Ask Dr. Z

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."

I have read the Retinoblastoma arterial chemo administration question examples ID:11790/ID:11838/ID:2490. Is there a medical reason for using CPT 61650 - prolonged administration which is an Inpatient only procedure instead of using CPT 96420 or 96422 Chemotherapy administration intra-arterial which is not an Inpatient only procedure. Are there clinical factors that make CPT 61650 the best coding for the procedure performed?

"The patient has acute bilateral iliac DVTs with IVC thrombus. The Excel mechanical thrombectomy catheter was advanced, and a single pass was performed through the left external iliac vein. Attention was then turned to the right common iliac, and using the Bold mechanical thrombectomy catheter and appropriate tension over the confluence. Subacute to chronic appearing thrombus was removed."

Can this be coded as 37187-50 since it was done on both sides, in two different vascular families? Or should it be coded as one 37187? And if they also did a mechanical thrombectomy of the IVC at the same session as the bilateral thrombectomies, can this also be picked up with 37187?

Do you know what manufacturer application an actual device was approved that led to the creation of HCPCS C1604-Graft, transmural transvenous arterial bypass (implantable), with all delivery system components? I have read through the HCPCS Summary and decision documents where that info is usually found but have been unable to locate it.

Which code would you use for the Augmentation of the left acetabulum with cement??

Vertebroplasty

Target level: Left anterolateral aspect of the L4 vertebral body lesion

Pedicle access: Unipedicular

Access trocar size (gauge): 11

Manufacturer: Stryker/Carefusion

Cement type: Polymethyl methacrylate (PMMA)

Clinically significant cement leak occurrence: Small volume leakage in the adjacent disc space

Augmentation of the left acetabulum with cement

Target level(s): Left acetabulum

Access trocar(s) gauge: 11 gauge

Cement type: PMMA.

Manufacturer: Stryker/Carefusion

Clinically significant cement leak occurrence: No

Thanks in advance for your assistance.

"A patient with radial artery thrombosis underwent thrombectomy by surgical cutdown (34111). After removal of a significant amount of acute thrombus both proximally and distally, there was good distal radial artery backbleeding but no good inflow. Thrombectomy of the inflow was attempted by filling the Fogarty catheter with saline (initially it had been filled with air), but this did not result in any significant improvement. The surgeon then inserted an angiocatheter into the radial artery and performed an angiogram, which revealed significant residual chronic thrombus in the proximal radial artery. Additional thrombectomy was then performed with good result." Would it be appropriate to report code 75710 for the angiogram performed in this case? If so, would we also report code 36140 for the catheterization?

Do you use the location modifiers (-LD, -RC, ect.) on code 92972?

Is 21603 still reportable with 32480 when chest wall tumor is removed en-bloc with left lobe?

"Procedure: Thoracotomy was performed. The left upper lobe was found to be infiltrating a portion of the chest wall involving segments of ribs 3, 4, and 5. Therefore, this portion of the chest wall was resected en-bloc with the left upper lobe. The left 3, 4, and 5 ribs were transected anteriorly and posteriorly. The second intercostal space was cut along the upper border of the third rib to complete the resection of the chest wall. The left pulmonary vein was dissected free and transected with a stapler load. Finally, the left upper lobe bronchus was also dissected free and transected with load stapler. Then mediastinal lymphadenectomy was performed. The specimen was removed en-bloc from the operative field. Goretex patch, dual layer (20cm x 30cm) was used for plastic reconstruction of large chest wall defect."

I am really at a loss here. This is more than a straightforward Foley removal to charge as an E&M. Would this go to an unlisted and 77002?

"Ultrasound confirmed the presence of the Foley balloon in place within a contracted urinary bladder. Through the lumen of the Foley catheter, an 8 French dilator was advanced, and contrast was administered opacifying the contracted urinary bladder. Balloon was clearly identified as well. Under fluoroscopic guidance, the Foley catheter was advanced forward. An area in the suprapubic region was then infiltrated with 1% lidocaine. Under direct fluoroscopic and sonographic guidance, a 20-gauge needle was advanced into the region of the balloon and the balloon was punctured successfully. The balloon was deflated. Foley catheter was then removed intact. Patient tolerated the procedure well without immediate complications.”

Is the coil embolization separately billed or included as part of 35151 for the popliteal aneurysm repair?

1. Right proximal popliteal artery to distal popliteal into the tibioperoneal trunk artery bypass with greater saphenous vein

2. Open thrombectomy of the right posterior tibial artery with fogarty balloon

3. Open thrombectomy of the right anterior tibial artery with fogarty balloon

4. Ligation of the right popliteal artery aneurysm

5. Right lower extremity arteriogram with supervision and interpretation

6. Embolization of two separate right popliteal genicular arteries using terumo azur 035 coils.

7. Selective catheterization of two separate genicular arteries

"We then used a navicross and glide wire advantage and selectively catheterized the popliteal artery genicular branch. Two terumo coils 5x11mm were then deployed. We then selectively catheterized a second genicular popliteal artery branch and coil embolized with a 6x17mm genicular branch"

Is it correct to charge 76380 CT limited for a intraoperative 3D CT C-arm study when used during a neuro spine case or orthopedic implant case? Can the 3D code 76376 also be charged?

Procedure was “Hepatic radioembolization preparatory angiogram and Tc99m-MAA administration.” Can we code 36247 catheter placement for MAA administration? CPT Assistant, February 2012 says, “The administration of a radiopharmaceutical is inherent to nuclear medicine studies.” Is catheter placement included in nuclear medicine studies? Selective angiography was done with catheterization at left hepatic artery trunk. Radioisotope: Technetium-99m MAA administration was done from catheter position: Segment 4 branch off the left hepatic artery trunk. Contrast was also used, but it was not mentioned when or how it was given. 78202 and 78830 were done.

Can we code 36247 with 78202 and 78830 without 75726? Or should this be 75726, 36247, 78830, and 78202?

Would this documentation support CPT codes: 93656, 936557 and 93623?

PVI was achieved for all veins with entrance and exit block. High dose isuprel induced 2 separate triggers from the posterior roof near the left-sided veins. A detailed sinus rhythm scar map was created showing patchy scar in this region. Scar modification was performed after which no further PACs were noted. Atrial pacing induced brief typical appearing flutter. Pulmonary vein isolation continued through a 30-minute waiting period.

Please advise.

What CPT code(s) would be billed for the following.

The right tunneled PICC tip was shown to be in the internal jugular vein.

Aggressive saline flush was performed, which was successful in

repositioning the PICC tip to the SVC/RA junction.

Fluoro was used but no contrast

Thanks

The left main coronary has normal takeoff from the left coronary cusp, has mild disease. The LAD is totally occluded. Left circumflex artery has a 70% very distal stenosis. The 2 obtuse marginal branches have 90% stenosis as well, and actually one of them is more like a left PDA. The RCA is a small nondominant vessel and has a 90% proximal stenosis. The left internal angiography demonstrated patent LIMA to LAD. Saphenous vein graft angiography demonstrated patent graft to the first obtuse marginal branch, and graft angiography demonstrated patent graft to the left PDA. Left ventriculography was performed with ejection fraction of 60%. Pullback from the left ventricle to the aorta did not reveal any severe stenosis.

My concernt is there is no mention of placement of catheter in bypass grafts.

Is catheter placement reported with shockwave llithotripsy in the lower extremities? For example, would 36247 be reported with C9764? In the other lower extremity revascularization CPT codes, it is bundled and there is an NCCI edit. But there is no edit for these.

Preliminary Ultrasound of Left breast demonstrates slightly thickened wall, few internal debris within cystic lesion. Ultrasound -guided FNA of the above complex cystic lesion at 5 o'clock position of Left Breast was performed using 18-gauge needle attached to 10 cc syringe. Less than 1 cc of blood-tinged was aspirated followed by insertion of biopsy clip. Specimen was sent to the department of Cytology. Unilateral left mammogram confirmed that the clip is in satisfactory position.

Should we use 19000 or 10005?

Can 19285 & 77065 be coded separately?

The patient comes in for TCPVR procedure with elective right heart/left heart cath and angiograms. Would you code the RHC/LHC and angiograms with 33477?

We are trying to figure out what code we would use for repositioning of lumbar drain with fluoroscopic guidance. The drain was manipulated and slightly withdrawn from the spinal canal. Location confirmed by fluoroscopy. What would you recommend coding? Thanks!

According to AHA Coding Clinic 2nd Q, 2014 - Breast Codes: Biopsy and localization devices, under the Q&A section, the answer to Q #3 states both 19301 and 19283 (in my case 19281) can be coded together if performed on the same breast. What if the marker is placed in the lumpectomy cavity, not if a different location on the same breast. Would it still be appropriate to code both procedures? There is a CCI edit and modifier is allowed, but I am thinking that that is if the lumpectomy and marker placement was done in different locations on the same breast.

Would this be 35226 or 37799, or would it be something else entirely since technically its repair of a previously placed right common iliac to right external iliac bypass graft?

Approximately 3 mm x 4 mm defect in the proximal 3rd of the bypass graft in the posterior lateral aspect. After debriding the friable portion of the artery, there was too large of a defect for immediate primary closure and so after mobilization of the bypass graft and trimming of the edges of the artery for more sustainable tissue, we performed a end-to-end anastomosis of the existing bypass graft in a primary fashion.

“I did not feel comfortable repairing this without additional exposure and mobilization, so then I transected the artery to obtain a circumferential evaluation of the artery, CryoArtery. After additional debridement I felt comfortable reattaching each end in end-to-end fashion with 5-0 Prolene suture in simple interrupted fashion in its entirety.”

Physician billing - Pt had a LHC w/ stent for anteroseptal MI and later in the same day, patient develops a high degree AV block so returns to the cath lab requiring a temporary wire placed same day, same provider but separate encounter. There is a 0-edit between the cath and the temporary pacer so the -59 modifier cannot override the edit. Does that mean that even in a situation such as this, the pacer is not billable?

Would you report code 10030 or an unlisted chest code for this report?

"CLINICAL INDICATION: Subcarinal cystic structure. Under CT guidance, a 17 gauge coaxial introducer needle was placed into the subcarinal cystic structure via right posterior approach. A 0.038 guidewire was inserted through the cannula, and the cannula was removed. The tract was serially dilated, and a 10 French pigtail drainage catheter was ultimately placed into the cystic structure. Fluid was manually aspirated through the catheter, and the catheter was attached to a drainage bag. The catheter was secured to the skin with a Percu-Stay device. Fluid was sent off for cell count, cultures, and cytology. IMPRESSION: Uncomplicated CT-guided drainage with catheter placement of mediastinal cystic structure."

Our radiologist is performing needle placement only via fluoroscopy for a cervical spine injection. The pain management provider is actually giving the injection. Can the radiologist bill anything for the fluoroscopic needle placement only?

Can you please clarify whether the Penumbra (Indigo) is still considered aspiration thrombectomy or is it now considered mechanical thrombectomy. Previous responses stated it is aspiration, but our Cath Lab disagrees. The Mechanical Thrombectomy E-Learning Module states the only device that is appropriate for use with 92973 are the AngioJet devices. There are many MTD devices shown in the module, are none of them other than Angiojet coded with 92973? Of note, the Optum Guide to IR has an example that codes a Penumbra thrombectomy as mechanical.

My provider is documenting that he placed a stent in common iliac vein, and placed a stent in external iliac vein. however he is only using 1 stent. Would this fall into "a single therapy"? Do I only bill 37238 since he used 1 stent? Or do I bill 37238,37239 since 2 different vessels were treated? 

Code G2066 was billed with 93298 for remote loop recorder device interrogation; however, code G2066 is now deleted. What code is replacing G2066?

The cardiologist I code for have and in-office cath lab and perform LE resvascularization and a few other procedures there. My question is with meds given, are they allowed to code also 96374?

Common meds are

Versed

Fentanyl

Protamine

Zofran

Benadryl

Flumazenil

From right side femoral access,  catheter was placed in infrarenal aorta above bifurcation and performed angiogram, and catheter was placed in left external iliac for left leg runoff. Findings state aorta patent with iliacs and complete left leg findings. Can we report code 75625 in this case? Not sure whether significant portion of aorta was imaged since he said catheter was placed above bifurcation.

How would you code the axillary cutdown when the Impella is removed? Is this billable?

This is another persistent afib patient returning for repeat ablation.

" A voltage map revealed pulmonary vein isolation from prior ablation procedure. In this context we decided to extend the line of isolation. Radiofrequency applications with 25 to 45 watts were delivered around the left and right pulmonary veins to achieve wide antral circumferential isolation. Entrance and exit block was confirmed bilaterally. High esophageal temperatures were noted while ablating the posterior aspect of the RPVs. Applications were interrupted once the temperature reached 38.5 C in the esophagus. After pulmonary vein isolation was achieved, pace capture at 10 mA x 2 ms was performed along both lesion sets. Additional radiofrequency energy was applied at the areas of capture."

If the pulmonary veins were identified as isolated from a prior ablation is the extension of the line of isolation in the presence of persistent afib still reported as 93656?

Is it appropriate to report 36569 when an RN, employed by the hospital (Vascular Access Team), places an PICC? There is no physician involvement, other than the reading of a post procedure chest x-ray.

They are using ultrasound and had wanted to report 36573, but, don't believe that to be appropriate due to lack of physician supervision and interpretation. Do you agree?

If a renal duplex scan is done plus the mesenteric artery, do I bill code 93976 only, or do I also add 93976?

In a case where the patient was scheduled for an upgrade from dual PM to BiVi PM, the doctor was not able to implant the LV lead. I’m coding 33225-74 because it is specific to why patient was on the table, because additional supplies and time was used, and because the doctor states “concern for complications” and aborted the procedure. The doctor then added a new RV lead and exchanged the dual PM so I’m also coding 33207 and 33233. Do you agree with my codes? Also, if the patient is for a brand new BiVi PM and doctor cannot place the LV lead and just places the dual PM, should I be coding 33225-74 as well? I have been just coding for a dual PM insertion. I’m interested in your thoughts. Thanks!

Cardiac Surgery came in and opened the right carotid artery. Cardiologist then performed the Aortic Valve Replacement using the Carotid Artery for Delivery of the Valve. Is this still an unlisted procedure code 33999?

Physician placed an AFX 2 with a Proximal extension Vela 25-75. Is the correct CPT coding for this a 34703 and 34709 for the proximal extension?

What should be coded for the following?

A four-quadrant sector transducer scan reveals that there is only some a small amount of ascites fluid in the right perihepatic space, no fluid seen in the left upper and left lower quadrants of the abdomen and also in the right lower quadrant and hypogastric region respectively. Therefore we elected not to perform a repeat paracentesis at this time. Instead we elected to perform closure of the prior peritoneal cavity tract which had resulted from the prior ultrasound guided paracentesis performed a few days ago. Therefore we embarked on performing a circ lage suture to pucker the tract followed by skin to skin apposition with adhesive skin glue. Using sterile technique and 1% local regional anesthesia with buffered lidocaine for total of 10 cc. This resulted in complete cessation of fluid coming out. We then performed a dry dressing.

Impression :successful management of a peritoneal ascites leak coming from the prior site of peritoneal fluid drainage

Need Dr. Z's opinion with this op report :) Thank you in advance!

An arteriotomy was made mid common femoral artery extended across the femoral bifurcation to the origin of the superficial femoral artery which was widely patent. Occlusive highly exophytic plaque was at the femoral bifurcation. An endarterectomy plane was identified, taking care to preserve the abrupt termination of the plaque at the origin of the profundofemoral artery. We endarterectomized from the proximal superficial femoral artery retrograde to the level of the inquinal ligament w/a penfield elevator. At the origin of the profundofemoral artery I divided the plaque with Potts scissors, resulting in preservation of a nice ostium. I tacked down the plaque at the origin of the profundofemoral artery w/7.0 prolene sutures and passed the plaque off as a specimen. The 8 mm graft was spatulated to match and end to side anastomosis completed with 5-0 prolene sutures.

Then the op goes on to discuss completion of the axillary to bifemoral bypass.

Would the profunda reimplantation to the graft be part of establishing inflow/outflow in code 35141 or would this be separately billable with a 22 mod or unlisted 37799?

"Patient has right CFA aneurysm with complete occlusion of right SFA and profunda femoris. We dissected the CFA proximal to the aneurysmal area. The vessel was encircled with a vessel loop and controlled. We repeated the same process for the SFA and profunda. The aneurysm was then entered anterior arteriotomy with a 11 blade. The arteriotomy was extended proximal and distal with scissors. We completely transected the proximal and distal ends of the affected artery in order to proceed with reconstruction. An 8 mm Dacron graft was sewn to the CFA in an end to end fashion. The same process was repeated for the distal anastomosis to the SFA. Next, the profunda was transected and ligated. The distal portion was mobilized in order to anastomose to the Dacron graft. End to side anastomosis with 5-0 Prolene was performed. All the arteries were flushed prior to completing the anastomosis."

Just confirming -

If TIPS procedure is performed, and ICE (Intra-Cardiac Echo) is used - does it fall under the "all associated imaging guidance" or can Intra cardiac echo be charge separately with 93662?

Patient has pre-existing brachiocephalic av fistula which now has aneurysms. Physician resects the cephalic vein from where it was anastomosed to the brachial artery. A subcutaneous tunnel was then made distal to the antecubital fossa

with the distal cephalic vein brought in juxtaposition to the previous brachial artery anastomosis. The anastomotic segment was cleared to allow for end-to-side anastomosis to be completed from the brachial artery to the cephalic vein. This was then completed.

due to lack of significant palpable thrill, in order to better provide outflow from this retrograde system, incision was made overlying the basilic vein in the forearm. Subcutaneous tunnel was made and the distended basilic vein was passed through. Distal basilic vein was transposed and juxtaposed to the cephalic vein. A venotomy was made within the cephalic vein and the basilic vein spatulated to accommodate an end-to-side anastomosis.

Since original anastomotic site used, is this revision (36832) or new creation (36819)?

Since code 27096 now includes fluoro, does G0260 follow the same rules and include Fluoro? Because in the lay description it says The physician injects the sacroiliac joint for the purpose of arthrography, which is taking radiographic pictures of the joint internally to visualize the cartilage and ligaments. The contrast material, or gas, is drawn into a syringe and the target structure is localized. Through a posterior approach, the needle is inserted and advanced into the sacroiliac joint, the articulation between the sacrum and ilium in the pelvis, and the contrast injection is visualized under the aid of separately reportable computerized tomography (CT) or fluoroscopic guidance.

In facility do we report G0260 and 77002?

Please advise thank you

I have a vascular surgeon who wants to bill CPT 64905 for the TMR a newer technique that he states is allowed with Nerve Pedicle Transfers. He did a below knee amputation. After that the op note reads:

"The Tibial Nerve was identified and isolated. The Soleus muscle was meticulously dissected until the motor nerve plexus was identified. A coaptation was created between the nerve and the motor nerve plexus using 6-0 prolene, and the vascularized muscle was closed around the nerve."

We have exhausted our appeals and are unsure if this is going to work or if a Unlisted code should be used?

Can you please clarify if we should use 19285 or an unlisted code for an ultrasound guided needle localization of right axillary lymph node? CLINICAL HISTORY: Patient is seen for an ultrasound guided Pintuition Seed localization of a malignancy and tissue marker in right axilla. FINDINGS: The patient was positioned on ultrasound table and the right axilla was prepped and draped in the usual sterile manner. High resolution real time ultrasound imaging was performed. The malignancy and tissue marker to be localized was identified in the axilla. Ten (10) cc of 1% lidocaine was utilized for local anesthesia. The localizing needle was inserted and the needle tip was advanced through the lesion using real time ultrasound guidance. A Pintuition Seed was then deployed through the needle and the localizing needle was removed. A post localization mammogram was performed confirming accurate localization of the lesion. CONCLUSION: Successful ultrasound guided Pintuition Seed localization of a malignancy and tissue marker in the right axilla.

Does this support a dual chamber insertion?

"Using fluoroscopic guidance a lead was inserted into the area of the left bundle via guide sheath. Pacing and sensing parameters were appropriate with LV activation time of 71 ms. The guide was slit. The lead was anchored in position using sutures around the anchoring sleeve. Next, another sheath was used to place an atrial lead in the area of the right atrial appendage. The lead was anchored in position using sutures around the anchoring sleeve. The leads were then connected to generator and the pocket was irrigated with saline.

The device and leads were placed in the pocket and the pocket was closed with a combination of subcutaneous absorbable sutures and Steristrips. Pacing and sensing parameters were checked through the device and were appropriate, there was no phrenic stimulation with high outpatient pacing from both atrial and ventricular leads."

Can you advise me as to what the correct CPT charging would be for 4D CT angiography? I understand the charging for 3DCT angiography for S&I is 76376 and 76377 as to whether this was reviewed on an independent workstation. I cannot find any information concerning 4D CT charging.

What code should be used for white smatter small vessel ischemic changes? Some coders use R90.82; some use I67.82. Is there a definitive code that should be used?

In the cases where US is done prior to thoracentesis if not enough fluid, we report the limited chest US only. However, if US is done on both RT and LT side but only LT side has enough fluid and thoracentesis is done, are we still able to report the limited US done for the RT with not enough fluid?

Is this considered a revision or a ligation of the AV fistula?

"Intraoperative ultrasound was used to visualize the arterial anastomosis. An oblique incision was made with a scalpel, and the incision was deepened with electrocautery and metzenbaum scissors until the brachial artery and fistula were both identified. The artery and fistula were both confirmed to be as such with Doppler. A 6 mm Dacron tube graft was brought onto the field, opened with metzenbaum scissors so that it was formed into a patch instead of a tube, and wrapped around the proximal fistula for sizing. This was then sutured into place sizing the fistula to the graft with interrupted 5-0 prolene suture. A palpable thrill was still noted over the fistula. Hemostasis was obtained with electrocautery. The wound was closed with 3-0 vicryl, 4-0 monocryl, and skin glue. A radial pulse was palpable on completion."