Ask Dr. Z

Would this be reported with code 33533 or an unlisted code? "LEFT ANTERIOR THORACOTOMY INCISION; MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS X1; LEFT INTERNAL MAMMARY ARTERY BYPASS TO LEFT ANTERIOR DESCENDING ARTERY. The patient was sterilely prepped and draped, and a small incision was made just over the left nipple. The muscle was divided, and I entered the thoracic cavity. The double-lumen tube was used to selectively ventilate the right lung in the left lung collapsed nicely. I then dissected out the left internal mammary artery in a skeletonized fashion using the LIMA left device. I dissected this up to the 1st rib. Heparin was given, and this was clipped distally and transected. I then placed the off pump retractor and opened up a pericardium placed stay sutures. The LAD was dissected and opened in its midportion with a proximal silastic snare and a 2 millimeter shunt placed. The snare was removed. The left mammary was anastomosed using running 7-0 Prolene, removing the the shunt just prior to completing the anastomosis."

I have a case where, during an embolization procedure, it seems that the left gastric artery was accidentally punctured. After the embolization portion of the procedure was complete, they went back to the left gastric artery and performed a balloon angioplasty, leaving the balloon dilated for a prolonged period of time. When they removed the balloon they were able to determine there was no longer bleeding from the left gastric artery and concluded the procedure. Would the treatment of the left gastric artery injury with the balloon angioplasty be coded as 37246?

I have a patient who had a PVA done for recurring persistent A-fib/flutter. During the procedure the patient went in and out of atrial tachycardia and typical atrial flutter. After veins were isolated the physician ablated the atrial tachycardia and terminated it. He went into a flutter, so it was decided to ablate that as well. The note says, "During manipulation of the catheter, the atrial flutter terminated." The physician went ahead and "utilized Carto 3-dimensional mapping as a guide, and energy was then targeted in a linear fashion from the tricuspid, mid isthmus to the inferior vena cava. Subsequent pacing from coronary sinus demonstrated the isthmus was not blocked. The tachycardia line was mapped, and consolidated lesions were placed in areas of lack of double potentials, and this resulted in unidirectional isthmus block..." My questions are: 1) can we bill 93655 for the atrial flutter even though it terminated before the ablation was done? 2) If we are able to bill 93655, is it appropriate to bill it two times because he ablated both atrial tach and an atrial flutter?

"Patient entered room in persistent AF. Polaris was placed into CS for LA stim/recording. ICE cath was placed into RA. Soundmap of LA was created. Transseptal access was obtained. PentaRay was used to create LA FAM. Thermocool STSF unidirectional D cath was placed into the LA. Ablation was done around the bilateral PVs in WACA fashion with 20W along post wall and 30W everywhere else. A roof-and-floor line was created to attempt to isolate post wall; however, at the post aspect of the right inferior PV the esophageal temp rose, so ablation was limited here. The bottom right corner of the post wall box was left partially ablated. Another vertical line was created throught the mid post wall, so it was partially isolated. Entrance and exit block confirmed with pacing along the lines at 10mA/2mS and with PentaRay for valiation map." Can code 93656 be billed for WACA? Since the report does not state PVs isolated, can code 93656 be billed? If remaining AF after PVI, can code 93657 be billed if only partial isolation?

How would you code an S1, S2, S3 lateral branch nerve ablation? Are they coded per level (64635 x 1 and 64636 x 2) or per sacral facet joint (64635 x 1 and 64636 x 1)? And would an L5, S1, S2, S3 RFA be reported with 64635 x 1, 64636 x 2?

During enodvascular repair of (34848) my physician reports: "Ultimately, the guidewire advanced into what appeared to be the splenic artery. We advanced our catheter into the splenic artery. Contrast injection confirmed that we were within the splenic artery, but that a wire had gone out into a small branch and created a perforation and that there was active extravasation. To treat this, we first advanced the 8 French sheath into the main celiac trunk. A 0.014 inch guidewire was carefully manipulated distally down the splenic artery. Over this guidewire, we then introduced a Renegade micro catheter. Through the Renegade microcatheter, we introduced a series of 0.018 inch interlock embolization coils to occlude the splenic artery distal and proximal to the area of extravasation. Contrast injection through our sheath showed that we had successfully occluded the splenic artery and eliminated the extravasation." Can he bill for embolization if he caused the perforation? (37244)

What are the correct select cath codes for the following? I believe the correct codes are 36245-59 (celiac) and 36246 (RRHA). "Vessel catheterized: celiac axis. Findings: The celiac axis was catheterized with a 5 French Simmons 1 catheter. Angiography demonstrates the left hepatic artery arising from the celiac trunk perfusing hepatic segments 2, 3, and 4. Vessel catheterized: superior mesenteric artery. Findings: The superior mesenteric artery was catheterized. Angiography demonstrates a replaced right hepatic artery. Vessel catheterized: replaced right hepatic artery. Findings: The replaced right hepatic artery was catheterized. Angiography with rotational cone beam CT demonstrates multifocal hypervascular tumor throughout the right hepatic lobe. Technetium MAA was administered to the right hepatic artery."

I know that codes 47536 and 47537 cannot be reported with code 47538 for the same access, but can codes 47535 and 47538 be reported together? I am coding a case in which the patient had a bile duct stent placed and also had his existing external biliary drainage converted to internal/external drainage. Your Interventional Radiology Coding Reference states for code 47538, "External or internal/external biliary drainage catheter removal, replacement, and conversion are bundled at the same session as the stent placement via the same access." I would just like to make sure I am interpreting this note correctly. I cannot find guidance in the CPT Codebook stating that codes 47535 and 47538 cannot be used together.

Code 49185, which came into use as of 2016, falls in the digestive system section of the CPT Codebook. What if sclerotherapy is performed in a site other than the digestive system? For example, an axillary post operative seroma? Do you still recommend using code 49185, or would code 20500 be used in these cases?

"78-year-old male with a history of AAA repair with Medtronic endurant graft 6 years prior. He presents with a type 1 endoleak with an enlarging aneurysm. An abdominal incision was made, and the aorta was exposed and dissected free. The common iliac arteries were dissected free. Supraceliac clamp was placed. The endograft was separated from the intraluminal thrombus, and the iliac limbs were pulled out of the iliac arteries. The aortotomy continues up to the infrarenal location. Using a pin cutter, the suprarenal fixation was cut, leaving the imbedded portion of the suprarenal fixation within the wall of the aorta. The entire endograft fabric was removed. Intraluminal thrombus removed. A 22 mm tube graft was brought on the field, and an end-to-end anastomosis was performed at the juxta-renal level to the tube graft. An end-to-end anastomosis was performed from the graft to the terminal aorta. Clamps were released, and hemostasis was achieved." Is 35081 the correct code? We were considering 34830 except it was not the same day.

What would we code for the direct puncture of the transverse sinus through a burr hole: 75894 or 36299? "After confirming the anatomic landmarks both visually and also with the Axiom navigation system, a short micropuncture needle was used to gain access to the transverse sinus just proximal to the transverse sigmoid junction. Under fluoroscopic guidance, the microwire was advanced in an anterior inferior fashion, and the micropuncture needle was exchanged out for a 4 French dilator sheath and was then connected to an RHV with continuous heparinized saline flush. Next, an Echelon 14 microcatheter was advanced over a Synchro2 Standard microwire and advanced into the dilator sheath such that its projectory included the sigmoid portion of the pouch and then looped superiorly into the transverse portion of the fistulous pouch. Selective catheter venogram was undertaken from the fistulous pouch. Next, under negative roadmapping technique, the following sequences of coils were then placed within the fistulous pouch: Ev3 3D Axium." 

Case with abdominal aortography, bilateral lower extremity runoff, FFR of the left CFA, and IVUS of the left CFA. Can the FFR be charged for? If so, what code would you use?

Can you bill US guidance (76937) with intracranial thrombectomy (61645)? Medicare is denying due to 61645 not being a primary code.

Is code 93793 used in conjunction with 85610, or is it one or the other? They do not bundle with each other.

Our doctor performed an excision of lipoma in the axillary area, and that same day patient was sent to OR due to pain. Doctor reopened wound and found a transected small superficial artery and repaired it by ligating it. Do we report a repair code from integumentary section or cardiovascular? CPT notes under the integumentary repair coding guidelines: "Involvement of nerves, blood vessels, and tendons: Report under appropriate system (Nervous, Cardiovascular, Musculoskeletal) for repair of these structures." The argument the physician has is they did not go deep enough to code from the cardiovascular section. We were looking at code 35860; the lay description does not specify if a major or minor vessel needs to be ligated.

Patient had RCA and LM selective coronary angiograms. Dr was unable to find the ostium of any of the saphenous vein grafts, all filled retrograde. LIMA to LAD was selectively injected with distal anastomosis intact and vessel beyond graft looked good, but total occlusion of origin of native LAD. Code 93455 was reported, but payor advised it was unsubstantiated. How should this be coded?

Do you know anything more about category III code 0505T for July 1, 2018? It is strange because it starts out as "endovenous fem-pop arterial revascularization".

Would it be appropriate for a facility to bill the technical component of the injection performed by one physician or other healthcare professional (62284) and also bill the technical component of the radiology S&I code (72240-72270) when performed by a different physician or other healthcare professional?

For the following, would you code 49000 and 97605 with 33877? "Co-surgeons were closing the surgical incisions following an open TAAA repair. During the close, patient developed pulmonary edema and was placed on ECMO. Patient improved on ECMO, but continued to be very labile hemodynamically with multiple episodes of hypotension. He had significant distention of the abdomen with concern for abdominal compartment syndrome. One of the co-surgeons proceeded with decompressive laparotomy through a midline incision from the xiphoid to suprapubic region to look for bleeding and release the abdominal compartment. Peritoneal cavity was entered and systemic exploration of the peritoneal cavity was performed. The liver and spleen were healthy and viable. Stomach, large bowel and small bowel were viable with good ulceration in the mesentery. There were good Doppler signals in the antimesenteric border of the small intestine and large intestine. Sigmoid colon was also viable. There was no retroperitoneal hematoma. There was significant swelling of the intestine. At this time large wound VAC was placed."

"There was an occlusion of the SVC distally extending to the atriocaval junction that was treated with angioplasty. In addition, fibrin sheath was removed from an existing tunneled dialysis catheter. Replacement of the tunneled dialysis catheter with a new longer catheter is performed." Can code 37248 be reported in addition to codes 36595-52, 75901, and 36581?

"The patient comes in with a malfunctioning tunneled dialysis catheter. After vigorous, explosive flushing with saline the catheter flushes freely. Heparin is then instilled." They are trying to get 36596 when I believe this would be an E&M. Please advise.

"The previously placed right IJ tunneled catheter was interrogated. A scout film was performed, which showed no kinking of the line. Heparinized saline was flushed via both ports, and there were no issues with drawing back or flushing. Contrast was injected via both ports. There was no central lesion noted. The tip of the previously placed catheter is at the mid to distal SVC. The catheter is ready for use." Is this reported with code 75827 or 75825?

What are the performing/documentation/billing requirements for code 93016? Many sources say direct supervision does not have to be face-to-face, but, rather, immediately available and in the office or nearby. I have also heard arguments that this code requires face-to-face contact throughout the procedure since it has its own RVUs. Most diagnostic test codes have supervision included in the interpretation portion, but this one is separately billable. What is your position? Can a physician be catching up on his/her documentation while being paid for supervision of a stress test? Though I think the physician deserves this, it seems questionable that an insurance company would pay extra for this work.

Can you help me understand the rule for coding IVUS in multiple vessels in lower extremity interventions? Instead of scanning the whole long report, here is a summary from one of the procedures that confuses me on how many times I can charge for IVUS. "1) Diagnostic RLE angiogram. 2) Right SFA IVUS. 3) Right popliteal IVUS. 4) Right tibial/peroneal trunk IVUS. 5) Right posterior tibial IVUS, atherectomy, angioplasty. 6) Ultrasound guidance (criteria met for billing). Findings: Occlusion of right ATA and 95% stenosis of right PTA. All others are patent." I have the following codes: 37229, 37252, 37253 x ?, 75710-59, and 76937. My question is how many times can I code for the IVUS? Just 37252 for the entire right lower extremity or 37252 once for the SFA and 37253 x 2 for the popliteal and posterior tibial?

"Patient scheduled as an outpatient IVC retrieval. Anesthesia was done by anesthesiologist. Sheath was placed in the right internal jugular. Pigtail catheter was advanced to distal IVC and IVC venogram performed. IVC is patent; no thrombus in filter. Sheath was exchanged for IVC retrieval sheath. Snares were advanced and retrieval attempted multiple times. Since multiple attempts were tried and unsuccessful, the physician decided to end the procedure. Manual pressure held at sheath site. Patient referred to other physician for retrieval." Do we code for completed procedure 75825, 36010? Or do we code for attempted procedure 37193?

We need some clarification on code 93318. When TEE is performed during CABG/open valve replacement or other OR type procedures, does the TEE report need to state that continuous assessment was performed, or is it acceptable to state it is an intraoperative TEE and give pre and post findings? Please advise what documentation should be included to charge this appropriately. Also, our echo techs state that during these procedures they come and go from the OR, but while in the OR they are performing continual assessment imaging on these cases. Is this appropriate for code 93318?

L3 kyphoplasty and L1-L2 interlaminar ESI performed during same session. Code 62323 has an edit pairing with 22514. Would it be correct to only bill code 22514 for this case since both procedures were performed in the lumbar area during the same session?

Is there a way to bill for verapamil, 10 mg, that was administered intra-arterially to the left external carotid artery by manual push prior to catheterization? Infusion time 2 minutes.

Would you code this as 36832 or 36838? I am not sure if we can use PTFE graft material based on 3M Encoder. Also, the procedure report title is Graft Revision with Proximalization of Inflow for Subclavian Steel. "Horizontal incision is made above antecubital fossa, and a vertical incision is made in the axilla. Subcutaneous tissues are divided in the incision. The AV graft is dissected free. Next the axillary artery is dissected free. Between the two incisions, I tunnel a 5 mm graft in the deep subcutaneous tissues. This axillary artery is clamped proximally and distally, an arteriotomy is made, and an anastomosis is performed here between artery and graft. Anastomosis complete. I then clamp the proximal graft and transect it. The stump of the graft is oversewn just off the brachial artery. I then spatulate the edge of the old graft and the new graft and perform an anastomosis here. Prior to completing anastomosis the arteries are back and forward bled. The graft flow is restored." 

"The 9 mm x 59 mm VBX stent was placed over the Amplatz wire on the right side. This was positioned across the aortic aneurysm with several millimeters extending into the neck. The stent was then deployed with the stent balloon. The balloon catheter was removed, and the stent was post-dilated with a 14 mm Atlas balloon inflated to nominal pressures. The balloon catheter was withdrawn. An Amplatz wire was advanced from the left femoral sheath through the stent graft and into the descending thoracic aorta. In simultaneous kissing fashion, a 9 mm x 59 mm ICAST stent and a 7 mm x 79 mm VBX stent were placed in the right and left common iliac arteries, respectively. This extended up into the aortic VBX stent by several millimeters." Would the VBX be considered a true endograft and be coded with 34701 and 37221-50? Or would this be coded with 37236 and 37221-50? The physician is treating the AAA and iliac stenosis.

"Right common femoral to aortic arch with arch angiography. Selection right subclavian with right upper extremity arteriography. Catheter then pulled back across the aortic arch to the left subclavian artery. The catheter was advanced into the proximal subclavian artery beyond the first vertebral artery, and left upper extremity angiography was performed from this position. Findings documented." Can code 36221 be billed with codes 36215, 36216, and 75716 for this case?

I'm not sure when modifier -QQ should be used. We only read MRI and CTA... Should we be attaching the -QQ modifier if we have none of the information they are referencing?

I was wondering if you could help me in understanding when it would be appropriate to utilize code 76125. I see that it's for cineradiography/videography; however, my cardiology department wants to add this charge for all procedures using fluoroscopy, and I feel that is incorrect. Please help me in clarifying what exactly I would look for in order to code this.

Coil embolization in three areas to treat type 2 and 3 endoleak. Are these considered separate surgical fields allowing coding 37242 x 3? The code guidelines imply must be trauma or bleeding to code separate surgical fields.

In the op note below I do not see where the right atrial pacing and recording was done. Since this is a necessary component of 93654, would we report this with a -52 modifier? "Mulitpolar electrode catheters were used to map and ablate the LV endocardial substrate and to ablate abnormal tissue. ICE was used to create a working shell of the LV depicting landmarks of mitral annulus, aortic cusps, and papillary muscles. At baseline patient was in SR. VT induction at baseline was not attempted. Endocardial map disclosed a large anterior an inferior scar extending from mitral annulus to mid scar with inferior extension to the apex. Based on the scar map lines to break up potential channels and enclose the border zones were depicted, and the RFA ablation lesions were delivered. After that induction was attempted with extrastimuli. A slow VT 550msec was induced, which terminated with ATP. This appeared to originate from apical inf wall. Ablation lesions were delivered here and in between the pap muscles. Repeat induction attempts no longer induced VT with double extrastimuli."

Our cardiothoracic surgeon is utilizing the "SPY imaging system" during his CABG procedures. There is a HCPCS code for OPPS reporting (C9733, Non-ophthalmic florescent vascular angiography). However, I am not finding a CPT code. Should I report using an unlisted code (i.e., 37799)? We found a comparable code, CPT 15860, but this code is specific for testing a skin graft or flap and does not seem to be appropriate for reporting imaging performed during CABG. 

Would a jejunostomy tract injection be reported with codes 20501 and 76080? Or would code 49465 be used? Dictation states: "Repeated contrast injections were attempted; however, the fistula tract was closed. No contrast was seen within the gastric lumen. Impression: Unsuccessful J-tube insertion." We are going back and forth on which codes to use since there was no J-tube to inject.

We often have to report codes 36901 and 36907 together. With 36907 being an add-on code (N status), there is no additional payment for doing a PTA. When intervening (PTA) to a central vessel only, is it permitted to report 37248 instead of 36907? Or can we only report 37248 if an additional access was obtained to complete the central PTA stenosis?

Our radiology folks want to know if they can bill code 73020 with 77002 and 20610 to document that the contrast is in the shoulder joint and to have a permanent record of same. There are no edits on these codes, but wouldn't code 77002 cover that?

Looking for clarification on CPT 47537 vs. 47531 and 50389 vs 50431. My understanding of 47537 is fluoro guidance is needed to perform removal so as not to disturb an existing stent in place, and that a diagnostic study may or may not be done. In any other case, if a cholangiogram is performed and the tube removed (without mention of a indwelling stent, requiring guidance to assist in removal), we would just code a diagnostic study (47531). For example: "Fluoro scout image demonstrated biliary cath with loop projecting over expected area of central bile ducts. Contrast inject through tube demonstrated prompt flow through hepaticojejunostomy and nondilated bile ducts. Indwelling cath was cut and removed in its entirety." My thought is to code this 47531 and not 47537, as it does not appear to specifically indicate a need for fluoro guidance to get the tube out, but just that they did a diagnostic study and removed tube at the end. I interpret 50389 the same - fluoro guidance is needed to assist in removal, not just to do a diagnostic study and tube removal. 

I have a couple venous sclerotherapy cases that state: "Under direct ultrasound guidance a 27 gauge needle was advanced into the dilated tributary vessel... After confirmation Sotradecol was then foamed and injected into the existing access sites. This was performed at all locations of access. Ultrasound was used to evaluate location of the foam as well as used to direct the foam into the tributary vesse branches." This sounds an awful lot like CPT codes 36465/36466, except it does not specify that it was NON-compounded foam. Is Sotradecol compounded? Also, can these tributary vessels be considered "truncal veins" as specified in CPT codes 36465 and 36466? Or should this be coded 36470? 

Is the IVC included in the TIPS zone? They did IVC selection with IVUS and plasty of IVC stenosis and did kissing plasty of TIPS stent and IVC. Can I code for the work in the IVC and the IVUS?

If a surgeon requests CT scan without diagnostic interpretation, because the imaging will be used for surgical planning, how do we bill for the technical component? Common examples are Sinus surgical planning and shoulder surgical planning. Some vendors recommend code 77011, while others recommend the CPT code that matches the body part (for example: sinus 70486, shoulder 73200).

Patient was placed prone, and a CT was obtained through the abdomen after intravenous contrast administration. Site of the type II endoleak was identified and accessed under CT guidance with a 19 gauge needle. Contrast was injected, showing multiple feeding lumbar arteries. Four vials of Onyx-18 were injected through the needle under fluoroscopic guidance, occluding the nidus of the endoleak and the origin of the supplying lumbar vessels. Gelfoam slurry was then injected as the needle was removed." Possible 37242 not sure if direct stick is billable code and/or CPT code.

We were told that if the intention was to evaluate the arterial and venous bilateral organs, but due to constraints only one organ was evaluated and documented (both arterial and venous), to report code 93976 (limited). Is this statement true? If the intention was to evaluate the arterial and venous blood flow of bilateral organs, the procedure was performed bilaterally; however, there was no flow visualized in the left organ because of blockage. There was documentation in the procedure note showing that the technician looked at left organ's vessels, but there was no blood flow due to blockage. Imaging of the left organ is recorded. Should we bill code 93976 (limited) in this scenario, or can we bill code 93975 (complete) here instead?

Can you please help me with this intervention performed during a congenital cath for a patient with a single coronary artery? The doctor drops a 92990. I am thinking 37246 for the following: Interventions: "1. 33 degrees cranial with 2 degrees LAO and straight lateral projections of a 16 mm/4cm Zmed II balloon across the RV-PA conduit advanced over a 0.035 Rosen wire. Balloon was inflated to 3 atm for 13 seconds and then again to 4.5 atm for 9 seconds. Residual waist seen on both inflations at the level of conduit stenosis. 29 caudal with 17 LAO and straight lateral projections of balloon inflation of a 14mm/4cm Atlas balloon in the RV-PA conduit. Inflated to 10 atm for 17 seconds and then inflated to 10 atm for 14 seconds. Residual waist seen on both inflations."

Often times I see where they do a primary mechanical thrombectomy in two separate vessels [external iliac artery (37184) and common femoral artery (37185)] to find out there is "residual stenosis" (no percentage documented) subsequent to the thrombectomy. If they did a PTA in the external iliac, and a stent in the common femoral, can we report code 37226 as well as 37220 additionally?

"The catheter is placed in the ascending aorta, and DSA of the aortic arch is performed, then the catheter is selectively placed in the left subclavian with hand injection angiogram performed." Angioplasty and stenting are being done to the left subclavian. We are being advised to use codes 37236 and 36225. Is this correct, or is code 36225 bundled into 37236? Is there another code we should be using for RS&I?

Patient came in for upgrade of her CRT-P to CRT-D. After electronic analysis of her pacemaker system, MD decided not to upgrade the system to CRT-D. He removed the CRT-P generator and relocated it to a more cranial location within the pocket. The leads were retested through the device, and the incision was closed. What could I code for this? The system was evaluated and tested. The same generator was removed and replaced in a different position, but still in the same pocket. While there is a code for the evaluation, I can’t see a code for removal and replacement of the same generator in the same location. Can you help me out please?

Patient excercised on a regular Bruce treadmill for 7.5 min. A limited color flow and conventional Doppler was performed with stress to access for changes in baseline Doppler findings. I am leaning towards 93350, but how would I differentiate between stress echo and cardiovascular stress echo? The CPT descriptors almost read the same. Does the "maximal and submaximal treadmill" (93016/93018), have something to do with choosing 93016/93018 over 93350? It seems both procedures are using treadmill/bicycle and echocardiograph monitoring. Most times our physicians are supervising the procedure. If you could help me understand when I would choose 93350 over 93016/93018, I would appreciate it.