Ask Dr. Z

Since combining image guidance with interventional procedures into a single code has become a trend, is the US guidance documentation such as "permanent image recorded" required for both the combination code and the individual image guidance code? For example: Breast biopsy under US guidance (19083) vs. puncture aspiration of cyst of breast under US guidance (19000, 76942). Or, because US guidance is built into 19083, it isn’t required to state "permanent image recorded", whereas in contrast 76942 is an individual code and it is required to state "permanent image recorded"? Please help.

I'm unsure how to code this. I need your expert opinion. "Preop and Postop: Vascular mass right forearm. Procedure: Excision mass right forearm. Patient brought operating room and placed supine. Right arm prepped and draped usual fashion. Incision lines made to resect mass and large area block 1% lidocaine installed. Incision created sharply with scalpel and carried down through skin and subcutaneous tissue. Sharp dissection used free up mass circumferentially. It was removed en bloc with skin attached.It appears to be venous aneurysm off basilic vein. The inflow and outflow vein were ligated and mass removed in its entirety. Hemostasis achieved in field and wound closed 3-0 Vicryl followed by 3-0 nylon."

How can code 50433 be used when it says new access? This patient had removal (50384), and they are using the same access to put 50433. Please advise. 

Should anything be charged additionally for the placement of a His bundle lead? I was told that HRS may have come out with a position statement that something additional should be billed, but I cannot find any documents from them on that. I enter facility charges for a hospital.

Can code 76937 be billed for Swan-Ganz placement during a CABG?

If an evaluation of a required element per CPT coding guidelines (LV, RV, LA, RA, TV, MV, AV, pericardium, and portion of aorta adjacent to the heart) has not been documented in the final report (nor the attempt to evaluate), then should a limited study be reported? If not, then why should a complete study be reported and how is the determination made of "does the documentation support a complete study"?

How would you report the following central venous access procedure? Would this be central or peripheral due to temporal access? Also, why might the provider consider this unsuccessful if the tip terminates in the SVC? "Central Line Procedure Note. Patient Age: 7-weeks-old. PICC - PEDIATRICS. The patient was positioned supine. This procedure was performed under sterile conditions. The catheter was cut to cm. The 26 gauge catheter was inserted into the right temporal vein. We advanced the single lumen PICC catheter to cm at skin entry level and secured in place. All ports were flushed with saline at the end of the procedure. Blood return was noted. A sterile dressing was applied. Line placement was not successful. Tip location terminates in the inferior vena cava (line insertion unsuccessful). Ultrasound was not used during this procedure. Additional Details: Results: Line unsuccessful. Both right and left temporal veins accessed, but unable to pass the catheter. Recommend escalation of PICC line placement to IR."

Diagnosis is retinoblastoma, and patient was brought in for intra-arterial chemotherapy. "Angiogram was done: Left carotid artery injection, superselective left ophthalmic artery injection. Intra-arterial chemotherapy was injected with 5 mg/30 mL Melphalan over 30 minutes into the left ophthalmic artery." Can I report code 61650 for the chemo infusion?

"Left M2 thrombectomy was performed via a left direct common carotid artery puncture due to not being able to selectively catheterize left internal carotid artery from femoral artery access. Additionally patient was taken from the angio suite to operating room for closure of the carotid artery." Would this be reported with code 61645 as well as an additional code for repair of carotid artery? Or should an unlisted code be reported?

Is the medial meningeal artery considered intracranial, and would the correct CPT code when capturing this procedure be 61624 when a transcatheter embolization is performed?

An echo (93306) was done, and the findings were "structurally normal heart". The only reason the patient had the echo done was because there is family history of heart disease. Is it appropriate to only code Z82.49 for this study?

I wanted to ask about the CPT code update for breast MRI for 2019. The one thing I notice with regard to the descriptors is that the new codes describe "without and with contrast", but do not seem to make allowance for "with contrast" alone, whereas the old codes (77058 and 77059) described "without and/or with contrast". Am I misinterpreting this to mean that there isn't a way to report a study for this where only contrast is used, and not "with and without" contrast? Also, CAD is only applicable with use of contrast materials? Does this align with current practice?

"Patient had a previous PVI performed over 6 months ago for I48.0. Since patient was still having symptoms, he was brought back in again for EP study and RF ablation for electrical isolation of superior vena cava and inferior vena cava with additional ablation of coronary sinus (where fractionated electrocardiograms were detected in the distal region). ICE was performed with transseptal cath and 3D mapping, as well as treatment with IV Isoproterenol. A deflectable decapolar catheter was positioned in the coronary sinus. This was used for pacing and sensing from the left atrium." Would this procedure be reported with codes 93653, 93621, 93662, 93462, 93623, and 93613?

Is there a CPT code for graft flow analysis (GFA) with CABG, or is just part of every CABG? My provider just recently started listing this as a procedure along with the CABG.

What is your recommendation for the 2019 midline catheter exchange CPT code?

Surgeon does cutdown to expose the artery, and the cardiologist sticks the artery and inserts the sheath, through which the TAVR is completed with no complications. We are having a debate about this being open (33362) or percutaneous (33361). We are coding for the cardiologist, not the surgeon, and it looks like there are a lot of opinions about this. But, if you get it wrong, you could set up an overpayment situation by Medicare.

Dual PM upgraded to biventricular pacemaker. The LVL was placed but was unsuccessful and was removed. The doctor placed a lead in the bundle of His in the RV. How would you code this?

I know that we are to code only one base intervention per main vessel, and then up to two branch interventions off a base. However, I'm not sure if I can code two interventions here. A DES was placed in the mid RCA (C9600-RC) for an 80% stenosis, and then there was a 70% stenosis in the distal RCA extending into the PDA. A stent was placed in the distal RCA and covered and extended into the PDA portion of the stenosis. It looks like it was a contiguous lesion. So would the stent extending into the PDA not be coded since the lesion started in the main RCA? Or since it extended into the PDA, would that count as a branch intervention and be coded C9601-RC?

This patient had "near occlusive" blood flow around the Impella. Rightt SFA and pop angiography. Antegrade sheath insertion in right SFA under USG guidance with connection to left common femoral retrograde sheath creating a left to right external fem-fem bypass. Unlisted CPT?

I read some recent material that midline catheters by definition terminate in the peripheral venous system. They are NOT central venous access devices and may not be reported as a PICC service. Currently we charge insert PICC without port or pump (also for midline) (36569).

The coding guidelines for the new 2019 PICC line codes (36572 and 36573) say to append modifier -52 when performed without confirmation of catheter tip location. Can you give an example(s) of when a PICC line is placed without catheter confirmation of tip location?

How do you code an open removal of PleurX catheter? "The previously placed cuff had been removed, and an incision was created over the xiphoid process through the previous incision and secured to the skin with electrocautery, and the PleurX catheter was palpable from the inside. I cut down onto the catheter, followed this up to the undersurface of the sternum where it was firmly adherent with scar tissue. Once the scar tissue was freed up between the catheter and the sternum, the catheter was able to be easily removed from the pericardial sac. The catheter was flush with the subcutaneous tissue, and the wound was then closed in multiple layers of Vicryl sutures. The remaining portion of the catheter was then removed percutaneously. Dressings were applied."

For the following, should the angioplasty be charged separately? "RPA Stent: The RPA was entered using a 7 French wedge catheter for a placement of a 035 Amplatz SS wire. The sheath was advanced to the proximal RPA. The distal RPA measured 15 x 13 mm, while the area of stenosis measured 13 x 14 mm. Therefore, the decision was made to implant a 16 mm ev3 26 mm stent over a 16 x 3 BIB balloon. After verifying the stent position by performing a test angiogram through the sheath, the stent was deployed at 5 ATM. RUL Balloon Angioplasty: The RUL segment was being overlapped by the RPA stent. In order to preserve good flow to the RUL segment, the RUL was entered using a 014 Whisperwire over a 7 French wedge catheter. The wire was exchanged to a 018 V-18 wire for balloon angioplasty. An 8 x 2 Advance LP balloon was inflated across the RPA/RUL junction x 2 to 8 ATM. Post angioplasty angiogram showed widely patent and unobstructed perfusion to the RUL segment." 

The 93010 is often done prior to procedures by our cardiologists. We often see it when a patient has an urgent or emergent cath performed. We see it before and after the procedure. Also on any device implants and ablations. There is an NCCI edit for these codes as well. There have been more than one discussion on if and when the 93010 can be billed separate with a -59 modifier and there have been different answers. There has been some opinion that these should be considered surveillance not diagnostic. I have not been able to find an actual policy or protocol on this subject. I was wondering if you could help with this 93010 coding issue.

Patient in for right and left heart catheterization. 93460-26 and 99152. The patient became hypotensive and went to cardiogenic shock. She never left the cath lab and decision was made to do a repeat limited coronary angiogram to rule-out catheter-induced injury. Can 93454 be billed with the initial cath?

Patient with retinoblastoma. Physician performs endovascular prolonged administration (more than 10 min) of chemo into ophthalmic artery. However, the ophthalmic artery originates off of the external carotid. Would it be correct to use code 61650?

Patient with history of PVI six years prior has developed atrial flutter with rapid ventricular response. Entrainment mapping confirms CTI dependent right atrial flutter, and this is ablated and restores sinus rhythm. Physician then proceeds to do transseptal puncture and check pulmonary veins are isolated. Right side is found to be re-connected and is re-ablated. No mention of any a-fib, only a-flutter in report. Is this re-isolation of right side PV reportable as PVI, or is it 93655 since no documentation of atrial fibrillation?

What are the documentation requirements for duplex scan of scrotum? The reports I am getting state, "Normal perfusion with Doppler is noted." And the conclusions state, "Normal testicles with normal flow maintained." I do not feel this is sufficient documentation. Please advise.

We need clarification of the new 2019 codes 50436 and 50437. At our hospital, the urologists refer patients to the interventional radiology department to place a 5 French catheter percutaneously into the renal pelvis and down the distal ureter or a 7 French sheath into the renal pelvis with a wire into the bladder. The catheters are secured, and the patients are sent to the operating room. The urologist would then perform the nephrostolithotomy. We have been charging a nephrostomy placement in the IR department. And then the OR would charge for the dilation of the tract. Please clarify how we should charge for this with the 2019 changes.

What is the correct CPT code for nuclear medicine planar myocardium imaging for cardiac amyloidosis?

Prior to the recent round of code changes for AAA repair, we were able to use code 34800 for a short section of tube graft used without any other grafts and without fenestrations. Since that code has been deleted, should we be using code 37236 or an unlisted code instead?

"The patient arrived with a displaced jejunostomy catheter. Procedure plan is to manipulate it back into place. Patient's abdominal wall and existing J-Tube were prepped in sterile fashion. Using water soluble contrast injection, the jejunostomy tube was manually advanced as far as possible with continued injection to confirm placement into the small bowel. Patient was discharged in stable condition." Would you use codes 49999 and 49465?

Arrhythmia attempted to be induced after drug infusion. Since 93623 is an add-on code, what codes should be reported for the following scenario? "The patient was brought to the electrophysiology laboratory in a fasting, non-sedated state and connected to the electrophysiology recording system, and blood pressure and pulse oximetry were monitored continuously. Bilateral groins were prepped, and the patient was draped in the usual sterile fashion. Baseline rhythm was sinus rhythm. The patient was prepped and provided with mild sedation by Anesthesiology. Minimal PVCs were noted at baseline. Isuprel bolus and infusion were administered with no significant increase in PVC burden. Calcium and phenylephrine were also administered with no significant PVC increase. The decision was then made to abort the procedure. The patient was transferred to the PACU in stable condition. CONCLUSIONS: No PVCs at baseline and after administration of isuprel, calcium, and phenylephrine".

Abdominal aorta at level of renals was cannulated along with the superior mesenteric, celiac, and right and left renals, with the inferior pole branch renal angioplastied and the left main renal stented. I have 36252, 36245, 3624-59, 37246-59-LT, and 37236-LT, but I'm not sure if the PTA should also be coded, or the stent only. 

We had a TEVAR that had complications. Per procedure: "Upon removal of the stent graft, we encountered resistance. Reliant balloon was placed in infrarenal aorta to control bleeding." Quick summary: "Based on removal of external graft, there was injury to right external iliac, which ended up requiring stent grafting of the iliac artery and subsequent cutdown for ligation of right common iliac artery and fem-fem bypass." We coded as 33881, 75957. Would the extra work be considered billable as 37617, 34820, 34813?

Does atherosclerosis have to be stated in the documentation to use the I70.2xx codes (for lower extremities)? Or does "occlusion" suffice. I'm getting confused on when to code the I70.xxx vs. I73.9 DX. The radiologist placed a stent in the SFA in a patient who has PVD and occluded SFA.

“The revised NCD is retroactive to 02/15/18; however, the implementation date is not until 02/26/19, so the -Q0 modifier will be required until February 26, 2019.” Could you please clarify what retroactive means? What is required during the period between the retroactive date and the implementation date? Does it mean that we do not have to submit patients to the NCDR – ICD registry after 2/15/18? Or, do we have to submit these patients to the registry until 2/26/19?

"Right and left common femoral veins were cannulated antegrade fashion. 11 French sheaths were placed. 5 French multipurpose catheter and 0.35 wire were used and placed through IVC into the right atrium. Intracardiac echo catheter was placed through the left side. We went through into the right atrium and interrogated this. We identified the septum. A specific defect or tunnel was not initially visualized with color flow. We did not see a jet. Attempt was then made with multiple wires and a multipurpose catheter. We placed this up against the septum. At one point, the catheter did go out into the pulmonary artery. However, despite multiple attempts and actually placing the catheter directly on the septum, no defect could be identified. Contrast bubble study was then performed. Again, this was done directly with contrast injection into the SVC and right atrium. There were no crossing bubbles across. At this point, we were confident that there was no septal defect identified." Should we report codes 36013 and 93662-26 or codes 93580-52 and 93662-26? And why?

"Patient's chest was prepped and draped, and the CV surgery team opened the chest and placed a 5 French sheath into the RV apex under direct visualization. At that time, we took over advancing a .014 wire through the sheath into the left pulmonary artery. Pulmonary arteriogram was performed. Sheath position was then adjusted by Dr. M. Ventriculogram was then performed. Measurements of infundibulum, pulmonary valve annulus, and main PA were obtained. A 4-15 Multi-Link Vision coronary stent system was advanced over the wire and into place across the infundibulum and proximal main PA under fluro guidance. Further angios were performed to check device placement. The stent balloon was then inflated to 16 atm. Angiogram showed stent position. The balloon was removed over the guidewire. Follow-up ventriculogram revealed satisfactory stent placement in the RVOT with no residual narrowing. At that time we turned care back over to the surgery team who removed the sheath and closed the chest." Would unlisted code 33999 best describe this procedure?

Can 37246 be coded in addition to 36902 in this case, or is it part of the fistula? "POSTOPERATIVE: Flow dysfunction in left forearm radial artery to cephalic vein arteriovenous fistula plus greater than 70% stenosis of the left radial artery. PROCEDURES PERFORMED: 1) Retrograde needle access in the left cephalic vein with placement of sheath. 2) Selective catheterization of left radial artery. 3) Selective angiogram of the left radial artery with runoffs. 4) Angioplasty of the left radial artery. 5) Angioplasty of the left cephalic vein. DESCRIPTION: A needle was placed into the left cephalic vein retrograde. A wire was passed, a sheath was placed, and then over wire technique was used to place a catheter into the left radial artery. Left radial artery selective angiogram was performed with runoff showing a greater than 70% stenosis of the left radial artery and left cephalic vein. Balloon angioplasty was then performed in the left radial and left cephalic veins. Post angioplasty angiogram showed good results. No residual stenosis and good flow."

I would like some clarification on the use of modifier -Q0 and -SC for ICD implants. I was under the impression -Q0 was only for biventricular devices. SC is for all ICDs. I'm confused! Any help would be greatly appreciated! 

Is this considered TIPS revision? "Due to clinical concern for TIPS shunt physiology effect on cardiac status, along with no appreciable improvement from it with regard to the patient's ascites and hydrothorax, the TIPS was embolized with a 14 mm Amplatzer Plug Version 2, after which it didn't appear near occluded and is anticipated to go on to completely occlude. This should be confirmed with a Doppler ultrasound in a few days."

I am hoping you can provide further guidance on the use of code 93655. I understand that 93655 can be used when there are two different arrhythmias (e.g., A-fib and A-flutter), and when arrhythmias are ablated in different anatomical locations (e.g., right and left atrium). But I am unsure what other scenarios 93655 might be appropriate for. Sometimes our EP lab charges for 93655, but I am dubious about its use, based on the documentation. Are arrhythmia "morphologies" the same as "mechanisms" (the term used in the CPT book)? Example: If a patient has three VT "morphologies", all located on an inferior wall scar of the LV, how is the ablation of these coded? What about an AT originating from a non-coronary aortic cusp that's ablated, followed by repeat mapping and ablation of "another early area more lateral"? Can you shed some light on the type of documentation I should be looking for to support 93655?

What is the correct CPT code for renal sympathectomy with denervation? I am unsure of several codes - 50549 or 0338T, as the procedure is being performed for loin pain and hematuria. There is no mention of any mass.

We have been trying to decide how to appropriately bill for a stress echo when there are different supervising and interpreting physicians. They are from the same practice/specialty, but I am not finding anything definitive on how to bill. When Cardiologist A is supervising (overseeing both the stressing and echocardiogram) and Cardiologist B is interpreting, do we bill the following: Under Cardio A: 93351-TC, 93320-TC, and 93325-TC. Under Cardio B: 93351-26, 93320-26, and 93325-26. Or: Under Cardio A: 93351-TC, 93320-TC, and 93325-TC. Under Cardio B: 93350-26, 93320-26, and 93325-26? We are having conflicting views in our office as to how to bill and are wanting to verify the correct way.

My doctor performed bone marrow aspiration and biopsy (38222). This was done under fluoro. He also did a cone beam CT without processing on an independent station. I am unsure of what to use to bill for guidance. Would it be 77002 or 76380-59, 76376? Sometimes "spinning" CT is mentioned; I am unsure if 3D is meant.

If a provider inserts a prosthetic valve over an already existing prosthetic valve would you recommend coding 33418 or 0483T? The provider did not remove the old prosthetic valve before placing the new prosthetic valve.

Can you please advise as to billing 93622 (LV pacing) in conjunction with 93656 (PVI)? Although allowable, what documentation criteria is required? Physician dictation states: "The ablation catheter was then advanced across the septum into the LA. This was advanced into the left ventricle where LV pacing was performed and confirmed safe transseptal access with RBBB morphology on 12 lead." 93622-74, as only LV pacing was performed? 

For excision of infected bifemoral bypass graft, would 35903-50 be appropriate or just 39503? Bilateral stands out and I automatically want to apply the -50 modifier.

Is 36902 justified, or should we only report code 36901? Or is there another option? “A 7 mm x 2 cm angioplasty catheter was placed and the narrowings were angioplastied. No significant waist was noted suggesting that these relative narrow areas were folds or kinks in a redundant vessel rather than actual stenoses. Afterward, the fistula appears to have reasonable flow within it. Post angioplasty angiogram demonstrates mild improvement. Post angioplasty angiogram also demonstrates some spasm in the radial artery which should resolve over time. Left arm dialysis access study demonstrates a redundant section of cephalic vein in the juxta anastomotic location with relative narrow areas within it, most likely representing folding or kinking of the access. Angioplasty may have improved this area. If patient doesn't improve after procedure or if symptoms recur rapidly, consideration can be given to placing a covered stent in this region to smooth out the contour and prevent kinking. If long-term benefit from angioplasty is appreciated then repeat angioplasty."