Ask Dr. Z

cpt 33233, 33234, 33235 was billed together, but cpt 33234 was ad mutually inclusive to cpt 33235.

We have just recently started using this technology. In 2019 a Q&A said the MD has to document 3D FFR. However our physicians will state the technology in a variety of ways. What is sufficient for coding 0523T?

1) LAD FFR by cathworks is 0.87

2) Diffuse mid LAD 40% stenosis. TIMI 3 flow. CathWorks FFR: 0.83.

Some have a section of their report where it is documented like this by staff:

3) Flow wire: FFR.

FFR measurement is 0.86. Measurements were obtained in the middle right coronary artery. CathWorks system.

(Because the title says Flow wire they are documenting Cath Works at the end. (When it is a flow wire the wire supply is listed in the statement.) We are working on removing the words Flow Wire from generated text.)

And to clarify - if 3D angio and FFR is done in the same setting - only report one code. Report 93571 or 0523T?

Thank you very much!

When coding a diagnostic study such as an Echo or EKG, if the findings state trace or trivial, should that be coded as a diagnosis? I did review question ID 18799 but the answer is that minimal should be coded. What about trace or trivial?

A chief tech at our hospital stated that vessel selection codes in intracranial embolization cases are now included in the embolization CPT 61624. I am unable to find supporting material for this statement. Can you confirm this?

In your Interventional Cardiology 2023 reference book pg 580 in order to bill for the code 0408T- Optimizer CCM system it would have to be a complete system (generator and leads). A complete system consists of a generator and 3 leads (2 RV and 1 RA leads). If the patient only receives two RV leads placed with the generator, would this still be considered "complete"? If it's not considered complete with just the two RV leads, how you we code this for facility? Thank you.

Clinical indication is: Ischemic Cardiomyopathy (functional class III), her EF 40% and does not meet criteria for CRT therapy.

Would this be unlisted? No catheterization due to extensive atherosclerotic disease. Agent: Packet of Gelfoam mixed with 5000 units of recombinant thrombin. fluid portion of the hematoma was accessed with a 5 French Yueh catheter directly. Under ultrasound guidance, Gelfoam slurry mixed with the recombinant thrombin was administered into the retroperitoneal hematoma. Via the 5 French Yueh catheter, other parts of the hematoma was also injected with Gelfoam slurry mixed with recombinant thrombin. A total of 50 mL of Gelfoam slurry mixed with recombinant thrombin (5000 units) was administered directly into the liquid portion of the hematoma. Catheter was removed.

Impression: Ultrasound-guided percutaneous administration of Gelfoam slurry mixed with the common and thrombin into the left retroperitoneal hematoma.

Any help would be appreciated!

Would this be 10035 or C9728/77012? We also charge for both facility and IR radiologists.

Excerpts from report:

PROCEDURE: CT-guided targe marker placement

Pre-procedure diagnosis: T8 metastatic lesion causing cord compression

Post-procedure diagnosis: Same

Indication: Presurgical planning for T8 laminectomy

Additional clinical history: None

IMPRESSION:

Technically successful CT-guided marker placement with the tip of the Kopans needle projecting adjacent to the tip of T8 the spinous process.

Imaging prior to biopsy

The patient was positioned prone. Initial imaging was performed using noncontrast CT.

Sagittal and axial images were obtained. The tip of T8 spinous process was identified.

Marker placement

Local anesthesia was administered. Under CT guidance, a Kopans needle was advanced to the target and deployed.

Imaging following biopsy

Immediate post-biopsy imaging was performed using noncontrast CT.

Post-biopsy imaging findings: No evidence of acute complications. Appropriate positioning of the tip of the Kopans needle

Thank you.

"The INARI thrombectomy catheter was inserted and advanced to the IVC/RA junction just below the mobile echo density. 4 ASPIRATIONS WERE performed with retrieval of significant harvest and TEE confirmed removal of large masses from the SVC/RA junction." Successful mechanical thrombectomy of right atrial mass in transit with removal of significant harvest using fluoroscopy and TEE guidance. - Would this be coded as 0644T or 33999?

Dr. Z, I am unable to locate a CPT for this procedure (unless is it unlisted). Is an unlisted code most appropriate? Thank you.

Sacral region was prepped and draped in usual sterile fashion. 1% lidocaine was used locally.

Under CT guidance 4 separate 20-gauge spinal needles were advanced through the sacrum disease 2 on the right and 2 on the left.

On the left at the needles were advanced through a large infiltrating tumor and positioned more towards the anterior aspect of the sacrum. On the right at the more superior needle was advanced through the sacrum and into the anterior presacral space. The inferior needle was positioned along the right lateral margin of tumor extending across midline.

A total of 30 mL of 0.5% bupivacaine and 80 mg of triamcinolone were instilled through the for needles.

The needles were removed.

IMPRESSION:

CT-GUIDED THE PRESACRAL NERVE PLEXUS BLOCK

Please let us know - What is the CPT Code for Robotic Assisted Resection of an Intercostal Neurofibroma?

Thank you,

Please explain why physicians cannot bill 36598, 36593 in hospital setting when physician administers tPA to port following the port study. Status indicator T implies that 36598 is not payable only when other services that are payable are submitted by same provider on same DOS. If 36593 is not payable due to POS then 36598 would be payable to physician in this setting. We are reimbursed for the 36598 we are never reimbursed for 36593.

I coded: 35081, 35371-50. I feel like I am not accurately coding for the femoral graft procedures. Open aortic exposure performed w/vessel control. Aortotomy made w/removal of thrombus and plague. Dissection carried down to the aortic bifurcation and RT & LT CIA arteries. Blunt dissection used from femoral incision up to retroperitoneum. Dacron graft applied end graft to end aortic anastomosis. Left femoral arteriotomy made & extended in CFA down to SFA, 1-2 cm. Endarterectomy performed. Left limb of graft approximate to arteriotomy. Right femoral arteriotomy performed, extended 2-3 cm into SFA. Endarterectomy performed. Graft applied end to side. Fogarty embolectomy performed, 5 passes, due to no backbleed from SFA. Anastomosis completed, flow reestablished to femoral vessels. Fascia closed. Femoral incisions closed. Am I missing a code or is there a more appropriate code?

Question ID # 4680 states that is a resection of part of the ICA took place its included within the 35301. It was answered in 2013 and we are wondering if there have been changes?

Facial veins are crossed carotid sheath was ligated and divided. CCA dissected free at the level of the omohyoid. The dissection was then carried out in a cephalad direction until the origin of the ECA and superior thyroid arteries were identified and dissected free. ICA dissected free up to the point where it passed below the posterior belly of the digastric muscle. It was noted to be somewhat redundant in this area, but it was dissected free past the area of stenosis. ECA/ICA and CCA’s were clamped. Arteriotomy in the CCA extended through the carotid bulb onto the ICA beyond the area of stenosis. All loose plaque and debris were removed. About a centimeter and a half of ICA was then resected just distal to the carotid bifurcation. The ICA spatulated suture the ICA was sewn to CCA reforming the back wall. The ECA & CCA were opened. After several heartbeats the ICA open.

Would 36901 and 36002/76942-26 be the correct codes for this procedure?

"LT ARM AV FISTULA ACCESSED FISTULOGRAM PERFORMED REVEALED NO PSEUDOANEURYSM OFF GRAFT ULTRASOUND USED TO INTERROGATE ARM SHOWING LARGE ANEURYSM W/FLOW AWAY FROM MAIN BRACHIAL ARTERY LIKELY SUGGESTIVE OF A BRANCH OFF THE BRACHIAL ARTERY.ULTRASOUND USED 18-GAUAGE SPINAL NEEDLE ACCESS ACTIVE ANEURYSM SAC INJECTED THROMBIN REPEAT INSPECTION SHOW LOSS OF FLOW IN SAC PATIENT HAD NICE PALPABLE RADIAL ARTERY AND GOOD FLOW INTO AV GRAFT.

PATENT AV GRAFT W/NO EVIDENCE OF ANEURYSM COMING OFF GRAFT ULTRSOUND ELVALUTION SHOWING ANEURYSM SAC MEDIAL TO AV GRAFT BUT FAR AWAY FROM MAIN BRACHIAL ARTERY THERE IS ACTIVE FLOW AFTER THROMBIN INJECTION THERE IS PULSATILITY AND NO FLOW IN ANEUYSM SAC."

I know you're swamped with 76937 questions with the new NCCI directive. I appreciate your consistency and diligence in helping us all understand this new directive!

Since 76937 is now bundled with any RS&I codes, does the requirement for permanent stored images essentially transfer to the RS&I code? I.e.: Embolization for hemorrhage is performed; vessel access with ultrasound guidance, but there's no documentation of stored images. Does this represent a reduced service on the embolization, now? Or insufficient documentation?

Thanks in advance!

For codes 93286 and 93287, the description states '"in person". We have documentation that does not state the service was provided in person. My question is, does the documentation have to specify that the service was performed in person?

I believe this guidance to be incorrect. Can you please clarify if 75625 should be reported? The celiac “trunk” is a small portion of artery that arises off the aorta. If the IR physician has accessed the right common femoral artery, taken the catheter to the aorta, aortogram done, then selected the celiac trunk only and released dye, the code assigned is 36245, as this is the first branch off of the aorta (75726 S&I). Notice that the coder does not assign a code for the catheter in the aorta (36200), even though the IR MD may have stopped and done an aortogram in the area. This is because a “selective” catherization always includes the “non-selective” catheterization before it. However, 75625 would be assigned for the S&I for aortogram.

Our Vascular providers whenever they do abdominal aortic aneurysm repair with 34705 and coil embolization of internal iliac artery they also place an extension graft to the external iliac artery to cover internal iliac artery origin in that side. Do we bill 34709 for this extension into external iliac artery to cover internal iliac origin along with 34705, 37242, and catheter placement?

This might be a completely stupid question, but I have been asked this question and don't quite know how to answer it. In your 2024 Interventional Radiology Coding Reference on page 158, can you explain why the superficial femoral on the left side (non-selective side) of the picture is a 1st order, while on the right side of the picture it is a 3rd order? I can't explain why the orders change.

The distal ascending aorta was opened. There was a fragile clot in the distal arch, which was able to be removed with minimal force. There was a small ruptured plaque underlying it. The arch was irrigated and suctioned to remove any residual debris. We elected at this point to cover the ruptured plaque with an endograft. A 26 x 26 x 100 mm Medtronic Valiant endograft was brought onto the field. The Lunderquist wire was passed through the delivery system which was delivered into the visualized aortic lumen and deployed such that it landed in zone 3, just distal to the left common carotid artery. The delivery system was withdrawn. An ophthalmic cautery was used to fenestrate the graft directly opposite the left subclavian artery ostium. Once this was completed, the leading edge of the endograft on the inner curve of the aorta was secured using a 4-0 Prolene pledgeted suture. He would like to bill this as a 33880 and 75956-26 but we wondered if an unlisted code is more appropriate since he was treating thrombus and not an aneurysm?

The right common femoral artery had pulsatile bleeding following deployment of both Perclose devices. A third Perclose device was deployed, however, the patient continued to have pulsatile bleeding from the access site. The 16 French sheath was then replaced into the common femoral artery for hemostasis. A 10 blade was then used to make a incision overlying the sheath access. Electrocautery was used to dissect through the subcutaneous tissue and the proximal common femoral and distal common femoral artery to the access site were dissected out and encircled in Vesseloops. The sheath was then removed and the Vesseloops were used for hemostasis. The arteriotomy was freshened with Potts scissors. Using multiple interrupted 5-0 Prolene suture the arteriotomy was then closed. A microcatheter was then placed through the Kumpe catheter into the primary trunk of the right internal iliac artery. 20 mm x 60 mm framing coils were then deployed into the trunk of the right internal iliac artery. This was then followed by four 8 mm x 60 mm filling coils.

How would you bill the following procedure, 93603, 93612 or can you use additional add-on codes? "An EP catheter was advanced to the RV apex via the SRO a DecaNav catheter was advanced to the right ventricle. The Catheter was withdrawn to the AV groove and placed out the CS. A 3D activation and EP map of the CS wa created using the cardio system. The maximal extent that the CS could be instrumented was to about the 1 o'clock position at which point the local ventricular signal in the CS was largely eqiuvalent to the QRS onset of hte PVC and pace mapping was 85%. Despite extensive efforts, the catheter could not be advanced further. In an effort to get to an earlier point for ablation, the DecaNav catheter was exchanged for an ablation catheter and further mapping points were taken in the area of interest. Despite the bidirectionally of the catheter, the ablation catheter could not be successfully advanced to the primary area of focus. As a result, further attempts at reaching the epicardial PVC focus were abandoned and the procedure was terminated."

We have times that we perform an echocardiogram pre- or intra-procedural for line placement, ECMO placement, device closures, etc. Would we still bill CPT codes 93303/93308/ 93320/93321/93325

If the provider performs a congenital RHC and injects IVC and SVC, do we bill 93584 or 78525 and 78527? What would be considered appropriate documentation for anomalous persistent SCV when it exists as a second contralateral SVC- does that mean if the patient has two SCV and the second one is on the opposite side?

Can you please tell me if this qualifies as CT guidance (77012) or should we be using flouro guidance (77002)? "Patient was positioned prone in the angiography suite. Preliminary CT Images were obtained using the angiography suite identifying an appropriate site for bone marrow biopsy as well as appropriate site for skin access. Under real time fluoroscopic guidance an on control device was advanced to the left ischium." (It goes on to talk about the samples obtained). The last line of the report states "Successful uncomplicated fluoroscopic guided bone marrow biopsy". 

I have an appeal denial from UHC stating that cpt code 37233-59-LT (1 Unit) remains not supported. As per the Society of Interventional Radiology Coding Manual, if an angioplasty or atherectomy of an occlusion is unsuccessful because the lesion cannot be crossed, then the appropriate access and/or selection only should be coded. As such, the request for CPT code 37233 is denied as "Not Documented."

I don't understand this - our provider documented atherectomy/PTA in left AT, and a partially successful atherectomy and PTA of the left PT (residual stenosis). Are we not able to bill for code 37233 for the second vessel because it was partially successful?

Prior to a Mako robotic knee replacement, a CT is required preoperatively. The CT is used to generate a 3D virtual model of the patient's anatomy. The virtual model is loaded into the Mako System software and used by the surgeon to create a personalized operative plan. Do we bill for CT of the lower extremity? We are starting to see pre-auth denials, so our radiology department is asking if we should use 77011 instead.

When assigning the unlisted procedure code 93799 for iFR studies, do we need to add the coronary modifier? Physician performed iFR studies in the LD and RC (93799-LD, 93799-RC).

Hello, Will you revise previous advice regarding 47562 vs 47563, for example in question ID 18535, based on Coding Clinic for HCPCS 2nd qtr. 2023? Clarification/correction of the advice in CC 1st qtr 2022 was provided. From my understanding of the advice, imaging with ICG (IVC) is not the same as IOC. Therefore, 47563 would not be appropriate for intravenous ICG cholangiogram, as it requires placing a catheter into the cystic duct to inject contrast. Than you,

What is compliant to code on selective angios w/o narrative dictated, i.e. "selective" indicates the vessel catheterized?

Dict:

Procedures Performed - Aortic arch angiogram. Selective brachiocephalic and subclavian angiogram

RCFA access

Findings: Heavily calcified aortic arch with severe atherosclerosis and a 30% aortic narrowing

Heavily calcified occlusion of the left subclavian artery with retrograde filling via the vertebral to the axillary artery

Moderate heavily calcified ostial brachiocephalic stenosis

Patent left carotid artery

36225, 75710-LT, 36215-XS?

If the clinical indication on a report is lumbar radiculopathy, and findings state spondylosis of L2-L3, L5-S1, can we use the combination code for both levels with M47.26/M47.27 or does the provider have to link which is causing radiculopathy?

Also, is it acceptable to code osteophyte of the vertebra when coding other conditions such as stenosis, spondylosis, etc.?

What is a CPT code that is comparable to unlisted code for reduction aortoplasty?

"A section of the enlarged ascending aorta was resected along the greater curvature. The resected margins of the ascending aorta were approximated between two felt bolsters with a double running 4-0 Prolene suture, thus reducing the dilated section of the ascending aorta to a much more normal diameter."

We have echos where we check the placement of lines, ECMO placement, device closures, etc. Would we still bill the normal echo codes either congenital or non congenital? 93303/93308, 93321/93320/93325?

Code 92972 has replaced 0715T in 2024 for percutaneous transluminal coronary lithotripsy. If atherectomy and/or angioplasty with stent is performed as well, should the C9600-C9608 series be coded or in conjunction with 92920, 92924, 92928, 92933, 92937, 92941, 92943, 92975?

If a patient received an IVL procedure in the iliac (just the IVL, e.g., C9764), and an atherectomy in fem-pop, how would this be coded by both the physician and the facility (hospital outpatient)?

I am coding for a new group, and we are using the following dictation to bill code 76377. The powers that be are stating the standard procedure in the department is that the radiologist is directly involved in the creation of the images. Is this enough dictation in the report to consider concurrent supervision and bill appropriately? "3D post-processing of the images was performed on an independent workstation, and the post-processed images were used in interpretation." I want to make sure we are compliant when using this code in our IR cases.

If there's more than one laceration repaired for two diaphragmatic injury, can code 39501 be reported twice? Example: repair of right-sided diaphragmatic injury with closure of mediastinal and left-sided peritoneal layer tear overlying left diaphragm, LEFT and RIGHT side repaired.

In regards to question # 18403: If one APP assists with the harvest and CABG and a second CT surgeon assists with the MAZE procedure, how does the CT surgeon get to code 33259-80 without also coding the parent code 33533? How should this be broken down? APP get 33533AS 33518AS 33508AS -xu--How do you code for the 2nd CT surgeon helping out with MAZE? you cant code 33259 w/o a parent code...which would be 33533, but he didn't assist with that..........

On question 13390, it was advised that mod 59 was not required when one physician of a group practice performed the diagnostic cath and another physician provided the intervention because they are "billed as if they are one physician." Even when one physician performs both the cath and the stenting, the cath must have modifier 59 (or appropriate X modifier), or the cath will deny because it bundles with the intervention. Can you please clarify the previous response of question 13390 that no modifier 59 is required? Thank you.

When an angioplasty is performed only in a coronary SVG, do we report code 92920 or 92937? Code 92937 says a "combination of", so I'm not sure if it would be appropriate to report 92937. Please advise.

I know the sternotomy and exploration are inclusive, but need guidance on the perforation repair. I have 33300 and 33268. Perforation occurred during a Watchman placement.

Emergency Sternotomy

Emergency mediastinal exploration

Repair right atrial appendage perforation

Excision left atrial appendage

Perforation on the medial aspect of the right atrial appendage was noted and grasped and controlled with DeBakey clamps. Vas clamp placed last across the site. Patient received 10,000 units of heparin intravenous.

Main portion of pericardium/mediastinum was evaluated. No obvious additional perforations. The right atrial appendage perforation was then oversewn with pledgeted 4-0 Prolene sutures. Hemostasis was achieved. The perforation appeared to be adjacent to the aorta slightly cephalad from the noncoronary cusp. The adventitia appeared to be slightly irritated; however, there was no perforation.

Left atrial appendage was ligated with a GIA stapling device.

For reporting CT CTA / MRI MRA on the same date of service. For stroke rule outs and different techniques used between the CT and the CTA. Is this a scenario in which both are chargeable and not just the CTA?

If the indication on the operative note for ICD implantation only states primary prevention of cardiac arrest, would it be appropriate to code I46.9?

Provider billed 33225, 33229, 78520, and 36005 LT-59. Insurance denied stating codes 36005 and 78520 are bundled. Per Encoder Pro both codes can be paid separately and a modifier is allowed. We appended a -59 modifier, but the claim was still denied.

Left upper extremity fistulogram. The stenosis in the graft venous anastomosis was crossed with the wire. Angioplasty of the stenosis in the graft venous anastomosis was performed using 8x40 mm Balloon; then sheath was redirected towards the arterial inflow. Balloon angioplasty of the arterial anastomosis with a 6x40 mm balloon. (Same Access) do I bill both 36902 and 36907?

What if the physician uses a second access to access arterial anastomosis, any other access code to bill for second access? 

"Procedure: Ultrasound-guided percutaneous core biopsy of left auricular lymph node. Clinical History: left auricular lymphadenopathy. Technique: Ultrasound of the left auricular region  was performed. The lesion was identified and multiple images were stored. The skin was prepped using ChloraPrep, and allowed to dry before sterile draping applied in the usual sterile fashion. Using lidocaine for local anesthesia as well as direct ultrasound guidance, using an 18 gauge Biopince needle, a total of four percutaneous core needle biopsies were made. Ultrasound images of needle entry were saved and sent to PACS. A sterile dressing was applied. The patient remained stable during and immediately after the procedure. Impression: Ultrasound-guided percutaneous core biopsy of left auricular lymph node."

Would this be reported with code 38505?

Two AT ablations

The tachycardia was most consistent with a microreentrant right atrial tachycardia at the high right atrial septum. A TactiCath 3.5 mm irrigated tip ablation catheter was used to deliver radiofrequency lesions to the SVC to IVC septum line ablation performed. The AT was altered with ablation.

A second AT was identified. The tachycardia was most consistent with a microreentrant left atrial tachycardia at the endocardial mitral annulus. A TactiCath 3.5 mm irrigated tip ablation catheter was used to deliver radiofrequency lesions to theendocardial mitral annulus. The AT terminated to sinus rhythm with ablation.

Can I code 93653 & 93655?

Pt came into holding room area and tunneled picc line was removed. Can 36589 be charged for a tunneled picc?

Does HydorMark clip placed after the biopsy support CPT 10035 + 38505 ?

The procedure was explained to the patient including benefits and risks.

Consent was obtained. The procedure was done with the Hologic Sertera core

biopsy unit in the supine position under ultrasound guidance. Initial images

were made. Skin of right axilla was prepped in the usual sterile manner. Local

anesthesia was made with the 1% xylocaine, sodium chloride and epinephrine

solutions. A small skin incision was made. A 14-gauge needle was used. The

needle was placed under ultrasound guidance, and the tip was passed through the

lesion. Seven cores were collected and placed in a formalin solution. All

specimens were sent to pathology at the XTS for histopathologic diagnosis. A

HydroMARK clip was placed in the area of the biopsy cavity, and a MLO view was

taken. The patient tolerated the procedure well. No immediate complications were

noted.

We understand that traditional Miller banding on a dialysis fistula is considered an open revision and coded with 36832. Is the more minimally invasive “modified Miller banding” also considered open and coded with 36832? Or would it be considered percutaneous?

"Basilic vein was marked on the skin using duplex and local anesthetic applied. A small 15 blade was used to make a skin incision and the basilic vein was identified. Basilic then encircled with a Prolene and a stiff glidewire was placed on top of the basilic vein and a modified miller banding was then performed. Incision site was then irrigated and closed with interrupted 3-0 Vicryl buried deep dermal followed by 4-0 Monocryl and skin glue."