Ask Dr. Z

When a patient has an echo 2D complete and a TEE performed the same day, do the results of one take precedence over the other?

Can you confirm the below terms all represent 3D? If any do not or are questionable will you please outline those?

• Quantitative Analysis
• Segmental volumes & surgical planning
• Rotational reconstructions
• Surface shaded rendering
• 3D Volume Slab
• Volumetric Rendering Technique (VRT)
• Minimum Intensity Projection (MinIP)
• Maximum Intensity Projections (MIPS) or (MIP)
• Shaded Surface Display (SSD)
• Spiral Acquisition

Do leadless pacemakers still need to be in registry? My cath lab team is now telling me they are not aware of them being in a registry, but I was unable to find where this requirement has been lifted.

We see cardiology cath reports for RHC and LHC where no CAD is found, and the only abnormal diagnosis given in the cath reports is "elevated bilateral filling pressure" or "elevated LVEDP". The patient has no heart failure in the HP, and came in for DOE or abnormal stress test with chest pain. What ICD is best for the diagnosis of "elevated filling pressures" diagnosis off the cath report? Also, if there is CAD found in the cath and the details read "moderately calcified", can we code the CAD and I25.84 for calcified lesion? If not, what documentation is needed for ICD I25.84?

Is this reported with 37765, even with the use of the Trivex system?

"I had her stand up, and the areas of the varicosities in her left anterior/medial thigh and anterior/medial calf were marked. After adequate induction of anesthesia, she was prepped and draped in the usual sterile fashion in prone position. Time out was performed.

Using 11 blade, stab incisions through the skin were made. Tumescent was injected with the transilluminated powered phlebectomy device and using the Trivex blade, phlebectomies of the left anterior/medial thigh and anterior/medial calf. She tolerated all this well. This required 11 stab incisions for completing the phlebectomy.

Using rolling technique, the tumescent solution was expressed out of the stab incisions. After that, Steri strips were applied followed by sterile wrap dressing with Kerlix, an ACE bandage, and coban."

Some of my claims came back denied for -50 modifier. Per CPT Codebook, if bilateral procedures are performed at the same session, should be appended 50 modifier. The insurance paid for one and denied the other. Am I using the wrong modifier? Or should I just billed two units?

ex: 34713

34713-50

37609

37609-50

Our IR physician performed electrocautery to remove pericatheter granulation tissue around a cholecystotomy tube. Code 17250 is for chemical cauterization only. The electrocautery codes I'm finding are for lesions. Any advice what code to use in this instance? 

I'm still confused on the use of modifier -50 and -RT/-LT for spine injections. Revisiting quest ID #13686, is it appropriate to code 64493-50, 64494-RT, 64494-LT, 64495-RT, 64495-LT for 3 level bilateral lumbar facet injection (Medicare patient)? Can you comment specifically on using -RT/-LT with 64494-64495 and also reporting 64495 twice? CPT is contradicting, "Do not report more than once p/day" .... "Report twice for bilateral".  I've been checking for updates but haven't found any. Are there any updates that you know of?

Can insertion and removal of IABP be billed on a different day? And do I need a modifier?

Can I report 93655 for SVC isolation after PVI for Afib? "The LSPV, LIPV, RSPV, and RIPV were circumferentially encircled as a pair. Isuprel was initiated and titrated pu to 20 mcg/min with the Pentaray on the posterior wall. No pulmonary vein triggers were seen. There were some right atrial premature beats. These could be SVC in origin, decision was made to isolate the SVC. The sheaths were withdrawn into the right atrium and the Pentaray catheter was used to perform a geometric map of the SVC-RA junction. High-output pacing around this region demonstrated phrenic nerve capture along the posterolateral SVC-RA junction. Using the ablation catheter and avoiding areas of phrenic nerve capture radiofrequency ablation lesions were delivered while the Pentaray catheter was advanced into the SVC. Isolation of the SVC was successfully obtained."

Do you still recommend unlisted code 33999 for this CHD case?

"A 4 French x 80 cm Abbott/Amplatzer TorqVue LP delivery catheter was advanced with the aid of a wire via the RFA to the DAO to the AAO and into the LV. An LV angiogram was performed. An angled Penumbra/Lantern microcatheter and Whisper wire were advanced via the TorqVue delivery catheter to the LV. With gentle probing the pouch of the aneurysm was entered with the Whisper and Lantern. The TorqVue was advanced over the Whisper and Lantern into the LV pseudoaneurysm. The Whisper and Lantern were removed. The duct occluder 2 was advanced via the TorqVue catheter. The device distal disc was deployed into the pouch of the pseudoaneurysm, the middle waist was deployed across the LV free wall, and the proximal disc was deployed on the on the endocardial LV wall side of the defect. An LV angiogram and TEE images demonstrated good position and no change in mitral regurgitation. The device was released. A repeat LV angiogram was performed. An ABG and ACT were repeated. All catheters and right groin sheaths were removed."

When TAVRs are done that do not require an incision (e.g., 33361), two interventional cardiologists do the procedure and the CVT surgeon is simply present. He states this in his dictation: "Description of Procedure: The patient was taken to the hybrid operating room and placed upon the table in the supine position. Monitoring lines and catheters were placed and then general endotracheal anesthesia formed. Details of the operative procedure will be dictated separately by the interventional cardiologists. I did not participate in the technical aspects of the procedure but was present for the entire procedure in the hybrid lab and available for any emergency or other technical assistance."

**As he never takes part in the procedure in any way can he bill as co-surgeon? When there's an incision to be made this is not an issue, he participates and his dictation reflects as much. He's been told that CMS requires him to be present even if he isn't participating so that there is still a CVT surgeon on the operating team.

If a retrograde left external iliac endarterectomy is completed through the same incision as a left common femoral endarterectomy (or any other femoral), would this be coded as 35355 or 35351 and 35371?

We have provider-based clinics, and the cardiologists are billing the same as the hospital, which is they are both billing 93350-26, 93016, and 93018. It was my understanding that if the full complete service was performed by the same provider that the 93351 should be billed. The POS is 22. I am in Compliance, and it is my responsibility to educate them correctly. Please assist me in the correct way to bill for physicians and hospital when it is provider-based?

Our provider group is contracted out to provide cardiology services for a detention center. If the detention center uses an automated remote monitor (i.e., Merlin On-Demand, Carelink Express, Latitude Consult), and the results are routed to us to collect, assess, and give to provider. Can we use 93296 (technical)? Can the provider use 93294/93295/93298 as part of their services rendered?

We plan on working towards fixed quarterly monitoring periods for billing purposes. The “scheduled” 91-day reports could fall anywhere within the 91-day window. Monitoring requirements, as we understand it, for billing include a minimum of 30 days' monitoring, and at least one report within the 91-day period.

For CIED remote monitoring and codes 93294/93295/93298, does the date of service (DOS) for the professional codes have to be on the same date as the DOS for the technical 93296? Is there a window of time that they must both occur in?

Our physician performed FFR in the 1st diagonal and in the left circumflex. May this be reported as 93571-LD and 93572-LC because it was performed in two separate coronary distributions? Or should FFR not be reported for the 1st diagonal because it is not a major coronary artery?

I am finding mixed information on how to code for the image-guided placement of a fiducial wire into a neck mass prior to surgical intervention. Would I report code 10035 or unlisted code 21899?

Is there a CPT code for RVAD implantation through open-heart surgery?

Patient presented with progressive chest discomfort. He was found to have an NSTEMI in the ER and dynamic EKG changes indicated of ischemia. He was brought emergently to the cardiac catheterization lab. Coronary angiography was significant for 99% mid RCA lesion. Would this documentation meet the criteria for I25.10-I25.9 heart disease of native coronary artery? Is there a particular percentage stenosed that qualify for these codes?

Patient had a TAVR via femoral access (33361-62). Complications arose during the same session, and it was converted to open procedure. The newly placed valve was removed, and a 21 mm Edwards bioprosthetic aortic valve was placed (via sternotomy)(33405). Should both codes be billed? And, if so, should a modifier be appended to 33361 (maybe -53)? Or should 33405 be reported alone perhaps with a -22 modifier?

Can a limited echo be reported the same day as TAVR (33361) by the same physician performing the TAVR?

I perform TAVR, and occasionally we do coronary angiography as part of standard work-up at the same setting to avoid a separate visit for the patient. I am being told that both this and ultrasound access are bundled with the TAVR. Is this correct since we would most commonly do these as separate, distinct procedures?

My provider wants to do a left renal vein venography with pressure measurements via right groin. This is for pelvic congestion syndrome. I am wondering if there is a code for a special catheter for these pressure measurements. The codes that I would use (36011, 75831) do not say anything about pressure measurements. I just want to know if I should be using a different CPT code besides the basic catheter.

How would you code for a facility when an intravascular ultrasound of a coronary artery is performed by one physician and then another physician performs the cardiac cath? We’ve reviewed CPT Assistant, December 2013 (page 18, Frequently Asked Questions), with add-on code 92978 and wondered if the guidance for to use the unlisted CPT code 93799 more for the professional side of billing or should be used both for professional and facility billing?

Our physician performed HawkOne atherectomy and Penumbra thrombectomy in the same SFA artery. In one case the thrombectomy was performed first in the other it was performed after the atherectomy. He states, "occlusion likely composed of thrombus and thrombectomy performed to minimize risk of distal embolization". Can the thrombectomy be coded if he didn't state there was actual thrombus retrieved? If we query the physician and he states there was thrombus retrieved how do we determine if this is a primary or secondary arterial thrombectomy? Medicare has denied billing a secondary thrombectomy 37186 with atherectomy 37225 even with an unbundling modifier for a separate device used. We would really appreciate your opinion on how you would code these cases.

Your reference book defines “multi-lead device” for PPM/ICD implant/revisions as biventricular, and states a multi-lead device does not need an atrial lead (pg. 546/560). CPT clearly defines "multi-lead" as leads in three heart chambers. CPT Assistant, 12/2013, clarified: “When a LV lead is implanted, the system is referred to as a multiple lead system.” But CPT further clarified their guidelines in 2015 and continues to reiterate their definition of multi-lead for 33206-33249, 33264 as a device “with pacing/sensing function in 3 or more chambers of the heart”. Please clarify if/when it is appropriate to report multi-lead codes (33229, 33264, 33221, 33231, and 93281, 93284) for devices that only have RV/LV leads? Is it correct that we code dual chamber biventricular devices as “multi-lead” when it comes to device revision codes, but they are considered “dual chamber” for programming evaluation codes? So we could conceivably report 33229 for a multi-lead PPM generator change in a patient with LV/RV lead, but would subsequently report 99280 for dual chamber programming evaluation on the exact same system?

Would it be appropriate to report code 77012 in addition to 64530 for a CT-guided celiac plexus block? The CPT code description for 64530 says "with or without radiological monitoring".

We had a patient with a chyle leak. Our radiologist performed a bilateral pelvic and abdominal lymphangiogram – percutaneous transabdominal access into the cisterna chyle, catheterization of the thoracic duct, and thoracic duct lymphangiogram and embolization. We coded 37244, 38790-50, 38794, 75807. We are questioning whether an unlisted code is needed for the thoracic duct lymphangiogram? 

Procedure: Left L3-4 and right L5-S1 therapeutic transforaminal epidural steroid injection. How should this be coded: 64483-LT and 64484-RT? Or 64483-50?

In regards to coronary and peripheral interventions, can you please clarify if the Penumbra thrombectomy (Indigo, CAT RX, Lightning) is aspiration thrombectomy or mechanical thrombectomy? Q&A #7672 (peripheral/venous) seems to contradict questions #14498, #12605, and #12649. I know the reps market this as mechanical thrombectomy. 

Prior to a Y90 treatment, the doctor places a Hyperform balloon catheter to occlude the GDA during treatment. The balloon is removed after the injection of the Y90. Can I code for catheter position of the occlusion balloon?

I believe this is a revision of AV fistula (36832) with perhaps a -22 modifier appended; however, the surgeon wants to use 35011 and 36830. What are your thoughts?

"Indication for Surgery: Left forearm cephalic vein aneurysm, ESRD, degenerated left forearm AV fistula aneurysm. Surgical Procedure: Excision of aneurysmal left forearm cephalic vein, placement of a left forearm PTFE AV graft. Procedure: A long elliptical was incision made along forearm cephalic vein that was aneurysmal; it incorporated the degenerated overlying skin as a long skin paddle. Cephalic vein was dissected free, clamped, and divided. Aneurysmal segment of cephalic vein was handed off as specimen. I then anesthetized a lateral curvilinear tunnel and passed a PTFE graft through the tunnel and created a beveled end-to-end anastomosis between the graft and the inflow cephalic vein at the wrist. The graft had a strong inflow pulse. Excess graft was trimmed and created an end-to-end anastomosis to the outflow cephalic vein at the proximal forearm. Graft had a strong thrill."

The description for code 93657 is as follows: "Additional linear or focal intracardiac catheter ablation of the left or right atrium for treatment of atrial fibrillation remaining after completion of pulmonary vein isolation (List separately in addition to code for primary procedure)".

Is it absolutely imperative that the provider explicitly document that atrial fibrillation remained or complex fractionated atrial electrograms were present following pulmonary venous isolation in order to report this CPT code? Or is documented ablation of the atrial wall itself sufficient enough to support 93657, devoid of mention of remaining Afib/CFAEs?

A dual chamber pacemaker generator was removed and replaced with a new dual chamber generator. The two leads were reused. Later in the day the patient returned, and the RV lead was explanted and a new RV lead inserted. We charged 33228 for first procedure and 33216, 33234 for the second. But we received a Charge Correction for these CPTs stating they could not be charged same day. Coder suggestion 33207, 33233, 33235? Do you agree?

Is it appropriate to code 93654 and 93655 when there are "2 separate PVC sites and mechanisms targeted"? Specifically these two? "Focal PVC ablation with two PVC sites targeted. First morphology: an epicardial LV outflow tract focus targeted from the distal branches of the coronary sinus. Second mechanism/morphology was an endocardial site located just inferior to the aortic valve at the aorto mitral continuity. Both sites ablated. Both PVCs eradicated." The discrete mechanism confuses me at times when trying to be certain they are separate. Any tips?

Would we use CPT code 37248 for the recanalization of the femoral vein performed here?

"We performed high pressure angioplasty up to 15 ATMs with a very tight waist that  resolved at full inflation. We performed three additional angioplasties up to 10 ATMs with no other waists noted. The balloon was deflated and removed and I performed a hand injection angiogram through the long sheath which showed further improvement in the patency of the femoral vein, although there was still an area of stenosis near the femoral head. We carefully prepared and de-aired a 7 mm Dorado balloon. This was advanced over the wire into the area of stenosis and multiple angioplasties performed. In the area of tough stenosis there was a waist seen that completely resolved at full inflation. The balloon was deflated and removed and I performed a hand injection angiogram through the long sheath which showed further improvement in the patency of the vessel."

Patient came in for an EPS with arrhythmia induction and was confirmed to have VT. After EP study doctor placed a single chamber defibrillator. Insurance is denying placement of defibrillator. They paid the EPS but not the defibrillator. I coded it with 33249/I25.5, I50.22 and with 93620-26,51/I47.2. How would you have coded this?

Patient has had previous MIs with one stent and EF of 40%

"Patient scheduled for TAVR procedure. Cutdown was done on the right groin to expose the right femoral artery. The artery was very calcified, and there was no soft spot. Dissection was extended upwards and downwards to expose the common femoral artery as it went up more to the proximal to the inguinal ligament and all the way retroperitoneal to the external iliac artery. The artery was calcified throughout, and no access could be obtained. Both surgeons at this point agreed they could not proceed, and the incision was closed in layers of vicryl and monocryl. The decision to follow up with a subclavian percutaneous approach was made, and TAVR successfully placed at a later date."

Since 34812 is now an add-on code, would 33362-53 be appropriate? We are unable to bill anything but the incision and closure, as no angiography/catheterization procedure was performed.

If an IVR procedure is done in the OR department, should the case be billed by CPT procedure codes or OR time charges? What is appropriate?

Do you agree with 61645 and 61624 for the following scenario?

"Patient with: 1) Flow limiting dissection at right ICA petrous segment. 2) Clot at MCA m2/3rd.

Vessel reconstruction was performed with pipeline flow diverter, post flow diversion, right common carotid confirmed proper position, post procedure tici 3. Aspiration technique performed. MCA angio demonstrated technically successful mechanical thrombectomy."

When the MD accesses the brachial artery in a brachiocephalic fistula, is this always reported with 36140-XS? Or is the perianastomosis brachial artery included in 3690X? Example: "Real-time ultrasound guidance was used to access the brachial artery in retrograde fashion. Fistulogram was performed. Based on the findings, angioplasty of the cephalic vein was performed."

A patient had an atrial fibrillation ablation, 3D mapping, and ICE, which was coded to 93656, 93613, and 93662. We use an Endcoder, which is also including code 76376. I have never used that code before with the ablation. Is 76376 appropriate to use with the ablation? Below is the documentation of the 3D mapping from the operative report. 

"Standard ablation mapping: The coronary sinus and pulmonary veins, left atrium, and left atrial appendage were mapped from a transseptal approach with circumferential mapping. Mapping was performed during atrial fibrillation, atrial pacing, and left atrial pacing. DC cardioversion was performed to restore normal sinus rhythm to allow accurate activation mapping during atrial pacing.

Intracardiac 3D mapping: The coronary sinus and pulmonary veins, left atrium, and left atrial appendage were mapped from a transseptal approach with point-by-point voltage and activation mapping using a Rhythmia device. Mapping was performed during sinus rhythm, atrial fibrillation, and coronary sinus pacing."

Can a hospital report both IVUS and iFR in the RCA when performed during the same setting with a LHC and DES? Would 93458-59, 92978-RC, 93571-74RC, and C9600-RC be appropriate? Guidelines state use up to one initial and four additional, but these are different devices so may we have two initials on the same vessel? There are no NCCI edits. We understand IVUS and OCT performed in the same vascular territory can only be reported once.

A physician outside our group was placing a transvenous pacemaker and asked one of our physicians to help by creating the right internal jugular access, which was done with ultrasound guidance. Is there anything I could (or should) bill?

Our provider performed angioplasty to proximal to mid 1st septal perforator and 2nd septal perforator. Do we also code this with 92920?

"Wire placement was performed with a Runthrough NS Extra Floppy 300 cm guidewire, which was advanced through the vessel beyond the lesion. Angioplasty was performed with a RX Emerge 2.0 mm x 15 mm balloon at 4 ATM. Balloon used to block flow into LAD for possible alcohol septal ablation procedure. Injection of echo contrast through balloon shaft under TEE showed brisk contrast filling of the RV chamber as well as contrast staining of the RV side of the septum and moderator band. We decided against alcohol injection given these findings and the procedure was stopped. Final angiogram with the wire and balloon removed showed patent LAD and septal perforators without evidence of acute vessel closure, dissection or perforation."

Can I report codes 36831 and 36907 as well as direct repair of aneurysm if provider amends to which artery?

"We confirmed it almost completely thrombosed. We identified both anastomosis as well as area non aneurysmal areas where we can obtain control. We then made small transverse incision over AVF in medial arm just distal to arterial anastomosis and obtained circumferential control. We did the same just proximal to venous anastomosis. Patient was heparinized. We then made longitudinal fistulotomy over both aneurysms. We encountered large amount of occlusive thrombus and removed it. We used Fogarty catheter (# 4) to remove additional thrombus from venous segment. Next, we placed 11 French sheath into distal AVF and performed fistulogram. We identified stenosis at venous anastomosis and treated it with POBA (6, 8, and 10 mm). We performed central venogram and identified moderate stenosis in SCV that we treated with POBA (8 and 10 mm). We then performed aneurysmorrhaphy (excised redundant tissue and primary repair w 4-0 Prolene running suture). We then excised redundant thin skin as well."

I have a patient who had a pacemaker pocket revision due to discomfort. No infection, relocation not done except for a slight move within the same pocket; I&D was not done. What code would be appropriate in this scenario?

"Blunt and Bovie dissection was carried out down to the level of the existing generator. The generator was removed from the pocket. Leads were dissected free of scar tissue. Dissection of the pocket was carried out in a superior medial direction extending over top of the transpectoral lead insertion position. The leads were coiled under the device in a more favorable anatomic location. The device was tacked to the prepectoral fascia as superior medially as could be obtained, just medial to the lead insertion positions. The pocket was irrigated with 180 cc of antibiotic irrigant solution on once again examined for bleeding. Both leads were pulled tested and remained fixed in place in the header. The wound was closed using a standard 3-layer closure technique."

My doctors are doing lithotripsy angioplasty. I am coding them as angioplasty, but they think there should be a new code for physicians to use to bill for this procedure (just like the atherectomy has one). Please clear this up for me.

I'm unsure if I should code any of the work that was done prior to the incision being made. Would you code and modify with reduced services 37197, 75820, 36005 or ONLY code 10120? Thank you for your help! DIAGNOSTIC VENOGRAPHY OF THE RIGHT CEPHALIC VEIN WAS PERFORMED THROUGH THE 4 FRENCH SHEATH. THE RIGHT CEPHALIC VEIN IS PATENT. A 1 CM LINEAR FOREIGN BODY PARALLEL WITH THE CEPHALIC VEIN IS PRESENT. FOREIGN BODY RETRIEVAL UNDER FLUOROSCOPIC GUIDANCE, ATTEMPTS TO SNARE THE FOREIGN BODY WITH 2 MM AND 4 MM LOOP SNARES WERE UNSUCCESSFUL. ATTEMPTS TO DISPLACE THE FOREIGN BODY WITH A 4 MM BALLOON UNDER FLUOROSCOPY WERE ALSO UNSUCCESSFUL. UNDER FLUOROSCOPIC GUIDANCE, A 5 MM INCISION WAS MADE OVER THE SITE OF THE FOREIGN BODY. WITH MINIMAL DISSECTION, THE FOREIGN BODY WAS ABLE TO BE REMOVED. A MAGNIFICATION VIEW SINGLE SHOT X-RAY WAS PERFORMED DEMONSTRATING SUCCESSFUL RETRIEVAL.