Ask Dr. Z

We know that a gastrostomy tube insertion without the use of fluoroscopy should be coded with an unlisted CPT. Would it be more appropriate to use code 49999, Unlisted procedure, abdomen, peritoneum and omentum, or code 43999, Unlisted procedure, stomach? The CPT code book classifies a percutaneous G-tube insertion within the Abdomen, Peritoneum, and Omentum section.

We have a patient who has pancreatic cancer. Patient is here for CT-guided celiac nerve block followed by celiac neurolysis with alcohol. Can we code both 64680 and 64530? Previous advice from 2016 said to only code 64680. Is this advice still correct for 2021?

"Patient was brought to the cath lab. He was draped and prepped in sterile fashion. A micropuncture needle was advanced from the subcostal approach. Pericardial cavity was reached. Straw-colored fluid was drained through the micropuncture needle, then a micropuncture wire was advanced and a micropuncture sheath was introduced into the pericardial cavity. A J-wire was advanced through the micropuncture sheath, and a pericardial drainage catheter was placed in the pericardial cavity. Around 450 cc of fluid was drained from the pericardial cavity. Afterwards, the drain was left in place and sutured." In this case can I report code 33016 (pericardiocentesis with image guidance) along with 33017 since the physician left the drain in place? Or does 33017 include the work for 33016?

The radiologist removed an infected port (36590) and packed the pocket with iodoform gauze and loosely closed with interrupted 3-0 Vicryl sutures and steri strips. The patient returned two days later for packing removal and full closure of the site. Can we bill 36590 with a -52 modifier for the first procedure and 36590 with a -58 modifier for the second procedure, or is the second procedure included in the first?

At the end of an atrial flutter ablation a vascular closure device is deployed but cannot be removed by the EP physician. A vascular surgeon is consulted who then performs a cutdown, removes the device, and suture repair of the femoral artery. Is this reportable with 35226?

Would Z45.2 (encounter for adjustment and management of vascular access device) be an appropriate ICD-10 code for the placement of central line (36556) or arterial line (36620)? One source says that these are appropriate, while another one does not define this diagnosis as including placement.

"No pulse in the right hepatic artery. Gastroduodenal artery clamped, aneurysm was entered, resection of aneurysmal tissue was performed. Saphenous vein was harvested and then anastomosed to the gastroduodenal artery in a reverse fashion. I then redirected my attention to the left hepatic artery. I extended the arteriotomy approximately 1/2 cm to widen the artery. I then fashioned the vein graft to fit this arteriotomy. A functional end-to-end anastomosis between the vein graft and the left hepatic artery was performed."  It has been suggested that I code this with code 35121; however, in my opinion, this is should be coded with an unlisted code 37799, as this was a hepatic artery - gastroduodenal bypass (no current CPT code for this procedure) and not a repair of an hepatic artery aneurysm. It is my understanding that code 35121 is for repair of aneurysm with graft insertion, not an actual bypass. Please advise which would be the more appropriate coding and the rationale behind your opinion.

Per Chapter 21 guidelines in ICD-10-CM, c., #3: “A status code should not be used with a diagnosis code from one of the body system chapters, if the diagnosis code includes the information provided by the status code.” Therefore: if stenosis is present in a coronary artery stent, T82.855A only would be reported; however, what if there is one patent stent in a distinctly separate coronary artery? Would this not warrant reporting both codes, and is it permissible?

Regarding NCD 20.33 TEER update: when is this effective, and will it be retroactive?

We need clarification regarding review of image, tracing, or specimen under the old E/M guidelines (prior to 2021). Can a cardiologist receive credit for personally reviewing the images and documenting a finding of their own services? Can this be done if their group are the ordering physicians and have billable CPT code? And are there any limitations? For example, re-reviewing the same records at each visit?

Is it appropriate to separately code a TEE during a pacemaker/ICD procedure? One example we have seen is a TEE done during a pacemaker upgrade. The TEE was performed to evaluate the pericardial space and the cardiac structures during lead extraction. This question is for both the facility and the physician coding.

Regarding the new office E/M guidelines, what list of conditions fit the definition of "1 acute or chronic illness or injury that poses a threat to life or bodily function" or "1 or more chronic illnesses with severe exacerbation, progression, or side effects of treat" for cardiology? In particular, considering unstable angina can come in a rainbow of different grades (some requiring hospitalization, some can be managed with outpatient LHC or a stress test), would this justify a level 5 for dx criteria? Please advise.

I'm needing some help with understanding proper coding and modifier use within a surgical global period.

Patient has fistula placed (36821) as well as tunneled catheter (36558) placed. Two months later, superfistulization (36832) is performed. Two weeks after that (still within 90-day global period) the tunneled catheter is removed in the office. What would be the proper modifier use in this scenario? Can catheter removal code 36589 be reported within this period in the office setting?

Or in the case where a fistula is placed in the LEFT arm, but fails in two months and a new one is placed in the RIGHT arm within the 90-day global period, would this be reported with modifier -79 because it's different arms or -78 because it's related, but not anticipated?

"Patient with AF burden 5-10% on most recent event monitor, also atrial aflutter (recent EKG), presents for PVI/CTI. The left pulmonary veins were circumferentially encircled as a pair. Adenosine was given within the left superior vein, and a PV reconnection was seen, suggesting breakthrough at the carina. Additional lesions were given in the carina and on the posterior aspect of the left superior vein. Adenosine was given again in the left superior vein and no PV reconnection was seen. The right superior and inferior veins were circumferentially encircled as a pair. Pulmonary vein isolation was performed until there was no further evidence of atrial activation within the veins. Adenosine was given and no PV reconnection was seen. The catheter was withdrawn into the right atrium into the cavotricuspid isthmus. A CTI line was created. Pace-testing confirmed block." Aside from 93656, should I report also 93655 (since atrial flutter was mentioned on history), 93657 (breakthrough at the carina), and 93623?

The CPT book now states to report an additional code if the Impella is removed via open approach. So if the provider takes the patient back to the OR to do an open removal and sutures the femoral artery, do you think we should report 33992 and 35226-XU?

Is the scout CT separately reported prior to US-guided liver biopsy: Code 74150?

"The lesion was difficult to initially identified on ultrasound. Therefore, a scout CT was performed. This demonstrated that the lesion was present behind one of the ribs. A second look with ultrasound was able to demonstrate the lesion using breathing techniques. The skin was marked. The patient was prepped and draped in the usual manner. The liver lesion was again identified with sterile ultrasound.  The skin and subcutaneous tissues were anesthetized with 1% lidocaine. Under direct ultrasound guidance a 17G coaxial guidance needle was advanced to the margin of the liver lesion. Three 18G core biopsies were then obtained."

A hysterosalpingogram was attempted on a patient but the procedure was terminated. What would be the correct code/s to report for this situation? "Patient was placed on the IR fluoroscopy table in the lithotomy position and the perineum prepped and draped in the usual sterile fashion using maximum sterile barrier technique. Preliminary scout radiograph of the pelvis is unremarkable. Duplicated speculum was inserted. Cervical os was never identified. Patient complained of moderate pain and procedure was discontinued. Collaboration with OB/GYN he will be required to complete the hysterosalpingogram."

There is a code for removal of an infected graft in the lower extremity, but I can't seem to find the code for removal of a graft that is not infected. The patient had a removal of a fem-pop PTFE bypass graft x 2.

What is the correct code for degeneration of the pubis symphysis? And can you give your rationale for the code selection?

What is the correct CPT code for embolectomy of the ileal femoral bypass graft?

Patient comes in for a dual PM @ ERI. Generator removed (ERI), RA lead capped (non sensing), RV lead removed (does not clearly state why). Then a NEW LV lead was placed, and a new generator.

How exactly would we code this? 33225, 33229? With a -52 modifier on 33229? Or 33207, 33225, 33233, 33235? With a -52 on 33207? LV lead is the only functioning lead.

Would this be a simple debridement CPT or a specific AVF CPT?  "Patient placed supine. Left arm prepped and draped. Patient given antibiotic. We examined arm with US (images stored). We had tourniquet in room in case proximal. We removed scab and discovered 4 mm pseudoaneurysm at the site of retained suture of previous access for thrombectomy. We established proximal/distal control with digital compression. We examined 4 mm defect in skin. It was degenerative without signs of infection. I debrided edges to healthy tissue and repaired defect primarily with 4-0 Prolene running suture. We now had thrill and pulsation in AVF. We examined repair with US (images stored) and confirmed patency. Dressing applied."

Is it appropriate to charge 77067, 77063, and 77065 for the following report?

"Screening with CC and MLO full field digital views of each breast was performed in combination with digital tomosynthesis( DBT). Standard mammographic views were supplemented with additional views for further evaluation of a mammographic abnormality. The mammogram was additionally reviewed by a CAD system.

Findings: The breast tissue is heterogeneously dense, which could obscure detection of small masses (50-75% glandular). Scattered, benign appearing calcifications are seen. The questionable asymmetry in the inferior right breast, seen on the MLO projection. However this does not persist on spot compression view.

The study demonstrates no mass, microcalcifications or areas of architectural distortion that are suspicious for malignancy.

Impression: No evidence of malignancy. Dense breasts."

Any guidance on annual cath/biopsy for transplant patients... does this documentation support medical necessity? Using Z48.21, Z94.1 for ICD-10 codes.

"PROCEDURES PERFORMED: Selective coronary angio, LHC, RHC, US-guided access of the left axillary vein, IVUS LAD and LMCA, right ventricular endomyocardial biopsy.

HISTORY: Male with a history of stage D non-ischemic cardiomyopathy. The patient underwent BTT-H VAT. He had a very complicated and prolonged postoperative course. He developed right ventricular failure. He required prolonged temporary right ventricular mechanical circulatory support. He required LVAD pump exchange. He ultimately recovered and underwent cardiac transplantation in December 2019. Patient has a history of HTN, type 2 DM and HLD he presents today for his annual invasive transplant evaluation.

CONCLUSIONS: ISH LT CAV 0, intravascular ultrasound demonstrates stable donor derived atherosclerosis, low right and left heart filling pressures, normal cardiac index, normal pulmonary pressures, successful right ventricular endomyocardial biopsy."

We are seeing more of our doctors perform shockwave lithotripsy ballooning during the same session as a TAVR. I have read that having calcified iliacs does increase the risk of serious complications during a TAVR. It seems to me that this is only being done to help facilitate the transfemoral access safely. Are we correct in not coding separately when we see this? Would there be a situation when we should be coding separately for the shockwave of the iliacs when done in conjunction with a TAVR?

Angiogram was performed, which showed distal right coronary artery 100% occlusion. Patient continued to have chest pain and therefore it was decided to intervene the left and descending artery, which had 90% stenosis. Angioplasty to both with placement of DES. In these instances and based on the information provided in your book 2017 Diagnostic and Interventional Cardiovascular Coding Reference, we code the highest level of intervention performed in each major coronary artery and branch separately, C9606 x 2? Is this correct?

Would coronary artery ectasia (or ectatic coronary) be I2541, Q245, or something else?

The PEDs congenital providers will occasionally place an arterial line during a congenital RHC for continuous monitoring due to patient safety concerns for some of their population. Because this (arterial line) is not routinely performed for a RHC, there has always been some question as to if this should be billed. They feel it should be billed. Below is an excerpt from the latest op report:

"For safety, it was deemed that an arterial monitoring line was needed to monitor blood pressure continuously and obtain blood gasses during the case. Accordingly, a 2Fr arterial monitoring line was inserted into the right femoral artery, under ultrasound guidance, using standard Seldinger technique, and connected to pressure transducer for continuous monitoring." 

Your thoughts are appreciated on billing code 36620 along with 93530 for both the facility and pro fee sides.

Our physicians utilize structured reporting, and certain phrases are made up to select to insert into the cath report. We have a phrase that says “iFR/FFR”, which indicates that one or the other was performed. Then it’s supposed to clarify which one was performed with the appropriate documentation. The question we have is in regards to the use of nitroglycerin, as we know that this can be used possibly for FFR per Q&A #14476. Would the verbiage in italics be an iFR and an FFR, or is it only an iFR? “Mid LAD lesion is 60% stenosed. The lesion is eccentric. The lesion is moderately calcified. iFR was measured. iFR ratio: 0.93. Other iFR .94 Nitroglycerin was given by intracoronary injection. The pressure wire was then advanced and appropriately normalized. After IFR/FFR was assessed, with the transducer in the distal vessel well beyond the area in question, the wire was withdrawn and there was no drift. There was TIMI 3 flow and no evidence of dissection on repeat injection.”

I am needing clarity as to coding the catheter placement in right external iliac. The provider accessed from the right common femoral artery and catheterized SMA and then he catheterized right external iliac. Would we code 36245 (SMA) and 36140 for external iliac?

Would codes 75807, 38790-50, 71550, 74181, 72195, and 76377 be used for the following report? "Three plane localizer imaging of the chest, abdomen, and pelvis followed by 3D steady state free precession (SSFP) imaging in the sagittal plane of the upper abdomen and chest and precontrast 3D THRIVE of the chest, abdomen, and pelvis acquired in the coronal plane were performed. The groin lymph nodes were then slowly injected with a total of 5.4 mL of the contrast/saline mixture described above while obtaining serial 3D THRIVE imaging during and following injection in the coronal plane over the next 20 minutes to evaluate lymphodynamics. Post-contrast 3D steady state free precession images were obtained in the sagittal plane 9 minutes following the initiation of contrast administration. The access needles were removed. The patient tolerated the procedure well and was transferred to the recovery area for extubation and further management. Postprocessing of the 3D THRIVE and SSFP sequences was performed by the attending physician on a separate 3D workstation."

My provider is doing balloon angioplasty for atherosclerotic disease in the left common artery (61630). He is also treating pre-existing vasospam in the left vertebral and left ICA. Would he be allowed to bill the left ICA 61650 when he has treated the left common with 61630 during the same session? With these being the same vascular family, I'm unsure if we can use modifier -59 to bypass the NCCI edit. The following is the proposed coding: Left common 61630, left ICA 61650, and left vertebral 61651.

I understand that OPEN AVF branch ligation (36832) bundles PTA in the same segment, but what if documentation only supports PerQ branch suture ligation with stenosis PTA? Would it be 36902 and 36909? "Outflow stenosis at cephalic arch was ballooned. Cephalic vein branch was ligated with less pulsatile at completion. Transverse skin incision... sheath inserted... Fistulogram with stenosis of outflow... Glidewire tracked into position and ballooned.. Two more silks were then wrapped around the outflow portion of the isolated cephalic vein branch and then tied down. As the sheath was removed, the vein was then transected, and three interrupted 3-0 vicryl deep dermal stitches were used to close the skin."

What are the coding rules for where we can get ICD for IR procedures? Our new educator only wants us to use ICDs off the IR report and/or the order. Are we not allowed to use notes from the ordering provider like H&P or long-term facility notes sent with the patient for the radiologist to review? If the H&P states PAD with claudication and the order and final IR report only state PAD, we end up coding only PAD, which is not covered. This also happens a lot with fistulograms for dialysis. The report and order state only ESRD. BUT the H&P have HTN, DM, heart failure as part of patients history. Seems like the more detail we code the more accurate the coding, so do we need to query for all details, or can we use H&P when coding IR? I realize this is an education of provider issue, but we are sending out way too many queries and all that does is irritate the provider.

A patient had a penile duplex examination performed after injected with alprostadil (prostin VR). Does this documentation support CPT 93980 and also CPT 54235? Does the actual injection administration need to documented?

“A penile duplex examination was performed pre and post injection. In the resting state, the cavernosal arteries were high resistant with low velocity flow. The immediate post injection images demonstrated medication microbubbles appropriately within the cavernosal compartments. The post injection cavernosal arterial hemodynamics during tumescence were low resistance with increased velocity (>25-30 cm/sec). The cavernosal Doppler waveform resistive index increased to >0.90 and was maintained for 10 minutes. Systolic rise times were within normal limits (<100 ms). The dorsal artery was patent with a normal Doppler profile. The dorsal vein flow during maximal response was absent. There were no dorsal to cavernosal perforators identified. Conclusions: Patent bilateral cavernosal arteries with normal response to injection.”

When a nurse inserts a Dobhoff tube, is it appropriate to report 44500 on the technical side? I know that 43752 can't be reported when performed by a nurse, but code 44500 does not specify "requiring physician's skill".

For the following documentation, would code 39220 be correct? "I began by making a standard left posterolateral thoracotomy skin incision over the eighth intercostal space. The subcutaneous tissue and latissimus muscle were divided with electrocautery, sparing the serratus anterior muscle. The eighth intercostal space was identified in the intercostal muscle over the top of the ninth rib and was incised anteriorly as far as possible and posteriorly to the spinal ligament. The intercostal nerve bundle was dissected off of the inferior aspect of the ninth rib, and then ligated with silk suture and clips. The ninth rib was divided posteriorly with shears, and a static pilling retractor was placed. The retractor was gradually opened throughout the case to provide adequate exposure and avoid inadvertent fracture to the ribs. The opening in the intercostal space was positioned directly over the intrathoracic portion of the schwannoma. On initial survey of the left pleural space, there was the expectant large pleural-based schwannoma adherent to the posterior chest wall, overlying the foramen at T9-T10."

Please help me understand why an electrophysiologist cannot bill 93650 with 93613. It is impossible to locate the His deflection without either fluoroscopy or 3D mapping. 3D mapping allows for a more precise localization of the His prior to an AV node ablation. Arrhythmia induction is not necessarily required to report code 93613, as our electrophysiologist will bill 93613 with atrial fibrillation ablation without having to actually induce atrial fibrillation if the patient arrives in normal rhythm. 3D mapping helps to localize exactly where ablation should be performed. It's seems logical to report code 93613 with 93650.

Does the following documentation satisfy requirements to report ICD-10 code I50.22, or would we need to ask the provider to state chronic systolic heart failure as the indication? "INDICATIONS: Severe non-ischemic cardiomyopathy with LVEF 30% on optimal medical therapy; class III congestive heart failure, complete heart block with pacing induced left bundle-branch block, heart failure duration exceeding 3 months, primary prevention."

I am not finding all of the new CPT codes 93241-93248 on the CMS fee schedule. Do you have any information on why the codes were not included? Will Medicare be paying for these services?

Recently our physicians have been placing a bifurcated endograft through a 12 French or greater sheath for aorto iliac embolic disease with limb ischemia and thrombus. Does this fall under aortic pathology for EVAR, or should we use an unlisted CPT? Question ID 4621 advised an unlisted CPT code but it is dated. What do you advise today?

What CPT code do we use to report a replacement of an S-ICD generator due to end of life (no lead replacement)? (New implant: Boston Scientific EMBLEM MRI S-ICD)

Is the verbiage "color flow/spectral Doppler" required in the documentation to code and bill for a complete vs. limited scan?

Can you clarify the Society of Maternal Fetal Medicine's recommendation for what procedure code to use to report a ductus venosus Doppler study?

(Patient with MRSA/Bacteremia) "Axillary stent - suspected as source of infection but not confirmed. The patient was taken to the operating room and placed in the supine position. After adequate regional block anesthesia he was prepped and draped in the usual fashion. An incision in the proximal upper arm near the axilla and this was carried down through the subcutaneous tissues. The fascia was incised. Care was taken not to disturb any nerves. The axillary vein was identified and proximal to the stent (mid arm) it was occluded and rubbery. The stent could be seen. I gently dissected the vein and then made a venotomy with an 11 blade and separated the plane between the stent and vein. The stent was grasped with a hemostat and gently retracted while continuing to separate the plane. Eventually I was able to completely remove the stent."

I am thinking 35206, or venous thrombectomy code 34490 because there was thrombus found inside of the stent incidentally, which was cultured and sent for path exam. Any assistance with this case would be appreciated.

"Patient brought to the cath lab, placement of a right pulmonary artery cath and a left radial artery cath, due to borderline biventricular pressures, cath left in place, patient transported to the exercise lab for cardiopulmonary exercise testing via bicycle ergometry with right heart cath and radial cath in place to evaluate hemodynamic response. Continuous oxygen saturation, ECG, expired gas, arterial pressure, right atrial pressure, and pulmonary arterial pressure monitoring were performed continuously throughout the test. Arterial and mixed venous blood gasses were collected every minute. Pulmonary capillary wedge pressure was measured every minute, etc… After the procedure was completed the catheters and sheaths were removed."  In addition to 94621 (CPET), would the correct additional codes to report be 93451, 93464, 36620?

Patient had very severe ICA stenosis and M2 occlusion initially. Planned for thrombectomy, but after primary angioplasty the thrombus was noted to have cleared. Further carotid angioplasty and stenosis was deferred, as well as intracranial exploration, because the patient was VERY sensitive to angioplasty, becoming asystolic instantly, requiring atropine resuscitation. Only cervical carotid angioplasty WITH protection device, but WITHOUT stenting was performed. Provider is asking if we can still bill 37236 on this one? Or should it now just be 37215-52? Please advise.

Could you please help with coding for the following OP note? Patient has an ICD implant. "Patient came in with RV lead fracture. I opened up his pocket and removed his existing pulse generator and disconnected it from the leads. I then took vascular access and implanted a new RV ICD lead. I then relocated the skin pocket superiorly since the lead implant was in a different location than the existing leads. I then capped the existing fractured RV lead. This is a single lead; however, it is a DF-1, which means that it has three electrodes and not just one. I capped all three electrodes. I then took the existing pulse generator and reconnected it to the existing RA and LV leads and also connected it to the new RV lead." When they remove and replace the same generator, I'm not sure if it would still be considered a "replacement" according to CPT language. Not sure if this should be coded as 33223 and 33216, or as 33241 and 33249?

Per AMA we can bill both core biopsy and FNA aspiration same lesion for 2021. If liver core biopsy done with ultrasound guidance and FNA aspiration same lesion under ultrasound guidance done also (same image guidance), can we bill 47000 and 10005-59, no 76942?

"The femoral nerve was identified under the US, which lies lateral to femoral artery. The full electrode tip is inserted entirely to the fascia lata. The nerve electrode was introduced into the top of femoral nerve, and the transducer was removed. After the needle removal, the lead was again connected to the stimulator to confirm the lead dislodgment didn't occur during needle withdrawal. A connector block was attached to the lead approximately 2 cm from the skin entry point, the excess lead was removed, and the lead site was covered with a sterile dressing. The device was connected and set up." Can you advise what CPT code to use for this pain management procedure?