Ask Dr. Z

"Ultrasound documented intraluminal thrombus with occlusion to flow proximally 1 cm from the arterial anastomosis. Following sterile preparation and local anesthesia, a micropuncture needle was placed with ultrasound guidance into the arterial  limb of the access just central to the arterial anastomosis directed toward the central venous vasculature. Access was secured with an 8 French sheath. Contrast injected through the sheath demonstrated intraluminal thrombus in the arterial limb of the fistula tapering to a focal occlusion in the mid fistula. Central venogram was performed, which demonstrated some luminal irregularity and focal narrowing with filling defects at the confluence of the subclavian vein with the superior vena cava. An 8 mm x 8 cm Conquest balloon catheter was then advanced to the subclavian vein, and percutaneous transluminal angioplasty was performed at the subclavian stenosis as well as at stenoses identified in the axillary vein." 

Codes are 36902 and 36907. Based on the documentation, can we report code 76937 for ultrasound? 

The patient had concomitant PVI ablation and LAA closure with a Watchman device. Code 93662 is clearly documented as having been performed with each procedure. Code 93662 is not reported with 93656, but can be coded with 33340. Could or should 93662 be coded x 1 in this case with modifier -59 for use with the LAA closure?

"We deployed the device through the gate. We deployed the suprarenal struts. We then advanced a limb from the main body to the distal common iliac. The IIA, as seen on the CTA, was occluded. We then ballooned the proximal neck and the overlaps with a Reliant balloon. Following this, we noted a dissection just distal to the stent. We placed a Viabahn into the proximal EIA. After another angiogram, we noted a propagated dissection. We then placed another Viabahn into the distal EIA. Following this, there were no further dissections noted."

I'm questioning if the Viabahn stents placed in distal common iliac to proximal external iliac due to dissection post graft placement are considered an extension in this scenario? Or would code 37221 be more appropriate?

What would be the proper code for CT-guided gastro tube replacement via same access without fluoroscopy? I'm thinking 49999 or 43999.

For visceral venography where there is not a specific CPT code, do you recommend unlisted code 37799 or 76946 for the imaging?

For the following, can we report code 34707 along with 34705 for the treatment of the left iliac aneurysm?

"Abdominal aortic aneurysm status post EVAR who presents with an enlarging left common iliac artery aneurysm and type III endoleak. A 32 mm x 14 mm x 14 cm Gore endoprosthesis main body graft was placed within the left sheath. The main body graft was then deployed below the renal artery ostia within the previous graft. The gate was then cannulated through the right groin using a pigtail catheter. This was proven using a twirling pigtail catheter within the main body. A 12 mm x 14 cm Gore endoprosthesis was selected and deployed in the right common iliac artery. The remainder of the main body graft was deployed above the left iliac bifurcation. A 12 mm x 12 cm Gore endoprosthesis was selected and deployed in the left common iliac artery."

From a common femoral approach, the catheter is selectively placed in the ipsilateral peroneal artery. Can I code this as a third order catheterization? The reason I am questioning is because in Appendix L in the CPT codebook they don’t list the tibial/peroneal trunk. Would it be correct to report code 36247?

I've recently begun coding for a provider, and I've seen him dictate a few reports that say something to this effect: "Exchange was made for a 1.4 laser atherectomy catheter, with which atherectomy of the P3 popliteal, tibioperoneal trunk, and proximal to distal posterior tibial artery segments was performed. Exchange was made for a 3.0 x 80mm balloon, WITH WHICH LOW PRESSURE BALLOON THROMBECTOMY AT THE MID LEFT POSTERIOR TIBILA ARTERY WAS PERFORMED, followed by higher pressure prolonged angioplasty at the same segment." 

In the findings section it reads: "Multifocal proximal to mid left posterior artery 70-80% stenoses, with mixed morphology concentric calcific plaques seen with intravascular ultrasound. Superimposed 100% short length occlusion of the id left posterior tibial artery with immediate reconstitution. Reestablishment of brisk antegrade flow through the occlusion after balloon maceration thrombectomy. Less than 10% residual stenoses at all treated sites after atherectomy and angioplasty."

He's essentially wanting to bill for a thrombectomy in the same vessel as the atherectomy. I believe we should just be billing for the atherectomy; is that correct?

I have read a few responses from prior Dr. Z questions regarding what documentation is needed to support IVUS CPT 97928. I'm having a little trouble deciphering if this documentation supports that CPT code.

Documentation within separate H&P includes a paragraph that IVUS was used to assess vessel size and degree of calcification and was followed by placement of Frontier stent and Euphora for optimum stent apposition.

The peak and mean aortic valve gradients and measurements are included within an additional cath procedure note, as well as pressure measurements for multiple LV and AO pressures. The hemodynamic procedure report generated during cath includes Euphora was inflated in LAD followed by documented times for insertion of ultrasound catheter with IVUS run started, run completed, IVUS catheter out times. Is this combined documentation between notes enough to support physician billing of CPT 92978-26-LD (please note CPTs 92941 and 93458 were also billed)?

The pt with Prox RCA lesion, 80% stenosed and previously placed Mid RCA drug eluting stent is widely patent.

The pt also with Dist RCA lesion, 80% stenosed and the lesion has in-stent restenosis.

Intervention

Successful PCI of pRCA with DES x 1 and DCB PTCA of distal RCA (Dual layer ISR)

IVUS was done at both Prox RCA lesion & Dist RCA lesion.

Should this case be coded as C9600 & 0914T?

How would I code for the removal of a SQ ICD with insertion of a biventricular ICD at the same operative session? When I try to code 0573T and 0580T (removal of ICD and substernal lead) with the insertion of the biventricular ICD (33249, 33225), it comes up with the zero edit that these absolutely cannot be coded together. Per the OR report: "Incised over the subcostal subxiphoid incision cut down to the silastic collar removed the ties from the silastic collar and removed the lead from the sub lateral sternal area, I then made incision over the lateral axillary region down to the pocket remove the device from the pocket and then was able to pull the lead through to the left axillary region and the device was removed. Then they placed new RA and RV lead followed by LV lead, and placed new ICD in pocket." 

Is there any way to account for both procedures?

Patient had a coronary CTA, which originally was dictated as "no evidence of coronary stenosis or plaque". Then an addendum was added that stated: “After additional review of the coronary CT angiography, a focal discrete severe lesion in the proximal posterior descending artery cannot be excluded, and further investigation is recommended with cardiac catheterization. The critical results of the findings were discussed accordingly.” They went on to perform a cardiac catheterization with intervention to the posterior descending artery. Is it appropriate to code the diagnostic catheterization in this situation?

For the following, would it be appropriate to report code 93641 (DFT), or would there need to be additional documentation?

"1: Single-chamber cardioverter defibrillator implantation. The device was attached to the lead and implanted.

Device testing was performed. Two-way communication was established between the device and its programmer; telemetered electrograms and pacing and sensing thresholds were measured."

We have noticed that sometime between 2022-2024 your chart illustrations have changed order regarding ipsilateral selection of popliteal on down. My illustrations (ZHealth, MAM, and Medlearn) range from 2006-2021 all show if common iliac access with ipsilateral selection of popliteal proper code is 36246. Superior geniculate = 36247, anterior tibial = 36247.

However, we have access to your 2024/2025 illustrations through Encoder and see that this area is totally different. It shows popliteal= 36245, superior geniculate = 36246, anterior tibial = 36246.

It looks like the SIR is in agreement with the old way, that popliteal = 36246 based on documents I have from 2024. Would you please share when this changed (date) and the reason/why behind the change?

Which procedure is primary when both PVC ablation and PVI isolation are performed at the same session? 93654 and 93655 OR 93656 and 93655?

Patient came for follow-up after a right upper extremity arteriovenous graft placement. She has developed steal syndrome, recommended to proceed with banding of the graft in order to alleviate the steal syndrome. Should we report code 37607 or 36832 for reducing the size of graft and banding of graft?

"Distal part of the graft just above the anastomosis was cleaned and dissected free from all the old clot and previously placed Surgi-Flo. A 2 cm wide pericardial patch was opened and washed and irrigation. A segment of the patch was cut and placed circumferentially around the graft just above the anastomosis. The size of the patch was designed in such a way to decrease the size of the graft to half. The segment of the graft wrapped by the pericardial patch was decreased to about 5 mm. The patch was closed around the graft using multiple interrupted 6-0 Prolene stitches. The hand and wrist were examined."

Would the statement "recurrence of conduction from prior ablation" documented after PVI was completed be considered Afib after PVI (93657)? What would recurrence of conduction mean? 

"Multiple application of the pulse field using Farapulse catheter using basket mode and flower mode with both ostial and antral isolation of all the four pulmonary veins. Post completion of pulmonary vein isolation mapping was performed and revealed evidence for isolation of all the four pulmonary veins.

Left atrial roof ablation: Due to recurrence of conduction from prior ablation, pulse field ablation was delivered in the flower mode of the catheter in the roof aspect with overlapping lesions between the left superior in the right superior pulmonary vein.

Left atrial inferior posterior ablation: Due to recurrence of conduction from prior ablation, pulse field ablation was delivered in the flower mode of the catheter in the inferior posterior aspect with overlapping lesions between the left superior in the right superior pulmonary vein."

Can we bill CPT 93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report) on the same date as a Holter monitor placement.

Example-

The patient presents with chest pain, and the physician orders an EKG (CPT 93000) which shows an abnormal result. Based on this abnormal EKG, the physician then orders a Holter monitor to further evaluate the patient's cardiac condition.

For an embolization, if the indication is for gastrointestinal hemorrhage, and when performing the arteriogram no active extravasation is found but an embolization is still performed, would this be coded as 37244 or 37242?

Can replacement of pacemaker generators codes 33227, 33228, 33229, and 33233 be billed with -KX or -SC modifiers?

For the following, should we report code 93655 after a PVI ablation (93656) is done?

"Attention was then turned to the right atrial caval tricuspid isthmus. Using a Biosense Webstrer Q Dot Micro catheter, a series of lesions were placed starting at the tricuspid annulus and working back to the inferior vena cava while pacing the distal CS. Target ablation index was 450. Ultimately bidirectional block was obtained. Ten minutes of observation followed, and bidirectional block persisted."

Is this 2 units for 93657 and 2 units of 93655? Or is this just 93656?

"The posterior wall did have some fractionated electrograms. The ICE catheter was withdrawn and a 5F quadripolar catheter was placed in the RV apex for pacing post ablation. The mapping catheter was withdrawn and replaced by a 31 mm Farapulse PFA catheter after the exchange of the sheath with the Farapulse steerable sheath, which was then used to create wide area circumferential lesions around the pulmonary veins as well as the carina between the veins. Four lesions were placed in each vein in the basket configuration, rotating the basket roughly 30 degrees for the second two lesions. The catheter was then moved to the flower configuration ,again rotating the catheter after two similar lesions for the second set of two lesions. These were placed to be certain to encompass the carina on each side. Following these, a series of lesions were placed sequentially on the posterior wall with overlapping positions to isolate the posterior wall and the posterior complex electrograms with lesions placed along the roof and low posterior left atrium."

My provider has asked if there are specialized CPT codes specific to the techniques called dynamic myelogram or digital subtraction myelogram? If not, can we use modifier -22 because these are more complex?

My understanding is there is not, but billed the same as routine. I need your expertise since I would use -22 for out-of-the-ordinary beyond our normal process of less than 5% of the population increased intensity, time, and technical difficulty of the procedure based on the severity of the patient's condition and physical and mental efforts required to do this. 

How would you code for a bilateral shoulder arthrogram if the needle placement is done under CT guidance, then taken to MRI for imaging?

Errors keep popping up:

23350 - 50

77012 - RT,XU; 77012 - LT,XU

73222 - 50

Is this correct?

Is there a general rule on whether we can use a -50 modifier on "bilateral" injections, such as the 644XX series and 0442T?

Lymphoscintigraphy for sentinel node localization was performed after the intradermal injection of 2.25 mCi of technetium 99m labeled Tilmanocept (Lymphoseek) at four sites around the lesion located along the right ear. SPECT-CT aquisition of the injection site and lymph node uptake was acquired and fusion was performed.

Would you report both codes 78195 and 78803 or just the 78195?

Can code 74420 be reported twice for bilateral retrograde pyelography at the same session?

Does this templated dictation meet the medical necessity guidelines for 75625? "An Omni Flush catheter was introduced over the Glidewire into the aorta to the level of the L1 vertebrae. An aortogram with iliac runoff was performed. Stenoses were identified."

Lately our providers have been using hydrodissection for organ and vessel displacement in conjunction with biopsies and catheter placements. Is this service separately reportable? Examples below.

"Non-contrasted axial images were obtained again demonstrating the mass in the posterior right hemipelvis. It is isodense to the adjacent uterus. There is mass effect on the posterior urinary bladder. Local anesthesia with 1% lidocaine. Deep anesthesia with a 15 cm 20 gauge Chiba. This was advanced into the iliac fossa, and hydrodissection performed. A 19 gauge 20 cm guiding needle was then advanced to the periphery of the mass."

“A 20 gauge Chiba needle was advanced to the left aspect of the sternum, and hydrodissection performed for displacement of the internal mammary vessels. A 17 gauge Bard guiding needle was then advanced via a left parasternal approach into the anterior mediastinal fat.”

"Hypodermic needle was advanced into the peritoneal cavity and saline infused for hydrodissection and bowel displacement. "

I have a provider ordering a nuclear Lexiscan to rule out any coronary artery disease considering hyperlipidemia. Also ordering an ECHO based on hypertension and to rule out LVH, in addition to ordering an LEA based on leg cramping as suspect PVD. Medical necessity will not be met unless the I25.10 is coded for the NUC and ECHO and the I73.9 is coded for the LEA. I don't think these should go on the claim or the testing claim, as they are only suspected and rule out diagnosis, but rather the signs or symptoms (but in this case medical necessity will not be met). Can you confirm if these rule out diagnosis can be coded or not?

"Biventricular defibrillator implant done: Right ventricular lead implant and coronary sinus lead implant. Post op x-ray could not see the leads. Went back into OR & removal dislodged CS lead implant of left bundle area lead & change of generator to a DF4/IS1 header. CS lead removal Venogram during prior implant showed lateral vein taking off from a separate ostium & the anterolateral branch not extending laterally. The middle cardiac was the only viable lead elected to remove the lead. Left bundle lead implant Medtronic C304 sheath was advanced to the RV septum over a glidewire. A Medtronic 3830 lead was used to map the septum in a unipolar configuration until a "W" pattern was found on V1. The lead was advanced into the septum while monitoring V1 configuration, impedance, LVAT, V6-V1 interpeak interval & QRS duration. Capture was confirmed in both unipolar & bipolar configurations. Sensing was satisfactory. There was no diaphragmatic stimulation with high output pacing. The sheath was split and removed." 

What are the correct CPT codes for this situation?

"Patient came in for right axillary hematoma with pseudoaneurysm at origin of the axillary profunda bypass on right side. Our physician did a right radial cutdown to obtain access to the axillary artery. She placed a 5x5 Viabahn covered stent at the pseudoaneurysm. Once that was placed, she then cut down on the abdominal wall to palpate and cut through the graft. She did an angioplasty and a repair with a bovine patch."

For the top portion we have 37236 with 36140. For the second incision would this be a repair (35286) or a revision of the bypass graft (35883)? 

"Attention to the abdominal wall on lateral side could palpate the graft. Small 2-1/2 cm incision and cut down to abdominal graft then transected and oversewed the graft with 6-0 Prolene. Prior to last stitch we fixed to each segment of the graft with hem clips. I repaired artery with small bovine patch angioplasty total arteriotomy was approximately 1-1/2 cm, and the total arteriotomy length was the same. This was sewn in place with 6-0 Prolene."

Our institution performs MRI-guided transurethral ultrasound ablation of prostate with a urologist placing the ablation catheter and a radiologist performing the ablation. On the professional side, code 51721 would be reported for the urologist, and code 55881 would be reported for the radiologist. Regarding the facility coding, would we submit the comprehensive CPT code, 55882?

If needle access had to be used to access an existing tract, but no new tunnel was created (existing tunnel was used), is that reported with code 36558 due to needle access or code 36581 due to using the existing tunnel?

Positive pregnancy test. On ultrasound examination no intrauterine pregnancy is identified. Is 76801 then changed to limited OB code 76815?

What would the appropriate CPT code be for the following?

CLINICAL HISTORY: Abdominal pain in the setting of an ileocolic intussusception presents for air reduction enema.

TECHNIQUE: A rectal catheter was placed, and air with pressure was introduced in a retrograde fashion using the Shiel's technique. The procedure was performed three times in total with 15-minute breaks between attempts utilizing a maximum pressure of 120 mmHg.

FINDINGS: Initially the intussusceptum moved from the right upper quadrant into the right mid abdomen to the level of the ileocecal valve. Afterwards, there was obstruction to the retrograde flow of air within the outline of the intussusception identified in the right abdomen. Air reached the cecum on one attempt, but on no attempts did air reflux into the distal ileum. The patient returned to the emergency department without complication.

Impression: Fluoroscopy time 10 minutes 12 seconds. DAP 425 uGym2. Unsuccessful reduction of ileocolic intussusception.

Is having findings of the infrarenal aorta enough to report code 75625?

PVC ablation is 93654. Would you consider bigeminy or trigeminy as additional ablation +93655? I reviewed previous answers on queries for +93655 where Dr. Dunn responded that it was not the areas ablated if it is the same mechanism but discrete mechanism of arrythmia different from primary ablated mechanism. 

We have a case where patient presented in the EP lab with ventricular bigeminy. Ablation performed on RVOT with no suppression of PVC, then another ablation in the aortic cusp and patient kept having PVC. Ablation catheter crossed the aortic valve, and ablation was performed. Then final ablation using half normal saline in aortic outflow tract and all PVCs went away. Am I correct with my understanding that same mechanism therefore only 93654?

We have a new MD who has started doing a shunt run with RHC. Is this included in the RHC as 93451? We don't do congenital heart caths at our facility, so I'm not sure how this should be coded.

INDICATION: 49-year-old female who was admitted to the hospital with hypoxia and abnormal liver function. She was noted to have an AV malformation in her abdomen, but no clear explanation for her hypoxia. She is referred for right heart catheterization with shunt run for further evaluation.

HEMODYNAMICS:

Right atrium: 0 mmHg Right ventricle: 22/1 mmHg

Pulmonary artery: 20/3 mmHg, mean 8 mmHg

Pulmonary capillary wedge pressure: 6 mmHg Pulmonary vascular resistance: 0.43 wood units

Fick Cardiac output: 9.32 L/min Fick Cardiac index: 4.94 L/min/m2

SHUNT EVALUATION:

R Wedge sat: 95.5% Right PA: 77.5% Left wedge sat: 96.7% Left PA: 77.3% RV: 78.8% High RA: 77%

Mid RA: 78.8%

Low RA: 63%

High IVC: 85.2%

Mid IVC: 83.5%

Low IVC: History 82.7%

Right femoral vein: 78%

Can we bill for catheterization with mesentric angiogram?

Can code 34707 be used for an endograft repair of an aneurysm entirely within the internal iliac? The code only says iliac, not common iliac, but it does say "proximally to the aortic bifurcation and distally to the iliac bifurcation". Can code 34707 be used in any iliac artery like 37221, or would you use code 37236 for internal iliac aneurysm?

If the provider performs drug-eluting balloon and stent on the same lesion, do we bill code 0913T or 92928?

How would we code the following: SVC-IVC linear ablation, intact CTI ablation, mitral isthmus and intact PVI/posterior wall LA isolation? We were thinking of reporting codes 93653 and 93655 x 3.

Patient had placement of an intra-atrial stent. Following the stent, transthoracic echo discovered a thrombus in the stent. This was removed by aspiration thrombectomy. Should this also be reported using code 0644T?

Oncology nurse accessed infusion pump, and aspirated blood to confirm adequate/direct access. Contrast slowly injected into pump - catheter opacified normally with no extravasation of contrast. Cath fully intact. Opacification of hepatic arteries was identified. Given slow rate of flow, no anatomic details of intrahepatic arterial vasculature could be elucidated. In conclusion, hepatic artery infusion pump cath is intact and not occluded. Tip of cath appears to be well positioned, with opacification of hepatic artery vasculature. 

Would this be "maintenance" of implantable pump 96522? I can't seem to locate a code specific to just a "check". 

We are looking for the documentation that shows medical necessity for a peripheral intervention is greater than 50% or is is equal to and greater than 50% and coronary equal to and greater than 70% or just greater than 70%. We see the 20.7 NCD, but the percent stenosis is only documented under the carotid section.

For facility coding, code C9789 was created for the instillation of mitomycin gel (Jelmyto) for the treatment of upper tract urothelial carcinoma. If the provider performs an antegrade nephrostogram via existing tract (50431), would you know if these two procedures can be reported separately? I don't see any NCCI edit, but code 50431 is bundled into so many procedures, and I'm not sure of the medical necessity of a diagnostic nephrostogram. 

"Indications: 74-year-old with a known diagnosis of left upper tract urothelial carcinoma. Previously managed with a left percutaneous nephrostomy (PCN) tube. Given the location and characteristics of the tumor, the decision was made to perform an antegrade nephrostogram followed by antegrade administration of Gelmyto via the nephrostomy tract to treat the tumor."

Our physician has billed add-on code 33370 with code 0483T. We are seeing that this code has base codes 33361-33366 and is intended for protection with a TAVR. I do not see an edit; however, we feel it is not billable. Is that correct?

When there is a CTO of a coronary vessel and it has been bypassed, do we still code the CTO? Example: LAD documented as having CTO in the midsection, but there is also a LIMA graft to the mid LAD. Does the presence of the graft negate coding the CTO?

With reference to the newsletter dated Dec 30, 2024, can you please provide the documentation requirements to report add-on code 0742T with primary code 78451 or 78452?