Ask Dr. Z

At our hospital facility we do a number of abdominal wall fat pad biopsies for amyloidosis. Are there any updates for what CPT code should be used for these? I've read unlisted code 17999, Unlisted procedure, skin, mucous membrane and subcutaneous tissue, from a 2019 Dr. Z. response. 

Patient had PA, PWCP, AO, and LV pressures. I think 93458 for the LV and AO pressures and then one of these add-on codes for the pulmonary piece: 93568, 93569, 93573, or 93574? Thoughts?

"Coronary angiography was performed. We then did the right heart catheterization and performed cardiac output in triplicate by thermodilution method. We then also did left ventricular end-diastolic pressure along with pulmonary capillary wedge pressure to calculate the mitral valve area and a 6-French Angio-Seal was deployed at the right femoral artery and D-stat pad was used to do the closure in the femoral vein. The right coronary artery shortly after its origin has diffuse disease to the mid-vessel stenosis maximum of about 40% proximal, and about 20% mid. The ascending root is mildly dilated, aortic valve area 1.1cm2 capillary wedge pressure was approximately 18 to 20 mmHg, pulmonary artery pressure 48/26. Initial left ventricular pressure 183/21 mmHg. Left ventricular end-diastolic pressure 26. 40 mm, peak to peak gradient across the aortic valve max gradient 50 mmHg."

What codes are supported for billing the endovascular procedure and why?

"Ultrasound-guided cannulation right common femoral artery- Selective left leg angiogram- Left anterior tibial lithotripsy with 3 mm x 40 mm Shockwave lithotripsy balloon- Angioplasty distal left anterior tibial artery with 2 mm x 100 mm ultra verse balloon-

Operative findings:

#1. The left posterior tibial artery still patent with minor areas of disease proximally and distally. The posterior tibial goes into the foot but does not appear to supply much of any blood flow to the digits on the left foot.

#2. The anterior tibial was able to cannulated with 0.018 wire and 0.014 wire. The wires could not be advanced all the way into the foot. After treatment of the anterior tibial with 3 x 40 mm lithotripsy shockwave balloon, it was quite obvious that the lithotripsy balloon could not be advanced all the way into the foot. This was replaced with 2 mm x 100 mm balloon which once again could not be advanced across the heavily calcified and diseased distal anterior tibial artery into dorsalis pedis. The procedure was then terminated."

Would you code this as 20206/76942 or go with unlisted 20999?

Pre-procedure diagnosis: Right thyroid bed vs. paratracheal nodule

Post-procedure diagnosis: Same

Device: Temno Evolution

Size: 18 Gauge

Passes: 5

Specimen: Surgical pathology

Successful US-guided right thyroid bed / paratracheal nodule biopsy.

What is the correct CPT coding for the initial insertion of a gastrostomy tube (Moss) with extension into the proximal duodenum? This was performed percutaneously and under fluoroscopic guidance.

I could use your expertise. A left heart cardiac cath was performed. The procedure report goes into detail about entering all major arteries and branches but does not describe how the catheter entered the left ventricular. There are, however, pressures recorded for the left ventricular reading. Are we to code from these pressure readings assuming the left ventricular was done?

The 2023 CPT book now directs us to bill the repair code when an Impella device is removed from an open exposure. If an embolectomy or endarterectomy is also required, would that still be considered a repair or would you bill those procedure codes instead? Is the repair code appropriate for open exposure and closure with just suture for the removal?

We have a debate amongst our team as to if you can charge an initial vertebroplasty and initial kyphoplasty in the same operative session. The patient had a T5 and T7 kyphoplasty and T12 and L1 vertebroplasty. Can we charge 22511 and 22512 for the vertebroplasty and 22513 and 22515 for the kyphoplasty?

Patient placed in a supine position. Skin left lateral abdominal wall cleaned and draped in usual sterile fashion. 1% lidocaine used as a local anesthesia. Patient monitored by radiology nurse using automated blood pressure cuff, EKG, and pulse oximetry. No sedation related complications.

Using CT for guidance. the tip of a 20-gauge Quincke spinal needle was placed immediately adjacent to the foreign body in the left side of the peritoneal cavity. Next, a mixture of 2 cc of endoscopic tatoo ink and a half a cc of Ominipaque 240 was injected through the needle. Patient tolerated the procedure well with no immediate complications. Patient was sent to recovery in stable condition. Radiologist performed this procedure.

How would this be coded? Would it be coded as 49411 or 10035?

The patient undergoes a procedure, can be various types of procedures for different reasons. The cardiologist performs a TEE pre, and post operative on the same day. Are both of these TEE procedures billable on the same day? Are they billable if they perform them on different days? They are performing these as a post operative check for the procedure. We are struggling with the medical necessity rationale other than a routine post operative check.

If the provider performs an endarterectomy of the external iliac artery to common femoral artery and places a stent in the common iliac artery, can we bill both codes 35355 and 37221? If so, does the documentation need to support two separate lesions to bill both, or can it be a contiguous lesion?

We have a patient who is returning multiple times for sclerotherapy of a lymphocele. However, after a few visits they are now sending the patient home with instructions as to wait 1 hour and then drain the doxycycline. "...The catheter was reconnected to a closed suction drainage bag. A sterile dressing was applied. The patient was instructed to reopen the stopcock after allowing the doxycycline to dwell for at least one hour. The patient was discharged."

There are mixed reviews as if it would it be appropriate to bill this out as 49185 or 49185-52 with the reduced services modifier for these cases. Can you please advise?

Report only has documentation for catheterization of the left internal carotid artery, but the findings section has imaging results for both the left and right internal carotid arteries. Can I code this as 36224-50?

How does Profee code for a left bundle branch pacing lead insertion? Please see example below. Patient had a dual pacemaker insertion (atrial and ventricular leads in addition to an LBB pacing lead. "LB pacing lead guiding catheter and .035 wire advanced, 3830 lead advanced and positioned in left bundle branch area. LB pacing lead position stable and lead sutured in place." Is this included in the insertion pacemaker/ICD codes? I'm not sure 33224/33225 would be correct in this situation either. Please advise.

We have a patient that received a DES for an acute MI originating in the LAD. In the cath report after IVUS and stenting they state "Following this super saturated oxygen therapy was started with ZOll system for 1 hour. Following this the system was disconnected, sheath was removed and Angio-Seal closure device used." I cannot find any guidance about a CPT for this type of procedure. Is this oxygen therapy included in the MI stenting procedure or should I look at an unlisted code?

May i ask you if we can still bill 77046-77048 if our radiology tech perform an abbreviated MRI with the following sequences :• · Sequences (all axial, no sagittal sequences)

o o Ax T2 FS

o o Ax FS Multiphase

 § 1 Pre contrast

 § 2 post contrast. Standard 10 mL gadavist 20 sec delay

o o MIP early phase

Thank you very much.

When a patient is having a pacemaker implanted and has second degree heart block causing symptomatic bradycardia, would both diagnoses be coded? I'm trying to determine if the bradycardia would be considered a sign or symptom and not coded, or if it can be added since it may or may not be present with a heart block and further explains the patient's condition?

Please help. We have a patient w/a multi-focal venous malformation. Physician did sclerotherapies at the shoulder, upper arm, and forearm. Separate draping was required for each one. These malformations are not at all connected. Can we bill for three units of 37241 for three separate Op sites?

Can 76376/76377 be reported on the same day as 93306, 93307, or 93308 when 3D imaging is used? Or are 76376/76377 only reportable when the 3D rendering occurs on a different day from the base procedure?

Would the below VATS procedure be coded as 32662 or unlisted?

"The 3rd and 4th inner intercostal muscles were widely dissected off of the posterior 4th rib to make room for division. Arm #2 was removed and a Stryker Pi drive drill with a long shaft was placed allowing precise division of the posterior 4th rib. Division of the posterior 4th rib allowed the rib to be retracted inward like a trap-door, which facilitated division of the surrounding muscles from the outer surface of the 4th rib. As the tumor was approached, a rim of external intercostal muscle and likely serratus anterior were taken with the specimen. Dissection continued anterior to the prior costal cartilage division, at which the remaining muscular connections were divided, completing the 4th rib resection."

During diagnostic cardiac cauterization, aortogram was performed to locate origin of the circumflex. Would the ascending aortogram be coded in this case?

Per cath report "Anomalous origin of the left circumflex. Prior CT chest from 5 years ago reviewed during the case. Circumflex does not originate from the aorta, it may originate from a branch of the pulmonary artery, although difficult to visualize origin. Non-aorta take-off was confirmed with aortogram."

Should bilateral renal artery stent placement be reported as 37236, 37237, or 37236-50? We understand that past guidance (such as from question IDs 5462 and 8218) states to use 37236, 37237 in this given scenario. The rationale given in Question ID 8218 was that modifier -50 “applies to lower extremity revascularizations, but not to renal, visceral, [or] upper extremities”. However, code 37236 is a "conditional bilateral" code as per CMS, meaning that modifier -50 is applicable to it. Is this to say that modifier -50 is only applicable to code 37236 when lower extremity revascularization of non-occlusive disease is performed? Or, should it apply to any applicable anatomy that has bilaterality, such as the renal arteries?

As we begin to see patients on ECMO longer and longer, surgeons are adding another catheter to support continued perfusion to the extremities. Would this be considered included in the ECMO, or could another CPT code be applied? I found that code 36620 might be a good representation code for this work. What are your thoughts?

"The 5 French catheter in the Right SFA was serially dilated to accept a 6 French distal perfusion catheter and flushed with hep saline. Contrast was administered through distal perfusion catheter with confirmation of flow down the SFA. The SFA cannula connected to the side port of the arterial cannula. ECMO flow initiated with good color change."

Physician performed a pocket revision for device erosion prevention and placed an Aigis antibiotic pouch. For this, would 33222/33223 be applicable depending on the device used?

Provider billed 93306, 96347 and q9957 and claim was partially paid. Payer denied 96374 as inclusive it this correct and/or can we add modifier 59

Incision extended to pre-existing pocket. Device was freed from the pocket. There is pus coming from the pocket which was irrigated & culture sent. Leads disconnected from old generator. All 3 leads were able to be easily removed with placement of stylette and retraction of the screws with gentle traction. The upper pocket incision was then. Access obtained to left IJ under ultrasound guidance with placement of guidewire. A 6 French peel-away sheath was then advanced over which a Boston Scientific pacing lead was advanced to the right ventricular apex and secured with active fixation. The explanted generator was then cleaned and attached to the lead and the atrial port. The RV and LV port were then plugged with pin plugs. Externalized device and lead used to continue backup pacing for a few days.

I am new to EP I currently have 33244, 33241. Would I also add 33234 since there were 3 leads removed, or since there was a new lead attached for the external device leave the 33234 off of the claim?

How would you code the following? Surgeon accesses right IJV, advances the sheath and performs a bilateral LE venogram. After diagnostic venogram, they proceed with intervention. Catheter is placed in IVC, then in RT CIV, LT CIV, RT EIV, LT EIV, RT common femoral vein and LT CFV; all with IVUS performed in each vessel. Compression is found in each vessel and measurements are documented. Surgeon decides to place stent in RT CIV, RT EIV and RT CFV. I am coming up with 37238-RT, 36012-RT, 37252, 37253x5, 75822-59.

An AVF angioplasty and embolization was performed and provider queried because stenosis percentage was missing for intervention. The provider responded that the stenosis was greater than 50% but angioplasty was performed for low flow volume due to failure of maturation and treated with assisted maturation (angioplasty) to increase the diameter of the AV fistula to allow for access in dialysis and adequate flow volumes to achieve dialysis. The patient also underwent coil embolization to redirect outflow of the fistula at the same time to increase flow volumes in the distribution of access in the cephalic vein. When angioplasty is performed for this reason, is stenosis percentage still required in the documentation?

Facility charges only. Performed by CT Surgeon and Cardio Interventionalist in EP Lab. Pericardium retracted, exposed right atrium SVC and IVC. Exposed the pulmonary veins and posterior SVC. SA node mapped by CIV in baseline and on isoproterenol. Area marked and SVC RF ablation line with 2 burns above SA node, series of burns along the crista terminalis of RA. 3 burns places across the IVC RA junction. Elevated heart rate on isoproterenol so further mapping and RF ablation- 34 burns on CTI. 2 more burns at SVC RA junction. Further mapping by CIV as well as endocardial ablation via femoral access with RF ablation catheter. Due to cross-clamping of the patient's pacemaker leads during the SVC lesions, we performed testing both before and after the case. All lead parameters including impedance, threshold and sensing we restable both before and after. The patient's device was programmed to DDDR, 60-125 beats per minute at the end of the case. I am thinking 33265, 93631, 93286, 93623 for the facility charges. Please help!! Thank you in advance, you're the best!

1. Successful creation of a TIPS from (likely) the middle hepatic vein a branch of the left portal vein with placement of a 10 mm x 9 cm Viatorr stent graft, extended cranially with a Viabahn VBX 10 mm x 37 mm stent graft. The portosystemic gradient

decreased from 12 mmHg to 10 mmHg following placement of the TIPS.

2. Embolization of a large coronary variceal shunt leading to esophageal varices.

37182,37241,36012?

93656 vs. 93653. To save space, I am only including the actual ablation portion of the report. 

"Pt presented for atrial fib ablation. A complete 3D electroanatomic map of the left atrium, pulmonary veins, and region by the left atrial appendage was drawn with an Octaray mapping catheter. All four pulmonary veins were still electrically isolated from prior ablation. There was a fragmented signal anterior to the right-sided PVs and one lesion was placed here on the septal side. Some scarring was noted along the roof and inferior posterior wall of the LA, with a few areas of other scattered scarring. Next, using a thermocool Smart Touch ST SF DF ablation catheter , the roof line connecting the left and right superior PVs was reenforced. A floor line was created conecting the left and right inferior PVs. A "+" was created in the PW creating four quadrants, and fractionated signals were ablated within each quadrant. Entrance and exit block were demonstrated. A repeat map of the LA confirmed posterior wall isolation. All lines were then removed, and protamine was given."

From your seminars I've attended in the past, there is always a slide regarding physician documentation best practices. Regarding peripheral studies, one of the bullet points is to state reason for repeat diagnostic study such as: change in clinical status since prior study, prior study doesn't include the area of current interest, prior study was inadequate for visualization of area of concern, emergent transfer and images not available. Is there guidance on what time frame is considered a recent CTA/MRA/Angiogram? Within that certain time frame the physician would need justification for repeat diagnostic at time of intervention. There is a discussion amongst our team as to whether recent means within the past 1,3 or 6 months. As always, our team greatly appreciates your guidance.

What is the CPT code for transapical access for TEVAR with coverage of the left subclavian artery: 33880, unlisted, or something else?

PROCEDURE SUMMARY:

- Target organ: pudendal nerves

- Image-guided chemical ablation

Chemical ablation

Under CT guidance, the ablation needle was advanced and positioned within the target(s). For each target lesion, the needle was placed and repositioned as necessary to achieve the desired ablation zone. Contrast injection through needle: Performed, confirming extravascular position.

Ablation needles: 21 gauge Chiba

Target #1

Ablation position 1

- Volume of chemical (mL): 5

Ablation position 2

- Volume of chemical (mL): 5

Intraprocedural imaging findings: appropriately positioned needles in the pudendal canal.

Needle removal :The ablation needle was removed and a sterile bandage was applied.

Imaging following ablation

Post-ablation imaging: noncontrast CT

Post-ablation imaging findings: post ablation changes without complication.

Contrast

Contrast agent: Omnipaque 180

Contrast volume (mL): 8

Radiation Dose

CT dose length product (mGy-cm): 2208

Will this be coded as 64999? What is an equlivent procedure for billing purpose?

I know there's official guidance that states if both stereotactic AND tomo are used to only report 19081, and if it's just tomo to report 19499. What code would you consider for this excerpt below? I'm getting confused when a report states, "Mammo guided WITH tomo."

"TECHNIQUES: Patient was placed sitting upright and erect.  FINDINGS: Mammographically guided with tomosynthesis core needle biopsies of calcifications in the upper-outer quadrant of the anterior left breast. This was done with aseptic technique and local anesthesia, 1 percent lidocaine with bicarbonate. The breast was compressed in the CC projection and biopsy was from the superior aspect of the breast. A small dermatotomy incision was made. Twelve biopsies were done with the vacuum assisted 9 gauge Eviva needle. A top hat marker was placed at the site."

Can we report thermodilution code 93598 with 93594 and 93505 for a congenital heart biopsy case? I know we cannot report it with non-congenital heart codes 93451-93460; however, nowhere in the CPT Codebook says that it cannot be reported with 93505. Moreover, the CPT Codebook says to use 93598 in conjunction with 93593-93597. Now my question is, can it be reported separately with 93505 in congenital cases? Is thermodilution still considered part of 93505? I'm not talking about Fick cardiac output method.

The patient came in for AV graft(36830) along with basilic vein graft after a diminished distal brachial pulse. Would there be a separate code for the vein patch angioplasty?

"Following initial construction of a brachial–axillary left upper arm AV graft, there was a complete loss of left radial pulse and Doppler signal, as well as a diminished pulse in the distal brachial artery. Due to significant concern for ischemic steal, I elected to revise the graft with more proximal looped inflow. The arterial anastomosis was taken down and the brachial artery was repaired with a patch of neighboring basilic vein. New inflow was constructed onto the axillary artery adjacent to our venous outflow anastomosis and a second graft segment was tunneled in the more medial upper arm. The 2 grafts were anastomosed to 1 another, creating a looped upper arm axillary–axillary AV graft. Upon completion, there was a palpable thrill in the graft, an ongoing faintly palpable radial pulse, and a multiphasic radial Doppler signal."

How would you code for the central venogram through the central venous catheter and then the removal of the catheter? I was thinking of only using code 36598.

"The left neck was prepped and draped, and the anchoring sutures were removed. The indwelling catheter was retracted into the peripheral aspect of the left brachiocephalic vein, from which a central venogram was performed. Imaging showed no central venous stenosis or central venous mural thrombus. It was felt that this patient would best be served by placing a Quinton catheter in a different location (reported separately). The Quinton catheter was then removed, and manual compression achieved hemostasis."

Is 37238-RT, 37239-LT, 37239-LT appropriate?

64% compression in the right common iliac

58% compression in the right external iliac

57% compression in the left external iliac

60% compression in the left common femoral

Stent to the right CIV that covered the compression of the right EIV

Stent to the left EIV

Stent to the left CFV

IVUS shows separate compression of the left CFV.

Insurance has denied 37238 for modifier. "After review of the medical record, bilateral stent placement in the lower extremity venous system was supported. There is a more appropriate modifier available."

I know these two codes bundle, but are they billable together same side when cervical and cerebral artery stents are placed?

Angioplasty and stenting of left internal carotid artery origin with distal embolic protection

Angioplasty and stenting of the intracranial left internal carotid artery petrous/lacerum segment

How would you code decannulation with vein repair? 33969 says cannulated vessel repair is included, but the provider feels it should be coded separately for additional work.

"The incision was carried down to the level of subcutaneous tissue using electrocautery. Fibers of the SCM muscle were then divided longitudinally to allow access to the IJ and the cannulation site. Once the cannulation site was exposed, we placed stay sutures using 5-0 prolene at the 12 o clock and 6 o clock position to help with retraction. With manual pressure being held proximal and distal to cannulation site, the cannula was withdrawn slowly in its entirety. The cannula was then passed off of the field. With the venotomy visible, we performed a venorrhaphy using 5-0 prolene in a running fashion. No obvious bleeding from the venorrhaphy was visible after pressure was relieved at proximal and distal ends."

When would it be appropriate to bill a wound vac on the same day as a skin graft application?

Would coding be 36247 (rt hepatic) and 36248 (Segment 8) for the catheter placements only or 36247 only for the below? I am having trouble with the catheter selection is segment 8 going further or an addition placement? A mesenteric catheter was used to select the celiac artery. An arteriogram was performed demonstrating the origin of the right hepatic artery. A microcatheter was used to select the right hepatic artery. An arteriogram and cone beam CT were performed demonstrating tumor enhancement from the segment 8 artery. The microcatheter was used to select the segment 8 artery. An arteriogram and cone beam CT were performed confirming tumor enhancement. The tumor was embolized with 0.5 mL lipiodol. A completion non-contrast cone beam CT was performed confirming adequate tumor staining. I appreciate your help with your this question!

Due to the fact that it was obvious that the distal aorta had to be dilated an angiogram was first obtained with the finding of the renal arteries to be higher than the area to be treated and therefore, the wires were placed on both sides. Next we dilated the area of the distal abdominal aorta to be able to place the stent there, which was an 11 mm across and 39 mm long. The wires were still both inside that stent and therefore, both of them were to be used to place the stents into each of the iliacs on each side, and both had to be simultaneously inflated. Once the stents were placed on both sides in the form of kissing stents, the patient had an angiogram done, which showed no obvious extravasation. the 8-French sheaths were used on both sides to make sure that upon injection of the sideports, the internal iliacs were not involved. Given the fact that the angiogram was acceptable, the patient had Perclose devices placed . Considerations: 37221-50, 37236 (stenosis bridging?) vs. 34701 or 34703, 37221-50 treatment of dissection or stenosis?

If the providers are performing a puncture aspiration of the breast (19000) stating with "mammographic or stereotactic guidance", what codes would you suggest to capture the guidance? We can't report 19081-19082, 19281-19284, as they are not using any localization devices and no biopsies are being performed. I understand that a mammogram could be done in advance or post-op, and in those cases a mammogram code could be used. But the provider is calling this mammographic or stereotactic GUIDANCE.

Would you charge 20550 or 20551 for the following?

"Ultrasound identified the biceps groove, and with transducer in a transverse view, an access site was selected. 1% lidocaine was administered for local anesthesia. 100 mg Solu-Cortef with 3 mL 0.25% bupivacaine were injected into the bicipital groove immediately deep to the biceps tendon."

From my research the bicipital groove is the place where the long tendon of the biceps brachii muscle passes through.

I am getting an edit that code 75561 is allowed with 76376 or 76377 but only with a modifier. Complete documentation is missing, but I want to check if the reconstructions are inherent in the cardiac MRI, before I query the physician. Thank you.

"TECHNIQUE: This examination was performed at UCI inpatient imaging facility on a Siemens Avanto 1.5T MR scanner. Axial truFISP survey of chest , multiplanar truFISP cine SA, VLA, HLA, LVOT, AV, phase contrast imaging through AV and multiplanar inversion recovery images were obtained at 10 minutes post contrast administration to assess for delayed myocardial hyperenhancement were performed. A total 18cc of Gadolinium contrast agent (MultiHance) was given without adverse effect. 3D post-processing was performed using a special cardiac software."

The patient was born with hypoplastic left heart syndrome who underwent staged palliation including Norwood/Sano, bidirectional Glenn anastomosis, fenestrated extracardiac conduit Fontan procedure, stent placement into Fontan fenestration and subsequent balloon angioplasty of stented Fontan fenestration and left pulmonary artery stent placement. She has plastic bronchitis and was scheduled for lymphatic imaging and possible occlusion of abnormal lymphatic collaterals to the lung. Transient balloon occlusion of Fontan fenestration was needed because of open fenestration with potential for right-to-left embolization of lipiodol droplets.

6F balloon wedge catheter was inserted thru right femoral venous sheath, advanced to extracardiac conduit and manipulated across stented Fontan fenestration. Transient balloon occlusion of Fontan fenestration was performed twice by interventional cardiologist during IR lymphatic procedure with lipiodol injection. I'd like to know how to report balloon occlusion of Fontan fenestration for facility and physician billing please.

Our doctor did a multiplane fluoroscopy of the mitral and aortic mechanical valves to assess motion with image X-ray interpretation, and X-ray data fluoroscopy time 0.2 minutes with a dose of 47 mGy dose area product of 9.44. since the doctor did not mention chest x-ray (how many views). Regarding a doctor who does both the mitral valve and aortic valve, can we use 76000 x 2?

Would 93567 be used here? PVI was performed. During isolation of the right sided PVs right phrenic nerve pacing was performed throughout ablation to ensure intact right phrenic nerve conduction. Right superior PV ablation had to be aborted due to transient right phrenic nerve palsy. The flexcath was exchanged back over the wire to the veracross sheath & repeat EAM was performed. The RSPV showed a persistent connection to the left atrium, so supplemental RF ablation was performed after mapping out the position of the right phrenic nerve. Ablation was successful in achieving PVI for Afib. Would this be considered part of the 93656 and no additional code would be supported? Would the physician have to state that a remaining afib was treated to support the additional code? Thanks!