Ask Dr. Z

I coded the following as 37238 and 37239 x 2. Was this correct?

"Indication/findings: Better visualized focal stenosis at the right transverse sigmoid sinus junction with long segment narrowing of the right transverse sinus and occipital superior sagittal sinus. Procedure: Stenting of the superior sagittal sinus was subsequently performed using a 6 x 40 mm PRECISE stent. Next, a 7 x 30 mm stent was placed across the torcula into the right proximal transverse sinus. Next, a 7 x 40 mm stent was placed into the right transverse sinus. Finally, a 8 x 40 mm stent was placed from the transverse to the sigmoid sinus."

Our vascular access team is looking into placing a PICC via superficial femoral vein (i.e., mid-thigh PICC). I'm thinking this is a central vein and would not be considered peripherally inserted. What CPT code would be reported for insertion of a venous catheter into the superficial femoral vein?

When plaque is excised from the common femoral artery walls using a scalpel before eversion endarterectomy, is it appropriate to report code 35371, or would I report unlisted code 37799?

Can you please help us understand which CPT code to use when they are performing a PET/CT brain with attenuation and correction for metabolic evaluation? Some references seem to direct us to 78608, but others seem to direct us to 78814 since it was performed with CT. What would you recommend using and why?

How would you code a right vrachiocephalic venogram?

"Access is on the right vasilic vein with catheterization of the right brachiocephalic vein. Findings: Patent RT BCV and SVC stent with no evidence of stenosis."

Would I code this as 36005-RT and 75820, or 75827?

A patient with recurrent A-fib undergoes PVI, as well as AVJ ablation to create complete heart block. There does not appear to be an NCCI edit between codes 93656 and 93650. May we report both of these? Or should we report code 93656 and 93655 instead?

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.

In September 2022, CPT Assistant gave the guidance to use 75774 for selective add on venography after a main vessel venography. As per AMA's proposed code change summery in September 2023, AMA accepted and revised the change, but it is going to be effective from Jan 2025. Should we start using this guidance as per CPT Assistant or wait till Jan 2025? Please advise. Thank you!

Our provider is requesting the correct CPT code for "performing a limited assessment of the abdominal veins by utilizing spectral Doppler images overlaid on grayscale images to obtain hemodynamic information. This does not typically involve arteries except in the kidney to measure resistive index."

We are a little stuck on the description of limited code 93976 stating BOTH arterial inflow and venous outflow. Does the "limited" portion refer to the targeted organ or part of the organ? Or is venous evaluation only enough for an otherwise limited study? We would like to confirm that reporting limited study, 93976, is appropriate when either arterial or venous evaluation performed.

Sometimes when I am coding LINQ placements (hosp OP billing), the provider lists a CVA or TIA as the only indication, and I presume they are looking for a latent, previously undetected arrhythmia. Then when I look into the patient history, I see that the CVA actually occurred 4-6 weeks prior to the LINQ encounter, and usually the patient has made a full recovery. The cath lab supervisor wants me to code these as an acute CVA from I63. She says that a history code like Z86.73 can never be used as a first listed diagnosis, but I believe that is actually an IP coding rule. Does Z86.73 support medical necessity for an OP LINQ placement?

Does this support code 93459? I don't see the graft selectively engaged.

"Under direct US guidance, access was obtained to the right common femoral artery with a micropuncture needle and micropuncture wire, and then a micropuncture sheath was placed. After that, it was upgraded over a J-wire to a 5 French sheath, and initially a JL4 catheter was used. We were unable to engage the left main coronary artery ostium. That catheter was replaced with a JL5 catheter, which was then engaged into left main coronary artery ostium. Multiple angiograms of left coronary systems were done. That catheter was then removed. Right coronary angiogram was performed with a JR4 catheter. Saphenous vein graft angiogram x2 was performed with that catheter, and the same catheter was used to place the catheter in the left subclavian artery. Over an exchange length wire, that catheter was replaced with a LIMA 5 French catheter, and left internal mammary artery angiogram was performed. Then, I went in with a pigtail catheter, and left heart cardiac catheterization was done."

Do you still recommend using code 37246 for lower extremity PTA for treatment of a thrombus? The physician documents a thrombus causing an 80% stenosis of the popliteal artery.

"There was separate thrombus resulting in 80% stenosis of the native distal (P3) popliteal artery and the tibioperoneal trunk. An additional 3000 the lesions were administered corresponding to a total of 100 units/kg. The lesion was angioplastied with a 3 x 200 mm followed by a 4 x 150 mm and a 4 x 60 mm Armada balloons. The final angiogram showed good results with less than 20% residual stenosis and only a minute amount of residual thrombus. The heparin effect was reversed with protamine.

Conclusion: This is a patient with acute thrombus of the native distal (P3) popliteal artery and tibioperoneal trunk treated with balloon angioplasty."

What is pass-through code to go with C1761?

The IR physicians are wanting to bill code 96365 for the prophylactic antibiotics done prior to procedure for lung chemoembolization. The IR physician places the order, but the RN (hospital setting) performs the administration and the IR physician isn't present.

My understanding this isn't a billable service for the IR physician even though they place the order. Can you please clarify or confirm? Thank you

Is it ever appropriate to report 76942 at the same session as 76937? (hospital/facility coding)

Example case in IR: Port-A-cath placement for cancer at same session as thigh muscle US guided core biopsy for soft tissue mass.

All required elements are documented for reporting ultrasound guided access for the port placement. Would it be appropriate to report 36561, 76937, 77001-XS (NCCI edit with 20206) for the port along with 20206 and 76942-XS (NCCI edit with 36561, 76937, 77001) for the muscle biopsy? The -XS modifiers clear the NCCI edits, but there is still the 3M edit stating, "Do not report 76937 with 76942." My rationale is that I'm reporting them for completely separate procedures performed from different access sites and performed on different anatomy areas. Is that the correct thought process for this scenario, or is it just a never ever report 76937 and 76942 together no matter what?

Patient presented with both AAA and iliac aneurysm. The physician placed an iliac branch endovascular graft in the internal and external iliac artery followed by an iliac extender graft. After this was deployed the physician started the AAA repair with a Gore main body with bilateral limbs. Would you code for the AAA 34705, iliac 34707, and 34709 since this was a completely separate repair from the AAA? If this repair had been performed with just an extension graft would you only use 34079?

Procedures performed were 37187 and 37212 with cardiopulmonary bypass for capturing thrombus in the filter. Would the cardiopulmonary bypass be included in the mechanical thrombectomy procedure since it was used as a filter to capture thrombus?

We have a patient who presented for Watchman procedure. The device was inserted, but "PASS criteria unable to be met despite repeat TS and new device: clinical decision was made to remove device". Would the correct code be 33340-74? Or 33340 with removal of foreign body?

On the previous day, patient was brought to cath lab emergently for STEMI, and an IABP was placed along with stents in LAD and D1. The following day, patient was brought back to remove the IABP and a relook at the left vessels; both stents are patent. We are billing for the 33968, but can we also bill 93454 for a relook with no new indications?

We have been coding sacrum biopsy as deep bone biopsy, as it is a part of a vertebral body. In May 2023 CPT Assistant, AMA is suggesting considering it as similar to a bone biopsy of a spinous process, which is superficial. But in Fall 2022, AMA is suggesting in their Clinical Examples not to use 0200T and 0201T codes in conjunction with 20225 when performed at the same time. So, AMA was considering sacrum as a deep bone in that scenario. What are your thoughts?

Please clarify catheter placements for a flossing technique access for example access into internal jugular vein and common femoral vein for snare for through and through. Would this be two catheter placements or one catheter placement of the furthest point? Depend on scenario? 

Findings:

Cholecystostomy tube evaluation demonstrates contrast filling around large gallstone. No opacification of the cystic duct. Extraluminal contrast through the drain tract exiting the skin.

PROCEDURE SUMMARY:

- Drainage catheter check under fluoroscopic guidance

- Additional procedure(s): None

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 with contrast injection through the indwelling tube.

- Initial imaging findings: Poor opacification of the gallbladder lumen. No opacification of the cystic duct. Extraluminal contrast along the drain tract, exiting the skin.

I am aware the removal was not done, so we can't code for removal but the cath check and contrast injection we can?

Would you suggest unlisted code 93799 or 33225-74? 

"The coronary sinus was cannulated with an EP catheter and a contrast injection through the sheath showed that the vessels were very tiny there was a lateral vessel and there was a middle cardiac vein however both were really timely. We were able to get out into the lateral vein with a whisper wire however the lead would not advance. Using a subselection tool we were unable to get the Glidewire very far past the mouth of the main body of the coronary sinus. Same thing happened with the middle cardiac vein. We can get to the septal portion of the middle cardiac vein however despite attempts a Glidewire and whisper wire would not advance out sufficiently to allow coronary sinus lead placement. All of the veins were very small and spidery. It was clear that a coronary sinus catheter could not be placed. The original device was left in place."

"Patient brought to cath lab emergently. A 100% occluded vessel was located in the LD, RC, and LC. Our culprit lesion was in the LD and treated with a stent. The LC was treated with an Aspiration thrombectomy of the OM2. No angioplasty or stenting was preformed in this vessel. Then the RC an attempted angioplasty was preformed since they were not able to cross the lesion they are planning on brining the patient back at a later time."

We know that the aspiration is included in the primary intervention of the same vessel. In this case would we be able to bill code 92941-LD with 93799-LC for the thrombectomy that was completed in the LC?

"Aspiration thrombectomy of OM 2. Thrombus was visualized in the distal arm to causing a 100% occlusion/TIMI 0 flow. Following the intervention of the LAD, the Choice PT was reintroduced and used to cross the thrombotic lesion. Aspiration thrombectomy performed using priorityONE 6 French aspiration catheter."

Need clarification on how to code the following: Our EP doctor brought a patient in for a CRT-D generator change. Patient has only two leads. One in the RV and the other in LV. Physician office thinks 33228 is more appropriate since there are only two chamber/leads used. I thought CPT assistant clarified that a multi-lead is system with leads in three or more chambers OR a CRT -device. Would 33229 not be the more appropriate code to use?

"After angiography hemorrhage was noted from the ETT. This was treated with frequent suctioning, PEEP, exchanging the ETT, reversal of heparin, nitric oxide, temporary RPA balloon occlusion (7mm diameter x 2cm long Tyshak 2 balloon with RLL wire position, this was the lung field where infiltrates were noted), and transitioning to a Servo ventilator. The decision to end the procedure was made. Serial ABGs and ACTs were repeated as the bleeding was controlled. Patient oxygenation was never poor but ventilation was and it slowly improved as the bleeding was controlled. We estimated EBL out the ETT of about 50ml. All catheters and right-sided sheaths were removed and hemostasis was obtained with direct pressure prior to the application of a Safeguard. The LFV sheath was exchanged for a 5 Fr x 8cm CVL, which was sterilely dressed." 

Looking for guidance on how to code the hemorrhage treatment and ventilator?

Our radiologists are sometimes doing a bone marrow aspiration along with a bone lesion biopsy. The patient is scheduled for a bone biopsy for FDG avid lesion (20220 or 20225), but during the biopsy he also does a bone marrow aspiration at the same site. Should this be charged/coded as 38222 or 20220/20225 based on the indication of bone lesion?

The patient has a gastric lap band with a port , they came to IR for an adjustment. The radiologist accessed the port on the band under fluoro and aspirated a small amount of fluid from the port to deflate the band. He is coding 76000 for the fluoro but what can we use for the access if anything?

How do you code conversion of a nephroureteral stent to an internal ureteral stent?

"The pre-existing left nephroureteral stent was injected with contrast, which demonstrates appropriate position of the proximal pigtail in the renal pelvis and the distal pigtail in the urinary bladder. A wire was advanced through the NU stent with the tip in the urinary bladder. Over that wire an 8 French x 24 cm internal ureteral stent was deployed with the distal pigtail in the urinary bladder and the proximal pigtail in the renal pelvis. Contrast was injected, confirming adequate drainage of the left renal pelvis to the urinary bladder. The cannula was removed.

IMPRESSION: Uncomplicated internalization of an 8 French x 24 cm internal ureteral stent."

What catheterization code would be used for the following? Is this considered non-selective or selective?

Access was obtained in the right axillofemoral graft near the anterior superior iliac spine with the underlying inguinal ligament and iliac crest available for compression, using a micropuncture kit. This was exchanged for a 6 French sheath over a Bentson wire. A kumpe catheter and wire were advanced into the subclavian artery and angiogram images were obtained.

Angiographic Findings:

- successful access of the right axillofemoral graft with acute thrombus

- Patent right subclavian, axillary, and proximal brachial arteries and main branches

- Acute thrombus throughout axillary graft.

I found a similar case on question ID 4047 but it is outdated (2012) with now deleted codes. Thanks!

Dr. Z - We have a case where the patient presented with acute MI. The patient was taken emergently to the cath lab. During the LHC, it was discovered the the patient had 100% occlusion in the mid-RCA secondary to ISR, duration of occlusion unknown. The patient also had 99% mid-LAD stenosis. We attempted intervention on the RCA CTO, using a Pilot 50, but the wire was going into the subintimal space, and further intervention on the CTO was stopped. Attention was turned to the LAD, and PCI/DES was performed. I bill for the hospital side. Would we code this as an attempted CTO, 92943-74, RC and C9600-LD, or would the hierarchy rule not apply since the patient was taken emergently to the cath lab for acute MI, making our codes C9606-LD and 92943-74? Thank you.

We performed a PVI ablation for atrial fibrillation. Following the PVI, we ablated the floor line and roof line (box set). “During this, the patient went into atrial fibrillation." Next, we performed a vein of Marshall ablation on the “mitral isthmus flutter”, followed by a CTI. We think this is coded with 93656 (PVI), 93657 (box set), and 93655 x2 (VOM for atrial flutter and CTI). Do you agree with these codes?

FINDINGS:

1. Injection of the right inguinal lymph node demonstrates connection and leakage into the space surrounding the JP drain in the right lower quadrant. Glue/lipiodol was injected, which filled up two of the afferent channels from the accessed lymph node.

2. Images from the catheter injection demonstrate no significant cavity.

3. The catheter was draining clear straw-colored fluid.

Impression: Lymphatic leak into the space surrounding the the right lower quadrant drain status post successful lymphangiogram with glue embolization, drain exchange, and alcohol sclerosis of the space surrounding the drain.

I have coded 37244, 38790, and 49423. I am hesitant to report code 49185 because it sounds like one site that is communicating, and there is an edit between codes 37244 and 49185. Would it be appropriate to report code 49185 with a modifier here?

Can they bill C-codes if provider using this equipment at the hospital, or can they only be billed by provider when he owns obl?

MD states "flow reversal" is the distal embolic protection when I emailed for clarification:

Procedure(s): Left carotid stent placement with flow reversal (TCAR).

He does not specifically dictate in his narrative distal embolic protection, but there is a supply used on the case. Does "flow reversal" documentation meet the guidelines to code 37215?

We were just recently made aware that code 75565 now has allowance to be billed more than once per session/encounter. CEU for this is 4 now, we just wanted to confirm this can be done for example twice per session/encounter if properly documented - as long as they are clear to the coder on which vessels were mapped that is the most important?

A question similar to this one was answered in 2012, and we wanted to see if there were any updates. The physician does a renal diagnostic angiogram from the main renal artery (36251). He then moves into two branches off the main renal artery for embolization of areas of extravasation (37244). Although the diagnostic angiogram was from the main artery, should we use code 36253 instead since the catheter was moved superselectively to do the embolization?

Does the report excerpt below support coding 93463 for the metabolic cart testing? Measurements obtained include right heart pressures, direct & indirect FICK and thermodilution measurements, and additional stats below after aforementioned measurements. Would the metabolic cart oxygen testing = 93463? (Unable to paste entire Hemodynamics due to character limit)

"A Swan-Ganz catheter was advanced to the pulmonary artery under fluoroscopic guidance and routine hemodynamic measurements were obtained (see below). A metabolic cart was used to measure oxygen consumption, which then allowed us to determine the exact cardiac output and index, rather than just using the estimate provided by the assumed fick (which uses a constant x body surface area to estimate the oxygen consumption) or the thermodilution (which can often times underestimate cardiac output in advanced heart failure, right heart failure, tricuspid regurgitation) methods.

PA Sat: 67 %

Systemic Sat: 98 %

Hgb: 12.5

Oxygen consumption: 335 ml/min

Inotropes: None"

1. RT brachial artery open exposure. 2. RUE angiogram. 3. RT subclavian artery pseudoaneurysm repair with a covered Viabahn stent. Incision made on medial aspect of RT arm. RT brachial artery dissected out and encircled with vessel loops. Direct needle access gained into the RT brachial artery with placement of a sheath. Kumpe catheter was advanced to the level of the RT subclavian artery where angiogram was performed and confirmed CT findings of RT subclavian artery pseudoaneurysm. There appeared to be a 3-4 cm segment proximal to the pseudoaneurysm as well as a landing zone proximal to the RT vertebral artery. I passed a 11 x 5 cm Viabahn covered stent and deployed this just distal to the origin of the RT common carotid within the RT subclavian artery. Angioplasty was performed and imaging demonstrated no endoleak. 

Is this considered an open procedure and coded with 37799 (with comparable code 35011 since there is no CPT code for open subclavian artery aneurysm repair via brachial incision) OR an endovascular procedure with 37236 and 36140? Thank you!

Can you please tell me what code(s) this would be, as I am leaning toward an unlisted code 22899?

Dx is lower back pain

TECHNIQUE:

After obtaining informed consent and performing an appropriate timeout, the area overlying the lower back was prepped and draped in usual sterile fashion. The skin overlying the interspinous processes of L3-L4 and L4-L5 were anesthetized. Using a 22-gauge needle interspinous access was gained in both levels. An injectate which consisted of 80 mg of Kenalog, 2 mL of 0.5% bupivacaine, was injected into both spaces. The patient tolerated the procedure well and left the angiography suite in stable condition.

FINDINGS: Hypertrophy of the posterior spinous processes

IMPRESSION: Successful L3-L4 and L4-L5 interspinous blocks.

I have a question about billing CPT code 51600. Our provider documented “pre-existing suprapubic Foley catheter, approximately 250 cc of Cystografin was instilled by gravity drip into the urinary bladder”. In a follow-up email, the provider also stated they evaluated the anatomy post administration. Is this enough to code 51600, even if a -52 modifier is needed for us not placing the catheter? I have seen in earlier Q&As that “gravity technique is a common method of contrast instillation into the bladder”.

My facility is working on building a charge for C9780 from the Surfacer System. It appears that for the Inside-Out approach, they are recommending a combination of 36010, 75825, 75827, and 76937 to capture the entire procedure portion of the service for non-medicare payors. Our concern is that the charge amount of C9780 vs. the other four will result in overcharging our commercial payors. Can you please advise if those four codes would be the equivalent of C9780?

https://wellspan.file.force.co...

Would this stellate ganglion cryoablation be reported with 0442T for cryoablation nerve plexus or other truncal nerve or unlisted 64999?

"STELLATE GANGLION ABLATION: The patient was positioned supine with head tilted to the left. Initial CT/US imaging was performed to identify and localize the region of the left stellate ganglion. Under continuous ultrasound guidance, the region of the left stellate ganglion was approached with a 17G IceSphere Cryoablation probe by traversing the region between the right jugular and carotid artery and the right vertebral artery. Location was confirmed with CT. A single 8 minute freeze cycle was performed, with CT images obtained at 7 minutes, followed by passive thaw. The probe was removed, and post-ablation CT images were obtained."

Physician performs a limited TEE CPT 93308-26 with 93325. On same day at different session physician performs a complete TEE with Doppler and color flow (93306-26). How should 93308-26 with 93325 be coded? I can use modifier -59/-XE on 93308-26, but what about 93325? Since it is an add-on code, guidelines state no modifier usage on add-on codes. How should this be coded?

Please clarify if documented as axillary tail mass the biopsy code would be 20206 and would be 38505 if axillary tail lymph node, or should axillary tail mass be coded as a breast biopsy ex 19083?

Would you clarify the documentation required for CPT 93880 - duplex extracranial complete bilateral study? Is documenting the common carotids, internal carotids and veterbrals enough or do we also need the externals. Since the CPT description states "complete bilateral study", would that not mean that all the extracranials should be documented and not just a few? We have conflicting guidance and would appreciate your input.

"Under CT fluoroscopy, the stomach had transited and now entirely draped in nodule and there was no longer a window. At this point we decided to abort the procedure."

Sedation time was only 7 minutes so unbillable.

We billed the CT guidance only. A coding auditing program is advising that we also bill 49180-74. Since the conscious sedation was unbillable, would this be correct?

The initial intention was to place a ND/NJ tube. However, the tube wasn't able to be manipulated into the duodenum, only to the stomach. In this case, I know we shouldn't code the 44500, 74340 due to the tube not reaching the duodenum/jejunum but would instead go with 43752. The issue is, it's an APRN-CNP placing the tube, and the description of 43752 is strict and clear about it needing to be placed by a PHYSICIAN. How would you recommend coding this? 44500-52, 74340-52 crossed my mind, but wasn't sure.

"Indication: Traumatic subdural hematoma.

Under fluoro and roadmap guidance, Prowler Select microcath advanced over Synchro Select 0.014 microwire into parietal branch of the RT MMA, distal to foramen spinosum, images obtained in biplane projections. Angiogram shows normal antegrade flow w/ no evidence of intracranial anastomosis and no opacification of RT ophthalmic artery or RT retinal blush. Tortuosity in proximal frontal branch of the RT MMA, cath not attempted due to concern for inadvertent embolization of central retinal artery. Under blank roadmap 100-300 micron Embospheres, mixed w/ contrast, injected w/ progressive occlusion of parietal branch of RT MMA. Under blank fluoro & roadmap, microcath slowly flushed w/ heparinized saline. Under fluoro guidance coils deployed into main trunk of RT MMA w/ progressive occlusion."

61626 vs. 61624? I say 61626 due to dura encasing CNS by definition and not CNS from coding description for 61626 also MMA is part of extracranial branches, so non-CNS. Do you agree?

I'm not a vascular coder so I need some help. Doc intended to do a coronary PCI but pre-op angio demonstrated extensive femoral disease and cath was not able to be advanced, so doc did diagnostic angio in the femorals. He accessed the right femoral and shot vessels, then accessed the left femoral and shot the vessels. For some reason I'm thinking 75716 would be used if the dye was shot above the aortic bifurcation. So, since doc assessed the right and left separately, we should use 75710 x2. Yes? No?