Ask Dr. Z

Pt is 56 yo with 3V CAD recent NSTEMI & severe ischemic cardiomyopathy. I am having trouble coding the Extracorporeal circulation code. The report states midline sternotomy was performed the LIMA was harvested from L sternal border endoscopic fashion (33533 & 33508) . Pt placed on extracorporeal circulation with aortic annula, 2 venous cannula and ascending aortic root vent. (33954 or 33956) Pt was placed on cardiopulmonary bypass, at the end of the procedure the patient was weaned off cardiopulmonary bypass. Everything I find on ECMO says it is performed after the CABG to give the heart and lung a rest to assist in healing or is ECMO also used during the CABG? Thank you for your assistance and time.

"An incision was made over the xiphoid process and dissection was carried down to the level of the xiphoid, which was dissected free and excised. The inferior aspect of the sternum was then elevated, and the pericardium was opened under direct visualization. The pericardiotomy was extended medially and laterally to allow for placement of the convergent cannula. A 5 mm scope was passed thru the cannula and the heart was examined. There was a moderate amt of epicardial fat present in the left atrium. There were some moderate adhesions over by the pulmonary veins. The ablations were begun. A total of 16 were completed, which appeared to cover the majority of the posterior wall of the left atrium. Some adhesions were taken down. A 24 French Blake drain was placed and fascia, subQ, skin was closed."

We are having a hard time determining if this would be 33254 since he excised the xiphoid and visualized the pericardium or if 33265 is more appropriate since a scope was utilized. Thank you.

Patient presents for cardiac resynchronization therapy due to severe LV dysfunction with EP 15-20% , chronic ischemic cardiomyopathy and left bundle branch block. A Medtronicquadripolar lead (C1900) was delivered into the proximal posterior lateral vein through the coronary sinus guide sheath, however given the small caliber of the vessel the lead could not be extended sufficiently into the branch. Multiple attempts were made but due to the unsuitable coronary sinus anatomy this attempt had to be abandoned. Lead was advanced to the region of the HIS bundle until adequate sensing and thresholds were confirmed. ICD was attached to leads.

Since the physician used C1900 lead in bundle of HIS to obtain LV pacing can we charge 33249 and 33225?

When a patient comes in for the hookup of their holter monitor, we bill CPT 93225 (connection, recording, and disconnect). The holter monitors are programmed to auto-disconnect. The patient typically returns the monitor to the office so the recording can be uploaded, reviewed, and interpreted. At that point, the professional component is billed.

Our question is: If the patient does not return the monitor, is it still appropriate to bill the CPT 93225 (even though we did not receive the actual recording) since the monitor was hooked up, recorded, and auto disconnected?

Recommendation to my question 18029 was to code 33264, for:

A biventricular device was attached to the existing leads. The left ventricular port was capped. The pocket was flushed and the device was then placed into the pocket. It was closed in a three-layer technique and the dermal layer was sealed with dermal adhesive.however:

Question ID 17177

A biventricular ICD replacement was performed with existing RV, RA, LV leads. The existing LVL was capped, and there were no appropriate branches for LV pacing, so a left bundle lead was placed. Is 33264 the appropriate code for this procedure?

Answer

Since a new lead and new generator were placed, report codes 33241 and 33249. -Dr. Dunn

Will you please advise on why there were different recommendations for these two scenarios?

Patient presents with fractured retained IVC filter fragments in IVC, pulmonary artery and right atrium. According to Question ID: 4176 all fragments removed from vessels would be covered with 37193. Would this apply to the removal of fragments from the atrium as well or would removal of foreign body 37197 be appropriate?

What is the CPT code for median arcuate ligament by laparoscopic approach?

My vascular surgeon performed a diagastric muscle resection, C1 transverse process resection, and stylohyoid process excision in order to accomplish a decompression of the right internal jugular vein. I am torn as to where to begin with a CPT code since all of these procedures were performed to accomplish one problem. I thought about using 35701-22, but this does not seem to capture all of the work involved. I don't want to code multiple CPTs, as that may seem like up-coding. What are your thoughts on how to approach this coding scenario?

Patient had CT abdomen and pelvis with contrast. Next day, cholangiostomy tube check was done through existing access without contrast. How do we code cholangiography without contrast? The result was normal function of internal and external catheter.

Our providers are sometimes performing stereotactic breast biopsies using contrast enhanced mammography to visualize the lesion within the same setting. In addition to 19081, should we also capture 76499 for that contrast enhanced imaging?

AFTER OBTAINING CONSENT, AN US CORE BIOPSY OF THE RT HIP SYNOVIUM WAS PERFORMED. PREPROCEDURAL IMAGING OF THE RT HIP DEMONSTRATED A TOTAL RT HIP ARTHROPATHY WITH EXTENSIVE SYNOVIAL THICKENING ALONG THE ANTERIOR MARGIN OF THE FEMORAL STEM. THE RT HIP WAS SCANNED AND THE REGION OF INTEREST WAS LOCALIZED, UNDER US GUIDANCE, 5 PASES WERE MADE AND BIOPSY SPECIMENS WERE OBTAINED USING AN 18 GAUGE BIOSY GUN. WOULD THIS BE CODED AS 76942 AND 20206?

Can you please provide the documentation to support that 37244 must be for acute active hemorrhage? We have an outpatient report for embolization of hemarthrosis. Is a planned outpatient embolization for this indication coded as 37242 or 37244? We have a dispute over documentation that it must be acute bleed indication, which we do not see supported in the CPT Codebook.

Patient presented with severe stenosis and regurgitation of bioprosthetic valve (previous TAVR). The patient also has a history of CABG. The bioprosthetic valve was found to be adhered to the ascending aorta and the ascending aorta needed to be replaced from the distal to the sinotubular junction. The bio valve and the native valve were excised, and a new valve was placed. 33405-22 for this portion. The surgeon then had to reimplant the previous coronary bypass grafts into the newly grafted ascending aorta. I am certain we need to go with an unlisted code for the ascending aorta replacement and thinking that we'll utilize 33859 as the comparable code after confirming with the surgeon. Also, adding 33530 for the re-operation. Is there anything additional that you would recommend?

Per the below results how would this Limited Echo be coded - 93308-26 or with unlisted cpt code due to administration of Epinephrine, Vasopressin, Norepinephrine, fentanyl - Implella pump flow measurements and VA ECMO flow rates included in results.

Echo Summary -

1. Overall left ventricular ejection fraction estimated at 10 to 15%

2. Severely decreased global LV systolic function

3. Mildly reduced RV Systolic Function

4. Moderately dilatedLt/RT Atrium

5. Severe MV regurgitation - Severe aortic stenosis

6. MV ERO 0.56 cm2

Vena contracta 1.34 cm

Jet fil1s the lt atrium

Peak continuous wave MR velocity 3.42 m/s

7. Epineprine 2 mcg/min; Vasopressin 0.04 units/min; norepineprine 5cmg/min; fentanyl 5mcg/min

8. Impella CP; P2Impella flow 2.2 1/min, CPO 0.5

9. NSR, HR83.

10. VA ECMO; 5.45LPM,SVo2 75.6; RPM 4315

Patient has paroxysmal Afib. Provider does PVI 93657 confirms isolation in each vein. Then documents -- Extensive left atrial substrate modification was then performed. The posterior wall region between the PVs was debulked by targeting prominent EGMs rendering the region to be scarred as verified by scar mapping. Roof and Floor lines were created by virtue of the posterior wall ablation. Burst pacing was performed from the CS but did not induce SVT. Would this documentation support coding 93657 since the patient has a history of Paroxysmal AFIB BUT it was not induced after the PVI?

HI Dr. Z,

Please let me know if this is how you would code this procedure? Bilateral inguinal lymphatic system accessed with ultrasound guidance. Lymphogram through the pelvis and abdomen. Next accessed the left brachial vein with cannulation of thoracic duct off the left subclavian. Lymphangiogram done in thoracic duct where extravasation seen near surgical clips. Embolization done with n-BCA. I am thinking 38794, 38790-50, 75807, 37244? Is 76937 allowed for ultrasound guidance of lymph system and do we code anything for the left brachial vein access site or is that part of 38794?

Thank you for your help

Do we report code 33289, as we do for CardioMEMS, for the Cordella PA pressure sensor? I am unable to locate coding suggestions. It looks like Cordella is FDA approved recently.

"The patient had successful TAVR placed and developed pericardial effusion. Provider performed an emergent sternotomy and evacuated a large amount of blood and placed multiple sutures. Hematosis was obtained and the chest wall closed. The patient had a dusky lower limb, and cardiology removed the sheath from the TAVR repair and the patient become significantly hypotensive. The provider then re-opened the sternotomy and removed more clots (the patient never left OR)." 

How would you report the emergent sternotomy since the TAVR was successfully completed as a percutaneous approach (33361)?

I am stumped as what I should use for coding this attempt. Can you please advise? Patient has RV lead impedance, so they planned to do an ICD RV lead revision. Doesn't seem like he did enough to charge 33244-53, 33216-53.

"Using general anesthesia with endotrachael intubation, a right infraclavicular incision was made and the old generator was explanted. The right subclavian vein appears occluded. It was decided to leave the original system in because three years of battery is left. Finally, the subcutaneous pocket was sutured using 2-0 Vicryl and the skin was closed using 4-0 Vicryl. The patient tolerated the procedure well and no complications were encountered during this implantation."

Hi All,

Need to know if can charge 33992 on this case w/ Impella insertion.

*** the right groin was accessed using the modified seldinger technique. A 7fr french sheath was placed in the femoral artery. We then used a 4fr RIM catheter to go up and over and performed a femoral angiogram on the left iliac and femoral artery. Under fluroscopic guidance we obtained access on the left femoral artery and using the modifier seldinger technique placed a 6 fr sheath. and 14 fr sheath. ..... we then successfully delivered an impella cp in appropriate position with the outlet above the aortic valve and appropriate lv-ao waveforms confirmed on the implella console. we used a 7fr ebu 3.5 guide catheter ... engaged the left coronary artery and perfomed coronary angiogram in mulple views... instered to stent in LC and distal lm.

IMPRESSION:

Drainage catheter check demonstrates complete evacuation of the pelvic. The

drainage catheter was removed.

PROCEDURE SUMMARY:

- Drainage catheter check under CT guidance

- Drainage catheter removal

- Additional procedure(s): None

PROCEDURE DETAILS:

Pre-procedure

Consent: Informed consent for the procedure including risks, benefits and

alternatives was obtained and time-out was performed prior to the procedure.

Preparation: The site was prepared and draped using maximal sterile barrier

technique including cutaneous antisepsis.

Drainage catheter check and removal

The patient was positioned supine. Initial imaging was performed . The drainage

catheter was removed, and a sterile bandage was placed.

- Initial imaging findings: Complete resolution of the fluid collection.

Contrast

Contrast agent: None

Contrast volume (mL): 0

When there is no contrast listed i'm assuming we can't use 49424-49423, because these are contrast based codes. For this note I would code only for the CT Guidance, is this correct? 76380 or 77012

How do you code the removal of an abdominal pacemaker? What CPT code range?

Right femoral endarterectomy and thromboembolectomy with patch angioplasty. Is this reported with code 35141?

Can code 49424 be used when IV contrast is administered for CT abscess drainage catheter assessment instead of injection and imaging through the catheter? 

I have been unable to find a CPT code for cannulation during the following mitral valve replacement procedure and believe it is included in the MVR. Please confirm. 

"PROCEDURE: Mini access right anterior thoracotomy. Patient was cannulated with femoral aortic cannula and ascending root cardioplegia catheter. Patient was placed on cardiopulmonary bypass, aorta was cross-clamped, once the heart was arrested the antegrade cardioplegic catheter was turned into an aortic vent line. Direct left atriotomy was performed and mitral valve was inspected, and found to have thickened leaflet with poor coaptation, the mitral valve was replaced." (The only CPT code applicable is 33430.)

Are the CMS rules still the same regarding billing of codes 99152/99153 and "the physician must oversee the trained observer, and the trained observer can have no other duties during the procedure"?

"Patient presents with right carotid body tumor for resection. During dissection it was found that the vascular pedicle was densely adherent to the carotid bifurcation. While dissecting this free, the lumen of the bifurcation was entered. The vascular pedicle was isolated, ligated, and transected. The remainder of the tumor was dissected free from both ICA and ECA and posterior attachments and sent to pathology. The laceration to the carotid bulb and proximal ICA could not be readily accessed, therefore the right ICA was transected, eversion endarterectomy performed, distal end-point tacked, and re-anastomosed in bidirectional running fashion. Completion duplex was performed, and wound was closed. Findings: Right carotid body tumor 4x5x3.5 cm resected. This required eversion endarterectomy, as tumor was densely adherent to the carotid bifurcation." 

Are we able to bill for the endarterectomy (35301) in addition to the tumor resection (60600), or would this be considered inherent to the primary procedure given its (iatrogenic) nature and repair during the same operative session?

You have given previous advice to code the psoas muscle image-guided fluid collection to 49406. My research shows that the psoas muscle is not in the retroperitoneal space. Would this still be coded to 49406, and can you please explain why?

"Operative Report: Finally, attention is turned to placement of percutaneous drainage catheter from the left iliopsoas abscess. Under fluoroscopic guidance and utilizing bony landmarks, an 18 gauge Hawkins needle is directed from a posterior percutaneous approach into the abscess collection. Aspiration yields frank pus. A sample is sent to micrology for analysis. Exchange is then made over guidewire after utilization of fascial dilators for a 12 French multi-sidehole pigtail drainage catheter. Appropriate catheter positioning is again confirmed with aspiration of frank pus. The catheter is secured at skin insertion site with non-absorbable suture and placed to accordion drainage."

In EP studies, if the physician documents that programmed stimulation was delivered from the atrium, is it considered the same as induction or attempted induction of arrhythmia? Can we report 93618 for programmed stimulation?

I would like confirmation on how to code stent placement on two coronary branches of left circumflex. If stent was placed in OM1 and OM2, will this be coded with 92928, 92928 or with 92928, 92929? Please advise.

Patient had an ICD lead fracture. The surgeon attempted to remove the RV lead, but when they "turned the stylet in a counterclock fashion in order to retract the active fixation screw of the ICD lead. The screw was retracting; however, it did not retract entirely. The lead was noted to be lodged well into the myocardium and could not be released with gentle traction." They then capped the lead and decided to implant a new RV lead. Would this be coded as 33216 and 33244-52 since there was an attempt to remove the lead initially?

A previous question in 2018 (ID 11764) asked about mitral valve replacement on an existing prosthetic valve. Your advice was to use either 0483T or 0484T depending on approach. Do you still recommend these codes? Some vendors and insurance carriers are now recommending unlisted code 33999. We cannot find any official coding updates that state 33999 is the correct code to be assigned.

From a RCFA access, the physician embolized R. sphenopalatine artery as an indirect embolization of the L. cavernous fistula. From a RCFV access, the physician embolized the R. cavernous sinus fistula.

Is this considered 1 or 2 operative fields?

I'm having trouble figuring what exactly was done here. The heading says "Right chest port revision", and then goes on to say a right internal jugular venotomy was performed, but no mention of ultrasound guidance. Then, the existing right chest port was explanted and a new double-lumen Bard port was tunneled. The catheter was inserted through the new right internal jugular access site and then connected to the double lumen port. The port was anchored to the right chest wall and flushed and aspirated appropriately. The impression says "Successful removal of a single lumen right chest port with placement of a new double-lumen port." Would this be coded 36582?

I have a removal of the SICD lead (33272) with placement of a new SICD lead. PG was not replaced. Code 33216 is defined as transvenous. Would you recommend an unlisted code?

Patient with liver cancer. Surgical report states visceral and hepatic angiography with radioembolization using Y90 SIR spheres. They billed 37243 and 79445. Then following this Y90 treatment, they billed 78201 for static liver imaging and 78830 for SPECT, and they document as follows: "Post-procedure bremsstrahlung planar and SPECT acquired. PLANAR - radiotracer is seen through RT hepatic lobe. No significant extrahepatic radiotracer identified. SPECT - radiotracer is seen through RT hepatic lobe. No significant extrahepatic radiotracer identified."  My question is, should they really be billing for a bremsstrahlung since it seems just to be confirmatory, not diagnostic, OR should they report the 78800, which does look at the distribution of the agent? I always thought they should NOT bill for 78830 post Y90 therapy when not diagnostic in nature. 

If iFR is performed on two separate vessels during a cardiac cath, is each reported separately with 93799, 93799-XS?

"The patient was then positioned, prepared, and draped for a right robotic-assisted video thoracoscopy vs thoracotomy. Three port incisions were made in the lateral chest wall, adhesions between the superior segment of the right lower lobe and the chest wall. The rest of the chest was unremarkable. We began by removing the adhesions to the chest wall, which were inflamed. As we were taking down these superior segments, a lung abscess was unroofed. Purulent fluid was aspirated and sent for culture. There was a small connection about the size of a dime adjacent to the chest wall that also drained a small amount of purulent material, and this was also unroofed irrigated and debrided. A 28 French chest tubes was then placed posteriorly."

I was not able to locate a CPT code that encompasses everything that was completed. Would this be an unlisted code and compare it to 32604? Or is there a better CPT code to use that we are unable to locate?

"Patient has a right CFA access site. Catheter is placed in the aorta for an abdominal aortogram with bilateral iliac run-off (75630), then via the right CFA access a stent is placed in the right external iliac artery (37221) for occlusive disease."  Since the catheter was placed beyond the intervention site (and is the highest order non-selective code), can you report code 36200 for the catheter placement in the aorta with the right external iliac artery stenting procedure (37221) performed via the right CFA access site, or is 36200 bundled for this ipsilateral access/iliac artery intervention?

Which CPT code would you suggest for the lateral femoral cutaneous nerve block 64447 vs. 64450? 

The provider treated a Type C Lesion of the LAD that had 58mm of the lesion length treated with 3 stents (Prox LAD, Prox to Mid LAD and Mid LAD). In the Medicare LCD prior to 10/1/2022, they stated use of modifier 22 was justified only if 4 or more stents were placed in a single vessel. They did not address Lesion Type or Length. I had always been taught that a 22 modifier could be used when 3 or more stents are placed in a single vessel when factoring in lesion length and/or lesion type. Do you feel modifier 22 justified in this case? What recommendations/rule of thumb should be followed when considering Lesion Length and/or Type to justify modifier 22 use?

I am coding the below with 3D (73677), and I am clashing with others that code it as 76377 x’s. I’ve done extensive research trying to find documentation that 76377 is per field not per artery.

"Right vertebral artery intracranial circulation was obtained with 3D rotational angiography and cone beam head CT of the right vertebral artery intracranial circulation were obtained and processed on a separate workstation and saved to imaging system. The catheter was then withdrawn into innominate artery.

Left internal carotid artery was selectively catheterized over a glidewire. AP, lateral, transorbital oblique, and Schuller's projections of the left internal carotid artery intracranial circulation were obtained. 3D rotational angiography and cone beam head CT of the left internal carotid artery intracranial circulation was obtained and processed on a separate workstation and saved to imaging system."

Would the following documentation support billing 33641 as part of back bench work, if done off bypass?

"We examined the new heart on the backtable, and we prepared the donor heart. The left atrium was trimmed. The great vessels were separated, and the aorta and pulmonary artery were trimmed. The inter-atrial septum was examined, and there was a patent foramen ovale. We closed the patent foramen ovale with prolene sutures."

Would the donor heart need to be placed into the recipient and CPB initiated in order to separately report repairs? There is a CPT parenthetical for 33944: "(For repair or resection procedures on the donor heart, see 33300, 33310, 33320, 33390, 33463, 33464, 33510, 33641, 35216, 35276, 35685)."

My physician performed a redo TCAR procedure due to in-stent stenosis of the right carotid artery. After procedure was completed and prior to closure the patient began to hemorrhage which was determined to be caused by a transection of the proximal carotid artery as documented below.

"The common carotid artery at the clamp site was 80% transected and the intima disrupted. The access site was fine. The proximal and distal ends of the artery were freed up and the clamps moved to assess the situation. I asked my partner to scrub in to help get to this point. About 1.5 to 2 cm of artery was excised to gent endpoints that are essentially normal. They had too much tension to close primarily. A 6 mm Goretex graft was brought to the field and cut to length. The proximal anastomosis was performed first with running 5-0 Prolene and then the distal anastomosis both end to end."

Would this repair be separately reportable with 35261? It is hitting an NCCI edit and is the same operative session/site?

When using the code 32555, does the ultrasound have to be in real-time? Example: Radiologist tech performs the ultrasound and marks the place for the provider. Once they are done with that, they leave and the provider enters and then performs the thoracentesis using the mark left by radiology. I am under the impression that image-guided is in real-time, but I wanted clarification on that.

Generally our pediatric cath surgeons access the PDA via normal connections from the carotid artery or femoral artery and don't go into the heart to place a stent. The stent is placed due to CHD so they do have abnormal connections , but technically our access isn't abnormal. Would you suggest we code these to 33902 or 33900 in 2023?

"The patient with AICD came for NIPS procedure. DFT ventricular fibrillation was induced with burst pace. Joules delivered: 34. Defibrillation threshold testing was successful." Both of the reviewers agree with 93642 because the ventricular fibrillation was induced. Please advise why you suggest 93799 instead of 93642.

The coding book says that 33902 can be used to stent a PDA via abnormal connections or post-surgical shunts. What about our PDA stents we are doing now, generally from carotid artery or femoral artery through the PDA into PAs for access? These patients all have CHD, so they do have abnormal connections, but technically our access to the PDA (which isn’t through the heart) isn’t “via abnormal connections”. Is this still the code we can bill for this case?

Patient's PVC ablation was cancelled after infusion of epi and caffeine-sodium benzoate failed to induce a high enough burden of PVCs. Can we charge for the infusions? Epi was 31 minutes, and caffeine was 23 minutes. Patient was under anesthesia for nearly two hours. Only other service was the EKG. Procedure note says pharmacological stimulation study to induce PVCs.

Can I bill an ICD interrogation (93287) that was done during the same session as a Watchman implant (33340)?