re-angioplasty with full flow reversal." 

Would you agree with coding 93656, 93657 or 93656, 93657x4 for procedure below:

Indication: Persistent atrial fibrillation despite three ablations. Under ultrasound guidance two sheaths were placed in the right and one in the left femoral vein. Patient subsequently heparinized. A phased array Accunav ultrasound catheter was advanced to the right atrium. Under direct ultrasound visualization, the interatrial septum was crossed anteriorly and inferiorly with a safe-sept wire through a BRK-1 needle through a SL-0 sheath. The LA was mapped with a pentaray. The common left vein was isolated. The RSPV was isolated. The RIPV was patent. The VOM was cannulated. 1.5 cc ETOH injected through a 1.5 mm balloon. The RIPV was reisolated. Linear ablation was performed with RF across the left atrial roof. Linear ablation was performed with RF across the left atrial floor. Focal posterior wall ablation was performed isolating the posterior wall. He was cardioverted to sinus rhythm. Exit block was confirmed posteriorly. Patient left EP lab in good condition.

Patient presents with a chronic total occlusion of the left common iliac to external iliac artery. The provider placed two stents: one in the common iliac artery and another in the external iliac artery. The provider believes the concept of a bridging/contiguous lesion does not apply to CTOs. Since this is a CTO extending from the common iliac through the external iliac, would it be appropriate to bill codes 37221 and 37223?

In POS 24 (ASC), can you bill the 36906 and an additional stent device code? If yes, what are those device codes? I am trying to understand if you can bill for the cost of implantable items like coils, stents, etc. in additoon to the CPT codes.

Patient presents w/bilateral LE claudication and an aortogram w/ileo-fem runoff finding of a distal aortic pseudoaneurysm in combination w/a RT iliac pseudoaneurysm along w/a significant stenosis in the RT CIA estimated at 75% w/IVUS. To avoid possible rupture/perforation of the aortic pseudoaneurysm if only treating the CIA lesions (no findings are documented for the LT CIA), the provider deployed an 11mm x 29 VBX stent into the distal aorta to cover the pseudoaneurysm. He then advanced kissing stents into the bilateral CIA lesions to reconstruct the aortic bifurcation. Since the provider treated both an aneurysm and stenosis in the same vessel (RT CIA) would we look to capturing the kissing stents (37221-50) as the primary procedure? Or would this be considered an aneurysm repair instead and if so what would be the code option since individual stents rather than an endograft (i.e 34705) was being used? Your guidance is greatly appreciated.

When a physician's review and interpretation is not completed until after the patient is deceased, is this still a billable physician's service? Example: External ECG was placed and removed prior to patient's time of death. It was analyzed and then sent to physician to review and report. Code 93242 was billed by us on date placed, and code 93243 was billed on date analyzed by company who completes analysis and sent back to our physician. Patient met untimely death prior to physician finishing interpretation two days later. What date should be used to bill 93244?

Patient had RA RV leads. Physician placed a deep septal/LV lead.

"Using the glidewire, a steerable His sheath and dilator were advanced past the tricuspid valve and extended towards the septum just distal to the tricuspid valve. A passive fixation 3830 His lead was advanced and using pacing morphology guidance, a suitable deep septal site was identified. The lead was advanced using passive fixation but failed to achieve appropriate pacing morphology (rsR in lead v1) and the lead was withdrawn and repositioned further proximally towards the septal tricuspid valve. A second appropriate site was identified using pacing morphology. The lead was advanced and appropriate narrowing with acceptable pacing morphology was identified. Adequate pace/sense parameters were obtained. We now have RA, RV and a Deep septal / LB lead WITH NEW GENERATOR. Analysis and programming of a biventricular PPM at implant."

How would this be coded? Is it 33229 and 33225? Or 33229 and 33216? He's calling it a biventricular placement.

Could you please clarify if we can code 36901-52 and 36012? It seems like he moved the catheter back to stent the subclavian after he had accessed the fistula.

"Under sonographic guidance, right common femoral vein was accessed with a 21 gauge micropuncture needle. A 7 French sheath was inserted. Right cephalic AV fistula was catheterized with 5 French Kumple catheter and 0.35 guidewire. Right cephalic fistulogram and central venogram were performed. Right subclavian/innominate venous stenosis was angioplastied with a 12 x 60 mm balloon and stented with a 14 x 60 mm Cook Zilver Vena stent. The stent was dilated with a 12 mm balloon."

If a vascular surgeon performs the carotid exposure and catheter placement in the ascending aorta for a transcarotid TAVR, can it be reported separately? If so, would it be an unlisted code?

How would you code this catheter placement?

"CTA showed deep venous thrombosis of the entire left lower extremity venous system. Sheath was placed in the left tibial vein. EKOS catheter was advanced and placed at the left common iliac vein extending distally to the femoral vein. The patient will be brought back for lysis check."

1) Vein graft to marginal branch of circumflex

2) Vein graft to 1st diagonal of LAD

3) Vein graft to RC

4) Vein segment going to the marginal branch was anastomosed end-to side fashion to the graft going to the diagonal.

5) Artery to LAD

The #4 section has me question if this would be three vein grafts (33519) or four (33521)? It sounds like he connected the #1 and #2 grafts.

What CPT code can I use to capture a left bundle lead with biventricular ICD generator upgrade, not a bundle of His lead? Code 33264 can be used to capture the generator change. Dual ICD generator upgrade with existing RA/RV leads and implant of LB lead with new biventricular ICD generator.

"The prior RA and RV leads were tested and found to have adequate capture and sensing function. A new lead was placed, the left axillary vein was accessed using the seldinger technique. Through a 7 French sheath and using a C315HIS preformed catheter a Medtronic 3830 lead was advanced to the RV septum in the area of the His bundle. A His bundle potential was mapped. The lead was advanced and moved slightly infereriorly. The lead was screwed into the septum, pacing from this lead did not produce a narrow QRS with iRBBB morphology. A number of sites on the septum were tried with a final site showing adequate pacing and sensing thresholds, a fairly narrow paced QRS and stim to peak LV activation of less than 80ms. BiV pacing from this site and the RV produced a very narrow QRS."

I'm having trouble deciding how to code this. "Patient came in with biventricular pacemaker with an infected pocket. All three leads and generator were removed. New lead was inserted into right ventricle via right internal jugular. Old generator was cleaned, attached to new lead, and sutured to neck to be used as a temporary pacemaker."  Can you please help?

Indications: Syncope and sinus pauses for cardiac ablation. Do you suggest 93656 and 64620 for the destruction of nerves within the autonomic nervous system with radiofrequency or unlisted?

"Fractionated electrograms in the anatomical areas of the ganglionated plexi (superior-anterior to the superior pulmonary veins, anterior ridge between the left pulmonary veins and the appendage and inferior posterior to the inferior pulmonary veins) were tagged for ablation. Radiofrequency current (40 watts) was delivered through the 4 mm-tip electrode catheter using two adhesive conductive pads positioned over the left posterior chest for the return electrode. Multiple RF applications were delivered to the anatomical areas of the ganglionated plexi with some automaticity elicited and rare transient decrease in the sinus CL but no pauses. Additional ablation lesions were delivered to tagged areas in the posterior SVC corresponding to the ablation site in front of the right superior pulmonary vein."

Can you give clarification for billing codes 37220-37230 for angioplasty/stent with thrombolysis (overnight lysis) when treating thromboembolic occlusion? I'd like to give my physicians some clear instructions for documentation guidelines on these interventions, and I have seen conflicting information and even some instruction that you cannot bill any intervention with thrombolysis since that is not for stenosis. Must there be the specific word "stenosis" used to bill for interventions with thrombolysis? What if just "occlusion" is used? Physicians use stenosis/occlusion interchangeably. If stenosis is not stated and they are treating thrombosis or thromboembolic occlusion, can intervention be billed with 37236-37246? Or do they just get nothing? 

Need help with codes... should I bill code 32480 (lobectomy) and 32488 (completion pneumonectomy) (modifier -51) or just use 32440 for pneumonectomy? Also plan on using CPT code 38746 for lymph node sampling.

PROCEDURE(S) PERFORMED: Robot converted to open thoracotomy. Left upper lobectomy, completion pneumonectomy. Mediastinal lymph node sampling. Lysis of adhesions.

How would you code a VenoValve placement? I would think it is either 37238 or an unlisted code, but the doctor thinks it is 37226. The reps also say to use 37224, which I know that is incorrect because that is arterial and the VenoValve goes into the vein. Of note, the patients who are getting this valve are enrolled in a research trial. 

Is it correct to report codes 37184 and 37185 if a thrombectomy of the right pulmonary artery and the truncus anterior and interlobal pulmonary artery is performed?

Is it appropriate to report code 50200 x2 if a radiologist performs multiple core biopsies on multiple lesions of one kidney? I know the CT guidance can only be used x1.

Since 33222 requires relocation, what would be the appropriate (facility) code for this case? 

"The pocket was opened and carried to the device. The device was freed from the capsule. Visual inspection confirmed that the previous lead cap was pushing through at the base of the pocket towards the outside. We removed that. We created a space for this underneath a very thick capsule of remnant of an Aegis pouch. We recapped the lead and buried it there and reinforced that with Ethibond. Wound irrigation was done with antibiotic flush. We then put the device back into the same pocket and closed that with a deep layer of 0 Vicryl followed by a superficial layer of 4-0 monocryl."

What CPT codes and modifiers would you report for HM3 LVAD insertion with closure the next day? Chest left temporarily open to protect RV function and hemostasis. They did a mediastinal exploration, washout, and open reduction and internal fixation of sternum using titanium plates.

My physician did a thoracotomy and excision of a descending aortic mass with an aortotomy. I'm not sure what CPT code this would be. Could I use a repair of a blood vessel code?

Patient received a treatment with mCi iodine-131 orally. One week later whole body with SPECT/CT imaging is performed. Are we allowed to code for 79005 separately, or is it integral to nuclear medicine imaging procedures subsequently performed a week later? Are codes 78018 and 78830 correct for the NM imaging?

"EXAMINATION: NM THYROID ABLATION TREATMENT

ASSOCIATED DIAGNOSIS: Papillary thyroid carcinoma

TECHNIQUE: The patient was treated with 102.5 mCi I-131 sodium iodide orally without immediate complication. 1 week later, delayed anterior and posterior whole body imaging from the vertex of the skull to the upper thigh was performed. Additional spot views of the neck with and without markers were also obtained.

FINDINGS: Planar whole body scan demonstrates an area of focal asymmetric iodine uptake in the right central neck compartment, which on SPECT/CT imaging corresponds to a small iodine-avid soft-tissue nodule in the right tracheoesophageal groove at the level of the thyroid bed consistent with postsurgical thyroid tissue remnant...."

When coding 75710, is the -RT or -LT modifier required ? I have an outside company reviewing charges, and they are requiring the laterality modifier.

We have a stroke patient who had a left internal carotid injection for diagnostic angiogram. Following that the physician placed a Sofia catheter to try to aspirate clot from MCA, but had to abort the procedure. 

Documentation states: "Multiple attempts were made to cross occluded M1 segment of proximal left middle cerebral artery using microwire and microcatheter without any success due to very calcified lesion likely subacute or chronic occlusion. Unfortunately, I was not able to advance intermediate catheter to M1 segment of left middle cerebral artery for direct suction due to very tortuous vascular anatomy, and the procedure was aborted."

Would you only code the diagnostic angiogram, or would you also add the attempted thrombectomy with a -74 modifier to account for the extra work?