Ask Dr. Z

What is the appropriate CPT code for CT-guided bilateral T9, T10, and T11 intercostal nerve cryoneurolysis? Would it be 0442T or 64999? I saw a previous post that suggested 0442T, but I also saw some other guidance that possibly unlisted code 64999 may be assigned.

Would you code 33264 for CRTD gen change and then 33271 for the new subcutaneous lead that was attached to the existing defibrillator lead using a Y connector? The patient already has an existing CRT D with three leads.

An incision was taken and extended down to the level of the device, which was removed. The pocket was then fashioned to accommodate the new device. A trocar was then taken and extended down to the posterolateral aspect of the lateral chest and a defibrillator coil was then delivered to this area and the delivery sheath peeled and a coil secured with suture. A Y connector was placed between this as well as the proximal SVC coil and the defibrillator was now replaced with a new device. The pocket was then inspected, irrigated and closed.

A physician performs a left heart cath, and the report states, "We then crossed the aortic valve and measured pressures." Is that statement enough documentation to code the LHC, or does there need to also be documentation of what the measurement numbers were? Here there were no LV or LVEDP measurements documented, just the statement pressures were measured.

Patient had a chronic right lower lobe lung infection with cavitated necrotic right lower lobe. The note states, "The chest was entered approximately under the periosteum of the ninth interspace. The cavity was palpated and delineated. I then resected three ribs for a segment of approximately 5 inches to fully unroof this region. It did appear to be approximately ribs 8, 9 and 10, although it was difficult to know for certain. The region was gently debrided. Clearly the cavity was foul and infected. There was no obvious bronchopleural fistula that could be visualized. The skin edges were turned down using a combination of #2 and #1 Vicryl suture." The code we came up with is an unlisted code of 21899 but can't determine the best comparable code for the procedure performed. How would you code this service?

Patient had an EVAR for aortic and iliac disease. We billed codes 37236 and 37221-50. Arteriotomies on both sides were closed and patched. Then, patient required an endarterectomy due to no distal signal in leg due to skin flap in femoral artery. Is code 35371 billable in this scenario?

"The ultrasound was brought back to the field and used to interrogate the bilateral common femoral artery arteriotomy site. No evidence of fistula or pseudoaneurysm were noted, and good pulsatility was seen in the arteries distal to the site of repair. Distal signals were checked, noted to be better on the right and absent on the left. Skin incisions were closed utilizing 4-0 Vicryl. Dermabond was placed over the incision line. I cut down on the left CFA. I opened the CFA and noted a large flap in the CFA. The CFA was endarterectomized and a bovine pericardial patch was placed with a 5-0 prolene. Hemostasis was obtained. There was an excellent signal in the CFA. Incision was closed in multiple layers with 4-0 vicryl and dermabond to the skin."

When agitated saline is used in transthoracic echo, should this procedure be reported with code C8923 or 93307?

Would this procedure be coded as 0441T or 0442T or would it be an unlisted code?

IMPRESSION:

Percutaneous right sciatic nerve block.

Percutaneous cryoablation of a neuroma located at the distal most aspect of the right sciatic nerve, at the level of the amputation.

Pre-procedure diagnosis: Phantom limb pain

Indication: Pain control

The patient was positioned prone. Initial imaging was performed.

Target #1:

- Maximal diameter (cm): 0.9

- Location: Amputation stump.

Under Ultrasound guidance, the needle was advanced adjacent to the sciatic nerve. Approximately 8 mL of bupivacaine 0.5% and 40 mg of triamcinolone was injected around the neuroma.

Under CT and ultrasound guidance, the ablation applicator(s) were advanced and positioned within the target(s). For each target lesion the applicators were placed and repositioned as necessary to achieve the desired ablation zone.

Thank you

On the following procedure I am looking for clarification. Per question ID 20868 & 21945 a left bundle (HIS) lead wouldn't be reported as a ventricular lead.

CPT assistant Bundle of HIS pacing lead with no atrial lead present CPT Assistant, March 2022 Page: 12 Category States that a HIS lead is a ventricular lead and should be coded as such. With that information for the below report would you do 33264 with 33225?

OP Note:

Upgrade of a dual-chamber ICD lead system to dual-chamber biventricular pacing ICD lead system by placement of a nonselective left bundle pacing lead via left subclavian pre-pectoral non-thoracotomy approach using ultrasound guidance for vascular access and utilizing nonselective left bundle pacing technique as the "left ventricular" lead.

Our provider performed an US pelvis (transabdominal only) with pelvic duplex. We reported codes 93975-26 and 76856-2659. Later the same provider performed an US appendix limited, and we reported code 76705-26. Is a repeat procedure modifier required with code 76705?

On pages 677-678 of the 2025 Diagnostic & Interventional Cardiovascular Coding Reference, it states that non-selective add-on pulmonary angiography code 93568 may be reported in addition to selective add-on code 93569 (unilateral) or 93573 (bilateral) when a percutaneous pulmonary artery angioplasty (92997, 92998) is performed. Why would a non-selective code be separately reported with a selective code?

I was wondering if an LV/CS lead was placed with a pacemaker or ICD, then the thresholds were unsatisfactory so it was changed to a LBB lead or RV septum lead, if we should bill a 33225-53 or just the 33225?

I have seen conflicting answers. I have read that I should add the 53 when completed and then changed to LBB or RV septum. Recently though I have seen on an AAPC magazine test that,

"When a procedure is fully performed but the outcome is unsuccessful, code the procedure as completed because the procedure was not reduced or aborted in any way."

Could you please advise on which way I should be billing this for my providers?

Patient had a planned CABG, MAZE W/ Atrial Clip & PFO closure. Since the PFO closure was planned and not an incidental finding is there a CPT code that we can bill for this. Since this was not a percutaneous procedure 93580 would not be supported possibly an unlisted code 33999 compared to 93580? Or would this be included within the primary procedures?

Obtaining smooth diastolic arrest an atriotomy was performed through Sondergaard's groove & retractor was placed w/ excellent visualization of the mitral valve. Did close small PFO compromising visualization due to back bleeding. P 2 prolapse with a torn cord medial half of the anterior lateral papillary muscle. Placed sutures from trigone→trigone increased exposure. Fastened 4-0 Gore-Tex & anchored them to the corresponding papillary muscle. 5-0 Gore-Tex then passed through the chorda loops free edge of the prolapsing P2 segment. Patient's previous anatomy high risk for Sam postoperatively I intentionally made the posterior leaflet more tethered down in the ventricle.

How would you code for a case where the side port of an intrathecal pump is aspirated under fluoroscopy but no contrast is used? I believe an old Q&A suggested 61070 with 77003 but based on the add-on code edits it doesn't seem like that is an option any longer.

Can we report code 76377 with below dictation?

"The obtained rotational 3D angiogram images were reviewed and processed on an independent working station.

Super Selection and Angiogram: Left Common Carotid Artery, 3D projection, series 10.

There is a Spetzler Martin grade 4 AVM left parietal arteriovenous malformation fed by dominant enlarged left M2 branches, likely rolandic and anterior parietal artery with early venous drainage into enlarged vein of Trolard and superior sagittal sinus in anterograde fashion. There is also deep drainage into internal cerebral veins into the vein of galen and straight sinus. The nidus approximately measures 3.2cm x 2.6cm x 2.25cm. No intranidal aneurysms or flow related aneurysms identified."

We have a stand-alone workstation for 3D ribs (VITREA). We are able to send our thin images to VITREA, and it will process 3D ribs and send it to PACS. The radiologist will look and read these 3D images. Is this something we can charge for using the 3D code 76376 or 76377?

An IC provider performed 93461 and had difficulties performing an access closure (due to diffused heavily calcified common femoral artery-the perclose device failed, they tried a footplate bit it kept getting stuck, then they tried a Minx7 french but that ruptured, lastly they tried an Angio-seal which still failed). Should 93461 get modifier -52 since the patient had to have the last device removed by vascular? Vascular also performed an artery repair with endarterectomy in addition to the device removal. The entire cath was successful other than closure.

My doctor did both TCAR and TF carotid stenting in the same session on the same side (left). Can both of these be reported as 37215-LT x 2 since they were done with different techniques from separate access sites? For sake of space I've only sent the conclusions: "Successful TCAR with dual stent deployment for symptomatic calcified L ICA disease. Due to severe ostial LCCA stenosis and slow flow into the stents, a secondary transfemoral LCCA stenting was performed with distal protection. No immediate complications."

Patient had drug-coated angioplasty of both popliteal and SFA. Is this still only coded once as 0913T?

Since the T12-L1 level is considered a cervical/thoracic paravertebral facet joint level for treatment with neurolytic agent, would the following procedure be reported with codes 64633-50 and 64636-50 (rather than 64634-50?)

"Procedure Performed: Bilateral T11, T12, and L1 MEDIAL BRANCH NERVE TO TREAT T12-L1 and L1-2 FACET LEVELS Radio Frequency Ablation under Fluoroscopic Guidance.

After negative aspiration for blood, CSF, or air, each needle was stimulated at 2 hertz for motor and 90 hertz for sensory without any problem and no radiating pain. 0.5 mL of 1% preservative-free lidocaine was placed at each level. Next, a lesion was made at 80 degrees Celsius for 90 seconds at each level without any problem. Then 40 mg of triamcinolone (total) was injected in divided doses at each level (condensed to save space)."

Can you please provide education on the radiology portion of this procedure? Bone marrow biopsy/aspiration is CPT 3822-LT. Having an issue with the radiology codes. Radiology is coding 77002 & 76377. Thinking it should be 77012 & 76376. Question is also do we have a "base code" for 76377? Would 76377 be coded with 77002 or 77012? This is for facility coding. 

"Patient on fluoroscopic table. Cone beam CT was performed to clarify the biopsy path. 3D rendering was performed under physician supervision, not requiring image post-processing on an independent workstation.

Skin prepped, under local anesthesia with fluoroscopic guidance, Arrow on control power bone access needle was placed into left iliac crest. Aspiration of bone marrow & bone plug aspiration was performed. CT exam was performed using one or more of the following dose reduction techniques, automated exposure control, etc.

Fluoroscopic time: 0.75 minute."

"Patient has an indwelling left sided nephrostomy tube. Contrast was injected performing a nephrostogram. This demonstrates the presence of a long segment area of narrowing at the ureteral intestinal anastomosis at 8 diverting ileostomy. Patient is post cystectomy and partial ureterectomy with ureteral intestinal anastomosis. The existing nephrostomy tube was removed catheter was placed into the distal ureter near the area of narrowing. Glidewire was then used to traverse the area of narrowing into the diverting ileal loop. Kumpe catheter was advanced into the diverting ileal loop and the catheter was removed. Under fluoroscopic guidance an 8.5 French by 22 cm nephroureteral stent catheter was placed with the distal tip coiled in the diverting ileal loop and the proximal loop formed within the renal pelvis."

Would this be 53899 or 50688/75984 or 50434?

In 2022 the code descriptor for 11981 was revised to include the terms bioresorbable and non-biodegradable. Is it now appropriate for physicians to report code 11981 for these antibiotic pouches placed during pacemaker implants and pacemaker generator change outs?

What CPT code would be used for an MRI of the soft tissue of the lower back? (The 2025 book only mentions an MRI soft tissue of the upper back being coded to the MRI chest codes.)

Provider utilized the Javelin IVL catheter in the coronary artery. Per Shockwave website this product is for peripheral use not for coronary. Would I still be able to bill 92972 on this case since the catheter was utilized off label?

Can you report EGD with biopsy with enteroscopy codes?

When is it allowed to bill 75710 and 75820 together?

Do you code the following report as 93925 and 93922?

US ARTERIAL LOW EXT BILAT WITH ABI (XPD)

PVD

TECHNIQUE:

CF Doppler common pneumatic cuffs

Rt CFA peak systolic velocity 143 cm/second biphasic waveform, profundus femorals 61 cm/second biphasic, SFA proximal 72 cm/second biphasic, SFA mid 36 cm/second monophasic, SFA distal 41 cm/second monophasic, pop 30 cm/second monophasic, posterior tibial 42 cm/second monophasic, dorsalis pedis occluded

Lt CFA 142 cm/second biphasic, profundus femorals 56 cm/second biphasic, SFA proximal 55 cm/second biphasic, SFA mid 116 cm/second biphasic, SFA distal 102 cm/second biphasic, popliteal 40 cm/second biphasic, posterior tibial 44 cm/second monophasic common dorsalis pedis 34 cm/second monophasic

Rt brachial pressure 185 mm Hg, ABI 0.3 also some noncompressible vessels

Lt brachial pressure 129 mm Hg, ABI 0.82

Imp:

Rt low extremity spectral broadening abnml waveforms segmental areas of occlusions and

severe disease w/ ABI 0.39. Lt low extremity spectral broadening abnml waveforms and mild disease w/ ABI 0.82

We have some confusion based on the 2023 guidance for percutaneous nephrolithotomy. For hospital coding, if a patient goes to the IR suite and has a nephrostomy tube placed (50432), then goes to the operating room the same day for nephrolithotomy with dilation (50080/81), can we report code 50432 for the IR doc? 

Similar scenario, but patient has nephroureteral catheter placed (50433), can that be billed the same day as 50080/81? When is it appropriate to code/bill for 50436/50437? If the urologist dilates a previous tract, then performs nephrolithotomy, is that sufficient to add 50436 in addition to 50080/81? Or is 50436 only to be used if this is done by a different provider?

Per documentation, patient has peritoneal abscess. Abdominal drain was placed, but now there is no drainage from past few days. IR provider had removed the drain bedside and dropped the charge for E/M, but asking coder to bill for drain removal. Is it billable? If it is what is the code?

Patient was brought to the OR due to a right femoral artery pseudoaneurysm. There was a hematoma in the issue and at the anastomosis of the previous bypass with old and new blood. Using question ID #16039 it appears we will code this as a ruptured repair 35142 due to the active bleeding at the anastomosis. Is there any new guidance on this?

"Hematoma RT groin entered; subcutaneous tissue the hematoma was encountered and was removed. A large amount of hematoma both old and new clot was removed at the base of the hematoma of the right limb of the aortobifemoral bypass was identified and the toe of the graft was noted to have been disrupted with the sutures no longer intact. Bleeding coming from the native vessel, most likely from circumflex iliac branches. The foot of the graft on the femoral artery was completely removed by cutting the Prolene sutures. Hemostasis obtained & decision to put a jump graft was made. Some of the clot was sent for culture."

We occasionally perform bedside gastrostomy tube checks outside of the radiology department where an RN or MD injects contrast, and then a supine KUB and x-table lateral are immediately taken. The two images are done consecutively.

The description for code 49465 does not specify a modality, only "radiological evaluation". Would the imaging process described above meet the criteria for this code?

Would this be unlisted code 37799 or embolization 37242? If using an unlisted code, what would be a comparable code?

"Patient with history of prior venous intervention now has large arteriovenous malformation with large neck involving right common femoral artery and right common femoral vein. Surgeon uses an Amplatzer Duct Occluder II device with positioning of each disc at either side of the AV malformation with excellent seal." 

When coding for the facility, can we report diagnostic angiograms, catheter placements, US guidance, 3D etc., or is this one code C8004 all-inclusive? If all-inclusive, can we report code 75726 when imaging the SMA or other families that do not include the liver?

The physician does not mention thrombus was removed. He states, "It was withdrawn, and pulsatile inflow was regained." He also only states 3 Fogarty catheter and NOT a thrombectomy 3 Fogarty catheter. Is this a query, or am I overthinking?

Is it more appropriate to report balloon rhizotomy of trigeminal nerve, 64610, with FL guidance code 77003 or 77002. The CPT instructional use in conjunction with note after 77003 includes 64610, but 64610 is not included in the list for 77002. 77003 specifies FL guidance for a spinal or paraspinous injection procedure.

Since balloon rhizotomy is not an injection procedure is it better to charge 77002? Our IR department charges 77002. The Coding department sends these accounts back to have 77002 removed but no recommendation to add 77003. There is no NCCI edit with 64610 and 77003. 64610 and 77002 does have an NCCI edit allowed with a modifier.

What is the difference between these two groups of codes: 34001-34203 and 35301-35372?

One of my radiologists wants to start performing PET/CT guided liver and renal ablations. What CPT codes would we use for that service?

Would the correct charges be 19085 and 77065, or do we need an additional charge for the 3D with CADStream? Facility added 77061.

"The patient was positioned in the MRI scanner in the breast coil, and localizer images were obtained. Axial 3D volume scans were obtained with the patient's breast in mild compression. 6.2 mL Vueway was administered intravenously, and post-contrast images were obtained. The lesion was targeted utilizing the CADStream workstation. Biopsy was performed from lateral approach. The patient was rescanned, confirming appropriate position of the obturator. The obturator was removed, and a 9 gauge MRI compatible biopsy probe was inserted coaxially. A total of ten core biopsy samples were obtained. A biopsy marker clip in the shape of a cylinder was placed at the site of biopsy. Post-biopsy diagnostic mammograms were performed of the left breast confirming biopsy clip in appropriate position."

I am stuck. Can you help me with coding this procedure?

"An arteriotomy was made with an 11 blade scalpel and matured with pots scissors from the profunda femoral artery through the common femoral artery to the distal external iliac artery. An endarterectomy of the external iliac artery, CFA, and profunda femoris artery was performed. The endarterectomy was complicated by prior layers of stents and metal closure devices. Multiple old stents were removed from the external iliac artery, common femoral artery and proximal SFA... The stents were removed under direct vision using appropriate retrieval techniques.. Next the external iliac artery was thrombectomized to remove any intraluminal chronic thrombus."

Can I code 37197 x3 for the stent removals, and the thrombectomies along with the primary endarterctomy?

Question ID #17760 states that if a posterior wall and anterior wall are done it is considered one unit as a box lesion. If they do a posterior wall isolation with no reason given and then the patient has continued afib, persistent afib, or CFAEs,  can this be coded as 93657 x 2? The patient doesn't have to be in afib to code for PWI per previous guidance. So can we report two units for this if there was a separate reason to do the anterior wall?

Is code 76377 only billable once per laterality, regardless of the number of sites 3D rendered? The MUE is 2, but the CPT codebook does not specifically state that this is related to laterality vs. number of sites.

Would this be coded as 20220, 20206, or unlisted ?

"After injection of 1% lidocaine, a small incision was made with 11 blade over the left subtemporal area. Using entry and progress views, 10cm 18G Chiba needle was entered into the mass and aspirated with 20cc syringe. Minimal amount of sanguinous material was aspirated and sent for cultures. Repeat Hyper CT of the head was performed to confirm location due to patient movement. A 10cm 18G coaxial Temno needle was inserted into the mass. Position of the needle was confirmed with fluoroscopy. One core biopsy specimen was obtained and sent for pathology. Hyper CT of the head was again repeated on a separate workstation to confirm needle location. New entry and progress view was selected. 10cm coaxial Temno needle was inserted into the mass and one additional core biopsy specimen was obtained. 0.1 mL sanguinous material was aspirated directly from Temno introducer and sent for cultures. After above aspiration and core biopsy, decision was made to complete the procedure."

I have a question regarding code 64590 vs. 64595. Documentation: "This was opened. The battery was removed. The new battery was replaced, and the leads were connected to the new battery." Since the battery was replaced, I would like to report code 64590, as that code appears to have the device payment; however, I am getting pushback that code 64590 would be incorrect since there was no pocket creation and therefore code 64595 would be reported instead. I feel that this would then be undercoded. That pocket creation requirement is what is causing the debate in this case for the battery/generator replacement procedure. Would you please clarify?

Can you clarify something for us please? Both of these CPT codes have the verbiage "with or without radiologic monitoring", but in your book only code 64680 specifically says not to code imaging guidance as it's bundled. I didn't see though where it says that for 64530 and neither one of them hit any NCCI edits for guidance except for fluoro. These were performed on different days with CT guidance so should we be coding 77012 separately or no? 

AF ablation were done at left pulmonary vein, right pulmonary vein, anterior roof, posterior wall, anterior mitral line, and cavotricuspid isthmus.

Can I code 93656 & 93657 x 2 because anterior mitral line was also ablated?

Our physician performed a core biopsy of a sternal mass. I am having a hard time deciding on whether to bill as soft tissue biopsy (20206) or bone biopsy 20220. How do you decide?

"CLINICAL INDICATION: Breast cancer with a PET positive sternal mass. The patient was placed in the supine position on the hospital gurney, and limited ultrasound was performed to determine an appropriate biopsy location. The overlying skin was prepped and draped in sterile fashion. 1% lidocaine was infiltrated into the skin to provide local anesthesia. Using real-time ultrasound guidance, a 17 gauge introducer was advanced until the tip was at the edge of the lesion. Using the 18 gauge core gun, a total of four passes were made until a sufficient sample was obtained as determined by the attending pathologist. The needle and trochar were then removed, and a sterile dressing was placed at the needle entry site."

Doc. is sparse-in px description he states he did endarterectomy fem on rt-and embolectomy on lt. can you help with codes?

Procedure- bilateral femoral arteries were exposed and controlled. Transverse arteriotomy on lt and fogarty catheter was used to remove extensive clot from left side. Artery repaired. (34201-LT) Right femora needed a femoral endarterectomy due to plaque. Hemashield patch was placed and embolectomy catheter run up right side to remove extensive thrombus from right. (35371-RT – I don’t see where he actually describes that he performed the endarterectomy – is this enough??) Excellent inflow established. Aortogram done showed the right iliac stent was occluding the left side. Because of this we placed 8*29 VBX stents in the iliacs extending above the previous placed stents. (37221-50?) Completion angiogram showed excellent flow. Sheaths removed. Sub q closed with vicryl and skin monocryl. Counts correct.

There has been some confusion on whether codes 79445 and 37243 are reported on the Y-90 mapping procedures. The patients are receiving MAA-Tc dose and then the Y-90 injection a week or so later. Is it correct that we would not charge 79445 or 37243 on these initial procedures? Impression states, "Successful Y-90 prep angio and mapping."

"Retroperitoneal exposure. Large accessory renal artery and IMA identified and encircled. Suprarenal proximal control obtained and distal control of each common iliac. Aneurysm opened. Patch of accessory renal and IMA taken en bloc. End-to-end proximal anastomosis with 18 mm hemoshield gold graft. End-to-end distal anastomosis to cuff just above aortic bifurcation. All clamps removed. Side biting clamp placed proximally, and Carrell patch of accessory renal artery and IMA implanted."

With the added complexity of patient having a horseshoe kidney, the provider wants to bill for both the IMA and left renal accessory artery re-implantation using code 35631, 35636 respectively. I thought that the re-implantations are included in 35091? Please help, thank you!

Patient having a TAVR has a transseptal puncture and septostomy.

"Catheter was advanced into the left atrium... Over the Safari, we advanced a 14 x 4 Armada balloon and dilated at the level of the valve as well as the septum. A septostomy was performed to ensure adequate crossing of the TAVR valve."

Would the septostomy have a separate code, or is it part of the valve replacement? Is there an additional code for the transseptal puncture?