Ask Dr. Z

Ask Dr. Z Knowledge Base houses over 7,000 coding questions and answers dating back to 2010.

Ask Dr. Z Disclaimer

Central Venous Access-Newborn Temporal Access

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."

Complete Echo

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"?

Ultrasound Guidance

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

His Bundle Leads

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.

50433

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. 

Excision vascular mass from forearm

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."

37607 Ligation or 36832 Revision w/o Thrombectomy

ESRD pt has a 36830 done outpt due to failed kidney transplant to prepare for new dialysis sessions. 2 days post op presents to ER with high output cardiac failure secondary to AVG and hemoptysis. Decision made to ligate AVG at bedside.duplex ultrasound at bedside identifies the proximal portion of the AVG, thrill palpable, 2 sutures placed resulting in a lesser thrill, but present. Flow reduced from 3.2L/min to 2.2L/min. A large pressure dressing placed. Pt then the next day is taken to the OR suite to have the "formal ligation" and the arterial anastomosis reopened, AVG identified and 2 staples applied the area then closed. Is it correct to code 37607-52-78 for the bedside and for the OR setting? Instead should only the OR session be coded as 37607-52-78 and the bedside as a 36832 revision of the AVG without thrombectomy since he used sutures to alter the AVG? Finally is it possible the bedside service is something else?

US guidance documentation

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.

Ophthalmic artery infusions

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?

Revision of Quad Graft

Patient comes in previous day and has a 4 branch graft inserted: proximal portion anastamosed end-to-end at the aorta, distal end anastamosed end-to-side to iliac artery. SMA, Celiac, & Bilat Renal arteries were transected an attached to the graft. Coded 35631 x1, 35631-59 x3; Next day bring patient back to the OR because they couldn't find pulses in the graft. They opened and performed a thrombectomy of each branch of the graft for all four arteries, but there was no thrombus. Thrombus was found in the trunk of the graft and they performed thrombectomy of that too. Still no pulse in the sma so they took down the sma anastamosis and found no thrombus so they re-did the anastamosis and had flow. So how do I code this? Treated as four bypasses like the insertion? 35876-78 (thrombectomy and re-anastamosis of the sma branch), 35875-78-59 x3 (for the other branches)? Or, since technically it's one graft, do I just code the 35876-78?

Embolization of the Medial Meningeal Artery

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?

Please assist with codes for baffle/re-fenestrate procedure-thanks!

A 5-French sheath was then ultimately positioned in the hepatic vein. Angiography was performed in the Fontan baffle. Similarly, a pigtail catheter was advanced, and in a retrograde fashion, entered the pulmonary venous atrium. Again, angiography was performed here to give us spatial orientation of the Fontan baffle and the pulmonary venous atrium. At this point, the hepatic sheaths were exchanged and a 6-French transseptal sheath was advanced into the Fontan baffle. Using again angiographic and fluoroscopic guidance, we were able to puncture through the Fontan baffle and into the pulmonary venous atrium. Once wire position was established, we sequentially dilated the tract with both static and cutting balloons. Ultimately, after multiple dilations, we were able to obtain access into the pulmonary venous chamber using an 8-French long sheath. Dr. X at this point took an unmounted Genesis 1910 stent, which was inflated to 5 mm, and a suture was placed circumferentially at that diameter. The hepatic tract was then closed with vascular plugs.

M2 Thrombectomy

"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?

Medical Necessity of CXR for MR when patient has ICD

I would like to know if the chest x-ray taken to verify intact leads, etc. prior to an MR is separately billable since the screening is required to meet Medical Necessity guidelines for the MR onpatients with an ICD or pacemaker?

Z82.49 Fam hx of ischemic heart disease

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?

Breast MRI

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?

Coronary Thrombolysis

The patient had coronary angiography, and a thrombolysis catheter was placed and thrombolysis initiated in the RCA on day 1. We billed codes 92975 and 93454 for this. On day 2, the patient was brought back to the cath lab. Relook was performed, a catheter was inserted into the RCA, and thrombolysis was continued. For this we billed 92975. On day 3, the patient was brought to the cath lab, and relook angiography was performed and the thrombolysis catheter was removed. How should we bill day 3 for the relook and cessation of thrombolysis?

2019 Midline Catheters

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

Graft flow analysis (GFA) with CABG

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.

33477 vs 93531

Doctor wrote these on the note -patient had ross-konno in 1994 and repeat RV-PA conduit 2008 with 24 mm aortic homograft PVR, he has been well.Echo has shown RVOT obstruction + conduit calcification, ct showed LAD about 5mm from conduit , patient was enrolled in the compassion ES3 study for Edwards PV implantation . No change in stamina , patient presents today for R-L heart catheterization and possible valve implantation . Then doctor wrote down-1. R-L heart cath be done , 2. Angiograph - PA,RV, coronary artery, femoral artery, aorta. 3. Balloon angioplasty - RV-PA, 4. put sent on RV-PA conduit , 5. Balloon dilation 6. Edwards sapien 3 implantation ..we billed- 33477 , 75710 -226, 76937-26, we did not bill 93531-26,93563,93566,93567,93568 because doctor mentioned the reviewing the ROVT .. ECHO + CT .. I donot know this is right or not .. sometimes other coders bill 33477 + R-L cath + injection codes , very confused , my question is - when we can bill 33477 + heart cath + injection ? when we should not ?

Ablation Superior & Inferior Vena Cava & Coronary Sinus

"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?

External fem-fem bypass

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?

DES in RCA and DES in RCA into PDA

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?

upgrade dual PM to biventricular PM

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?

IS it applicable to code 37220 and 37246

Procedure Note: To facilitate the advancement of French Sheath in the R common iliac, I used a 5mm balloon at nominal pressure to dilate the artery. At the conclusion of the procedure, we were PTA and balloon tamponade with a 10mm balloon to facilitate closure of the transcaval access site. This was done during the TAVR procedure." Is it correct to report codes 37220 and 37246?

TAVR open or perc

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.

Stent to RPA, angioplasty to RUL. Congenital case.

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." 

Open removal of PleurX catheter

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."

New 2019 PICC line codes 36572 and 36573 modifier 52

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?

Coding Midline Catheters 36140 vs 36569

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).

TOS 64713/21700/21616/35761 How should I code this case?

The scalene anticus muscle was identified and the phrenic nerve was identified coursing from lateral to medial on the medial aspect of the muscle belly. A phrenic nerve neurolysis was performed with scissors to mobilize the nerve from the muscular fascia over the scalene muscle. It was preserved. The muscle was divided sharply with scissors and the right subclavian artery was noted below this. At this juncture, a sharp dissection of the subclavian artery was performed. Two small branches were taken down between 3-0 silk ties and a 6-0 prolene suture was used to reinforce this tie on the arterial side. After a comprehensive mobilization was completed of the subclavian artery, the artery was retracted forward toward the clavicle with an Army-Navy retractor. The brachial plexus was retracted laterally and posteriorly and the rib was noted in the triangular space between the artery and the brachial plexus. Next, adherent tissues surrounding the brachial plexus were released with sharp scissor dissection which constituted in this situation the neurolysis.

Are vascular closure devices considered implants?

Are vascular closure devices considered implants? Perclose, Mynx, Angioseal…Some are temporary implants that are eventually absorbed, and some are like Perclose is a suture closure device. We have different opinions among our physicians, and we appreciate your insight and guidance.

93010 bundling to procedures same date

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.

pelvic angiogram left lower extremity angiography left femoral atherectomy

a 3J was advaned into the aorta then catheter into the aorta angiogram performed aortoiliac bilaterally patent with patent internal iliac arteries bilaterally catheter placed in femoral artery patent femoral and profunda moderate stenosis in the SFA all 3 tibial vessels were open there was some distal calf and plantar disease because of the iliac anatomy I elected to do left sided antegrade femoral access to the SFA I then performed crossed SFA angiogram confirmed R catheter in the popliteal artery advanced a hawk one atherectomy device I used a balloon to further treat the SFA which allowed to pass the artherectomy device final angiogram revealed improvement with preserved tibial runoff 75630 37225

Intraarterial prolonged Adminintration of Chemo Opthalmic Artery

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?

heart cath patient cardiogenic shock

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?

A-Flutter Ablation with Re-isolation Right Pulmonary Veins

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?

Cardiac amyloidosis

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

ENDOVASCULAR ASPIRATION IVC THROMBUS WITH VENOVENOUS BYPASS

US guided RT IJV, RT & LT common femoral vein access. Contrast cavogram via the rt common femoral vein. Initiation of extracorporeal circulation (Angiovac venovenous bypass with aspiration from right internal jugular sheath and reperfusion through the left common femoral sheath. Endovascular thrombectomy of chronic IVC thrombus. Completion venography. Removal of sheaths, catheters and wires with manual compression and pursestring sutures to good hemostasis. Technique: With peak flows of 3 L/m, and systemic heparinization with a target ACT of 300, the aspiration catheter was brought back into the IVC and direct contact with the thrombus obtained. Large volumes of the thrombus were aspirated, with no nontarget embolization encountered. Periodic contrast venography was performed through the right common femoral pigtail catheter. Maceration of the thrombus was also performed with the argon cleaner. At the termination of the procedure a small residual amount of clot, densely adherent to the wall of the IVC was left in position.

Documentation for 93975/93976

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.

Clarification of 50436 and 50437

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.

An epicardial VT ablation coded using 93654?

An epicardial VT ablation performed in the EP lab.

Short section tube graft

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?

Inferior pole branch renal PTA with Left main renal stent

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. 

Add-on 93623

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".

REPOSITION OF PERC G-I TUBE

"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?

Stent placement RVOT - open chest

"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?

AICD Mobile Thrombus extraction

Can you advise how you would code this case please? Pre op Diagnosis: 72 year old female with severe MR and AICD lead vegetation/thrombus          Post op diagnosis: Partial Thrombus extraction from AICD leads using snares and pigtail traction.          Type of anesthesia: GA with TEE guidance          Procedure:     Partial Thrombus extraction from AICD leads using snares and pigtail traction; minimal residual thrombus.      Access:Right CFV - 14 Fr sheath closed with preclose/proglide; optimal hemostasis;     Right IJV manual compression for hemostasis.     

CMS requirements for EKG reads

Has anything changed with the requirements for EKG reading? We have a physician who stated mid-levels cannot read and report EKGs. Is this correct?

93580

"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?

Need to ask Dr.Z?

Don't see the answer you're looking for in the knowledge base? No problem. You can ask Dr. Z directly!
Ask Dr. Z a question now!