Ask Dr. Z

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!

You answered a question in 2011 regarding -RT and LT modifiers being appended to lower extremity interventions (CPT codes 37220-37235). There was a disclaimer that the question was answered in 2011 and the answer may have changed. Have there been any updates to the guidance you provided? At the time you said no but should check with the payer. Thank you in advance for re-visiting this question.

MD performed debridement of three separate lesions of the lower leg. 1) Debridement including muscle and tendon 8 x 4 cm lesion.  2) Debridement skin & muscle 6 x 3 cm lesion. 3) Debridement skin & muscle 11 x 9 cm lesion.

Do we code 11043 x 3 for each lesion with 11046 x 4 or 11043 x 1 and 11046 x 6?

"The endograft was placed in the main body and two iliac components. Under angiographic imaging, I noticed some larger lumbar collaterals and they were marked as our limit to IVC coverage with a covered stent. cc x 7.5 Enodlogix infrarenal endograft was deployed within the IVC stent overlapping the previously placed bifurcated endograft. Distal end was deployed immediately below the lumbar collaterals. The remaining infrarenal segment of sclerosis was treated with 18x100 Abre stent. The pararenal and suprarenal segment of IVC was treated with 36x80 Zenith dissection endovascular bare metal stent."

Please help. What all stents would be coded? Also, regular vein stent codes or is there a code set for endograft stents in the IVC and vein? I only see the EVAR codes for aorta and arteries.

Patient presents for a planned stent placement in the left external iliac vein due to a stenosis seen on a previous lower extremity venogram. Physician accessed the left common femoral vein and placed a stent in the left external iliac vein. Physician documented that stent deployed nicely and flow now open. Code 36005 is specific for injection procedure for extremity venography. What catheter placement code do we use in this case?

Left Femoral access was obtained; RT Common Iliac was imaged and the catheter would not advance further due to claudication. RT Anterior Tibial access was obtained; angiography was performed and the stented lesion could not be crossed. A third access was gained; antegrade of the RT Common Femoral Artery; to SFA where PTA was performed. The hospital is capturing: CPT-37224 only. Generally the catheter placements are bundled with the intervention; however here there are multiple access sites (3) obtained. Should the other access sites also be coded for RT Common Iliac and Rt Anterior Tibial and if so what CPT's would apply here? CPT-36247/CPT-36140 or just CPT-36140 times two? Thank you for sharing your expertise on this issue!

Patient has a previously placed EVAR device now with an endoleak of the iliac limb. An initial TEVAR was performed during the same session as delayed placement of an extension to the iliac. What would be the proper coding for this since code 34710 bundles with 33881?

Provider performs TEE on 11/15 but does not dictate/sign off on the report until 11/16. Is the probe placement (93313) billed on 11/15 and the (93314) Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); image acquisition, interpretation and report only and (93325) Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiography) billed on 11/16?

A surgeon who specializes in CT surgery places the VA ECMO cannula for pediatric patients, and then the cardiologist monitors the function of ECMO subsequently. Does the surgeon bill 33946, or is this the beginning of management for the cardiologist, which occurs on the same day that the surgeon has placed the ECMO cannula?

I have a portion of the surgery documentation below, and am wondering, based on what I have provided, if this would be CPT 33264?

PROCEDURE: CRTD generator replacement. CRTD interrogation and programming.

After local lidocaine infiltration, a 4 cm incision was made along the left deltopectoral groove. The subcutaneous pocket was opened with blunt dissection, and local hemostasis was obtained with cauterization. The CRTD generator and the leads were extracted from the pocket. The leads were disconnected from the generator. The underlying rhythm is AF. Sensing P wave 1.5 mV, impedance 400ohms. Sensing R wave wave 14.5 mV, pacing threshold 0.75 V and 0.4 ms, impedance 360ohms. LV epicardial lead pacing threshold 1.5 V and 0.4 ms, impedance 265 ohms.

A new CRTD generator was connected to the leads and into the pocket after antibiotic irrigation. An antibiotic envelope was used for prophylaxis. The wound was closed. Pacemaker interrogation showed stable RA, RV and epicardial LV lead measurements.

Is the use of fluoroscopic guidance required to report arthrography RS&I codes (e.g., 73040, 73525, etc.)? If the physician performs pre-injection x-ray for localization, inserts the needle intra-articularly and injects contrast, then performs post injection xray to identify/evaluate contrast within the joint and takes additional x-ray views in neutral, flexed and/or internal rotation for diagnostic interpretation, does this satisfy the "radiologic examination" component of the code description?

Patient arrived for AICD laser lead extraction with distal embolic protection, revision of pacemaker to AAI pacemeaker. Sentinel device was advanced through the radial approach to the ascending arch and under fluoroscopy. The proximal basket was deployed in the innominate artery. The distal basket was deployed successfully in the left carotid artery. Prowater wire was used for the advancement and monitoring. Device was secured. After the completion of the lead extraction, we were called into the Cath lab. Device position was documented by fluoroscopy, baskets were retrieved per protocol over a wire. Device was retrieved through the right radial sheath appropriately with no complication. The parentheticals for 33370 say to use with a TAVR code. What about when done during another procedure like this one? Unlisted 33999?

EIA, CF, DF, SFA were dissected free, vessel loops proximally and distally, branches, pulled taut. Cooley clamp placed on EIA, 11-blade used to create arteriotomy in SFA, carried proximally onto the CF to the proximal CF artery. Total arteriotomy was approximately 8 cm. SFA endarterectomy performed. Distal end points tacked down w/sutures. Iliofemoral endart performed. Eversion was taken more proximal to the arteriotomy and up to the clamp. Iliofemoral endart was completed. 8-cm long arteriotomy and 0.8 x 8 cm Bovine patch was sewen into place using suture x 2. Patch went onto SFA approximately 3 cm.

Dr. wants to bill all 3 Endarterectomies-his response- Separate skin incision or separate artery incisions? Each artery is distinct/separate from the other arteries. Difference in work between a single iliofemoral endart vs a iliofemoral, superficial femoral endart, and deep femoral endart is extremely significant. Easily double the time of the procedure. They are separate arteries with separate CPT’s. Please help explain, 1 or 3 to be billed out?

The CPT Codebook, under Diagnostic Studies of Cervicocerebral Arteries, states 36221-36226 include closure of the arteriotomy by pressure or application of an arterial closure device. In the paragraphs regarding 36227 and 36228, the includes lists are stated, and are identical to 36221-36226, except for not mentioning closure by pressure or device. Can G0269 closure device be coded separately with 36227 and 36228, or is it included there also?

Catheter guided thrombin embolization of bleeding right femoral pseudoaneurysm/retroperitoneal bleed - Ultrasound-guided right proximal SFA access with catheter placement in common femoral artery with thrombin embolization. If it is direct puncture for thrombin injection to femoral aneurysm we bill 36002 . For this catheter based thrombin embolization do we bill 36002 or 37242?

My physician is stating that 34101 should be used since the thrombectomy was done via a brachial incision rather than just 34111. Thoughts?

"There was thrombus that could be seen in all 3 of these vessels. I then pulled up on the vessel loops on the brachial artery. I removed the stitches that were in the brachial artery arteriotomy and I passed #3 Fogarty thrombectomy catheter proximally for approximately 20 cm and pulled the clot out of the brachial artery until I had pulsatile inflow. I then retrograde flushed with heparinized saline. I then placed a Yasargil clamp on the brachial artery. I then took the vessel loops off tension on the ulnar artery and I passed #3 Fogarty balloon catheter down the radial artery for approximately 28 cm and pulled out clot 3 successive times. The fourth time I did not pull clot back. I then flushed with heparinized saline, but did not re-clamp the vessel. I then passed a #3 as well as #2 Fogarty thrombectomy catheter down the ulnar artery for approximately 20 cm."

Can you explain under which circumstances you would choose 36215 over 36225?

In our recent example, the doctor documents that he "selectively engaged the left subclavian" during a left heart catheterization, would I use 36215 or 36225?

Thank you!

In one of our cardiology clinics, they are billing I50.1 whenever the provider documents "mildly reduced ejection fraction" of the left ventricle in the findings/summary/interpretation of the TTEs without any mention anywhere else of the patient having heart failure. Is it appropriate to bill I50.1 when they only say there's a reduced rejection fraction, but there's nothing else about heart failure in the report? I thought having that key word "failure" was required to qualify for a heart failure code.

For the cardiomems device 33289 i know the remote interrogation code is 93264. Our doctor performed reprogramming in person is the cpt code still 0417T. I can't locate any information. Thank you for your help,

Under CT guidance, cholecystostomy was placed. This was a 8 French locking drain. At the conclusion, the GB drain was at the GB margin. Sideholes were outside of the GB lumen. We were unsuccessful in repositioning in CT. Patient was taken to specials and under fluro the drain was removed. Yueh centesis catheter was placed over the guidewire and contrast injected into the gallbladder. Showed filling of the GB lumen showing irregular luminal features compatible w/gangrenous cholecystitis. There was filling of the cystic duct and partial opacification of the CHD. A new 8 French locking drain was placed over the guidewire and a more desirable position within the GB. The catheter was secured to the skin.

How would I code this? Do we charge 47490 with the exchange/replacement 47536?

If a cardioversion is performed at the start of an ablation prior to any ablation work, but we do not have separate consent/discussion for the potential cardioversion with the patient documented, is the cardioversion still separately billable?

If a patient has a stenosis in a lower extremity bypass, fem-pop for instance, and it is treated with stent or angioplasty would you code from 37236-37246 since it is not an 'artery' of the lower extremity? Or is the bypass now considered an artery of the appropriate territory and would be coded with 37224-37226? Thank you.

Dr Z in 2012 you answered this question can we code both biopsy and ablation on same lesion. Is your answer the same in 2023, if the results from the biopsy are used to make the decision to ablate then we can code both?

Hello! We have a case where a provider did two separate bypasses via 2 arteriotomies and 4 anastomoses off of one vessel (right external iliac). He begins the procedure with a midline abdominal incision, lysis several adhesions due to extensive scar tissue to locate the mesenteric artery. He creates an arteriotomy and a PTFE graft is sewn end-to-side fashion to the right EIA. The graft was tunneled to the level of the SMA and perform an end-to-end anastomosis to the common hepatic artery. An arteriotomy was made and placed a 2nd PTFE graft onto the EIA in the region of the pelvis creating an end-to-side anastomosis and this limb of the mesenteric bypass was then tunneled in this retroperitoneal tissue up to the level of the SMA where an end-to-side anastomosis was created. Provider is choosing codes 35632 for the ilio-hepatic bypass and 35633 for the ilio-SMA bypass. My question is - can two bypasses be reported off of one vessel? If so, are these the correct bypass codes? Also, are lysis of adhesions separately reportable?

"Midline sternotomy incision was made with removal of anterior mediastinal tissue starting from the diaphragm inferiorly, then dissected laterally as far as the phrenic neurovascular bundles , dissection continued over the innominate vein,, all venous attachments of the anterior mediastinal fat to the innominate vein were ligated, dissection then continued superiorly to the lateral horns of the thymic tissue. Of note the anterior mediastinal mass encroached upon the left phrenic neurovascular bundle as it crossed over the left pulmonary hilum. I did have to transect the thickened mediastinal fat at this point to preserve the phrenic nerve. Enlarged LN at stations 5 and 6 were removed."

We are thinking that this is a radical thymectomy and should be billed with 60522. But are unsure of how to code for the lymph node removal as this code is not a primary procedure for the add on code 38746.

Your 2023 Interventional Radiology Coding reference under Dialysis circuit intervention #10 advises “When imaging of the dialysis circuit is performed from a remote access (not via direct access of the circuit), use code 36901-52 (or -74 for hospital billing) as well as the remote arterial access catheter placement code (e.g., 36217 for right brachial artery injection of fistula when access is via the common femoral artery).” Based on recent advice in HCPCS Coding Clinic, they indicate modifier 74 should not be used if the intended px is performed. Your facility coding advice to use -74 doesn’t appear correct. However, uncertain if an unlisted code would be used or code i.e. 36901 with no modifier. What code would you assign if a cephalic vein fistula is accessed via the right internal jugular and fistulogram performed?

Our provider performed a balloon angioplasty on the superior mesenteric artery. CTA demonstrated a high-grade stenosis on a previously stent in the same SM artery. Our system is telling us that it requires a laterality modifier (which we have used in the past for upper extremity interventions). Being that in this case we have the balloon intervention in the superior mesenteric artery, we are seeking information on if possibly another CPT code is required or if a laterality modifier will be required.

I have a case where the provider attaches a Dacron graft to the carotid artery to use as a conduit to give me more length to deploy the two stents. Made an arteriotomy with an 11- blade scalpel in the carotid artery. I then shaped the end of the Dacron graft appropriately and did an end-to-side anastomosis using 5-0 Prolene. After the TCAR was performed and the flow reversal system was disconnected - the conduit was then controlled at the arterial anastomosis and transected the Dacron graft using 6-0 Prolene suture to oversew this graft. Would we use an unlisted code for the Dacron graft conduit or would this be considered bundled to the procedure? Thanks

We are getting conflicting information regarding pre vascular mapping prior to AV fistula. Pt presents to ASC for vascular mapping of bilateral extremities. IV access obtained in both hands, Arterial evaluation includes pulses, allen test and arterial size in radial, brachial and ulnar arteries. Vein mapping in Cephalic Vein, forearm, elbow, upper arm, Basilic vein, elbow and upper arms. Central Vein , SVC evaluated. Again this is documented bilaterally. Can we bill 93985, 93970, 36005, 36005-XS, 75822 and 75827. Thanks for your input

Dr. Z,

An SMA stenting was performed (documentation not included) then the attempted work in the celiac artery. 37236 for the SMA stent. We're considering 36245-74 but not certain that is the correct way to bill it. Please advise.

Thank you

1. Right common femoral artery percutaneous access

2. Stenting of SMA

3. Selective celiac artery catheterization

I proceeded with attempts at canalizing the existing celiac artery stent. Using several different catheters I was able to get the angled glidewire to engage the celiac artery. I was not able to get the catheter to advance more than 1 to 2 mm into the artery itself and there was a question of whether the guidewire was actually going through the interstices of the stent or through the end of the stent itself. The attempts at canalizing this were successful several times but I was never able to advance a catheter through the interstices and after 40 minutes of fluoro time had been used I ceased efforts at recanalizing the celiac artery. Therefore, the guidewire and catheters were removed.

We wanted to clarify. Patient came in for bilateral masses biopsy due to bilateral masses noted on diagnostic imaging recently. MD first performed targeted bilateral axilla ultrasound and findings are normal lymph nodes, no adenopathy, fluid collection or masses. Then bilateral breast biopsy under ultrasound guidance was performed followed by mammogram. Our questions are, can we bill 76882 -LT, RT for the bilateral axilla ultrasound. Also can we bill for mammogram as well? MD didn't specify what kind of imaging was performed prior to patient coming in for biopsy. Can we report 77066 for bilateral mammograms? Thanks!

Patient presents for PVI ablation for persistent A-fib. TEE is performed, and RT atrium is mapped. Next (before TS puncture or any ablations are done) "Left ventricuclar pacing and recording was performed via the coronary sinus... to augment hemodynamic stability as opposed to RV pacing and to provide catheter stability during atrial fibrillation." This sounds suspiciously like a supportive measure to me, rather than diagnostic. No findings from the LT ventricle recordings are documented in the report, and VT is not documented either, although the patient does have a history of NSVT. Do you believe that the text I have quoted supports reporting 93622?

"Localized prone CT scans were obtained through the left pelvic cystic mass in suitable left transgluteal entry site was selected, marked and prepped and draped in the usual sterile fashion. 1% lidocaine was administered and stab incision made with a #11 blade. Utilizing intermittent CT fluoroscopy, a 5 French centesis catheter was advanced into the mass with 20 cc of serous fluid aspirated, sent for cytology, as requested. There were no adverse incidence.

IMPRESSION: CT-guided aspiration of left cystic pelvic mass."

Would this be coded with 49180 or 10160? Diagnosis reported for biopsy would be the pre-procedure diagnosis or the post-procedure diagnosis per the pathology report?

We bill code 92921 often, and we always get denied because this is a status code B charge. We typically write off the charge when we get the denial, but is there a better work flow for this? How should we submit this charge on claim form 1500? Do we need to submit it with a zero dollar amount since we know we wont get paid any way?

Our physician does a pulmonary vein ablation followed by a bilateral carina ablation using "pulldown of the cryo balloon". Can we report code 93567? He does not indicate anything about the patient remaining in Afib. I am thinking we cannot charge.

Since there isn't a code for temporary PPM removal, how are we to code (or can we code) this since that is the only thing being done during the encounter (usually at bedside)? There seems to be some confusion among my providers because some are wanting to report code 33234, but I don't think we can do that since it's a "temporary" PPM lead. Any guidance to help with provider education would be most helpful.

Devices used - Bifurcated stent graft - Access sheaths (15F, 7F)- cutdown- Diagnosis is not aneurysm. Can we report w a non-aneurysm diagnosis? revascularizing the aorto-iliac bifurcation because of occlusive disease at the aorto-iliac bifurcation, using a single unibody device . There is no repair of the infrarenal aorta. 34705?

Are we allowed to perform carotid stenting by the new criteria after the decision memo was released 10/11/23? I cannot find an actual effective date change on the policy yet, so I wanted to make sure we were clear to stent by the new rules.

Question ID 5448 says report code 49406 for trans-gluteal approach. Code 10030 would be for a soft tissue drainage in the buttocks, not in front of the sacrum, which is in the pelvic cavity.

Question ID 8089 says The catheter must be indwelling for 49405, 49406, 49407, and 10030. Indwelling is not just a couple hours. It is intended as a long-term drainage (more than on a single DOS).

If 49405-49407 & 10030 must be indwelling and 10160 is for superficial / subQ drainage and 49083 is for ascites, and 50390 is for a cyst, what would be the appropriate code for when only a needle is used to drain a deep peritoneal fluid collection and no drain is left behind?

Example: US-guided and therapeutic aspiration of intra-peritoneal fluid collection around transplant kidney.

Local anesthesia was administered. .. ultrasound guidance .. 5 Fr Yueh advanced into the fluid collection with spontaneous return of fluid. A total of 65 cc of fluid was removed, a sample submitted for laboratory analysis. Hemostasis was achieved.

Thanks!

I have been asked this question many times, and there is always conflicting information. For remote and in office pacemaker, ICD, and LOOP recorders, which diagnosis codes do we use? I was taught to use the Z95 series codes; however, there are some sources that state to use the Z45 series codes. Can you clarify which is correct and the reasoning behind it please?

The patient has a Watchman fabric separation. Right thoracotomy, cardiac arrest, decision made to cover Watchman with bovine pericardium.--anastomosed around Watchman to cover completely. I can't find a code to describe this procedure, or a code close enough to use 33999.

When a patient comes in for a procedure related to a research study, say a biopsy or CVC placement, what diagnosis code should be first listed on the IR claim? Should it be Z00.6? Or should it be the diagnosis prompting the study?

Based on the description below, are the following codes correct: 93654, 93462, 93662)? 

"Right femoral venous access was obtained; catheter was advanced to the R atrium & ablation catheter was introduced into the R atrium to create geometry, then advanced to the SVC, transseptal access was obtained under ICE guidance; the PVC was mapped & localized to the anterior mitral annulus, lesions were successfully made."

The list of procedures performed indicates the doctor performed R & L ventricular pacing & recording, but when I read the report I can not find any reference to the ventricles. Any help you can give is appreciated.

Is partial anomalous pulmonary venous return or congenital pulmonary vein stenosis considered abnormal connections?

In spite of having all the correct wording to code 76937 and an understanding that lymph vessels generally code to venous, I do not feel that 76937 would be appropriate here for injection into the lymph node. Can you please clarify based on this documentation? They are injecting for lymphangiography.

"The vessel was sonographically evaluated and judged to be patent. Real time ultrasound was used to visualize needle entry into the vessel and a permanent image was stored. The lymphatic access was confirmed by slow infusion of lipiodol by hand. Intermittent fluoroscopic and spot images were obtained. Vessel accessed: Left inguinal lymph node."

I reported code 38790-50 for the bilateral injections performed.

Can we code separately for iatrogenic ASD closure when done in conjunction with MitraClip insertion (33418)? If so, do we use code 93580 or unlisted since it is an acquired defect?

"MitraClip device was prepped and advanced under the guide sheath into the LA. Proper adjustment was completed, and after several attempts the device was able to grasp both anterior and posterior leaflets of the mitral valve in a medial position. The device was closed and deployed successfully. The acquired ASD from the transseptal was felt to be large (19 mm) and noted to have significant L-R shunt. Decision was made to close the acquired ASD defect. A 37 mm Gore Cardioform ASD occluder was advanced and deployed under TEE and fluoro guidance with excellent result. No residual interatrial septal shunt."