Ask Dr. Z

Patient's staged, 4/10/18. RCA PCI based upon his 3/27/18 cath films reporting a 75% stenosis. Cardiologist provides repeat coronary angio resulting in at most a 50% eccentric lesion. Decision was not to intervene. Is the repeat diagnostic coronary angio chargeable because findings were different?

I have a patient who currently has a dual chamber ICD. The physician did an upper extremity venography, pocket revision, and coronary sinus angiography. The CS showed no coronary vein branches suitable for LV lead placement. Attempts at LV lead placement were then abandoned. The pocket was flushed and closed. Am I able to bill for coronary sinus angiography? What is billable in this situation?

Can we bill code 93609 when the doctor did ICD implant? I understand that mapping can only be bill for EP study... since EP study was not done during the procedure can we code 93609? MD procedure was, "BIVENTRICULAR DEFIBRILLATOR IMPLANTATION, WITH CARDIAC RESYNCHRONIZATION THERAPY AND DEFIBRILLATION (CRT-D), INTRA-CARDIAC MAPPING".

The physician performs an AV node ablation. Patient already has a pacemaker in place. Indication is persistent atrial fibrillation. In the conclusion the doctor stated, "successful AV node ablation," and "ablation performed with complete heart block." Should complete heart block be used as well as the persistent atrial fibrillation as the post operative diagnoses?

While performing a CFA endarterectomy the physician revises a fem-fem synthetic bypass graft with no mention of any prior patency issues with the graft. I have included a few excerpts from the documentation below. I am wondering if code 35884 is appropriate to code along with the endarterectomy code 35371 in this circumstance. "The proximal anastomosis of the femoral-femoral bypass graft was excised from the common femoral artery to enable endarterectomy of the entire common femoral artery. The arteriotomy was closed using the saphenous vein patch and running 6-0 Prolene suture. Revision of the proximal femoral-femoral bypass graft was performed by incorporating the anastomosis into the closure using 6-0 Prolene suture medially at the level of the mid common femoral artery."

When separately accessed, an RFA is done on AAV in zone 3 and in an AAV tributary in zone 5. Would this be coded as 36475 and 36476? We are having a hard time determining if the tributary would actually be considered a separate vein.

"Patient arrived for scheduled PVI ablation. Sheaths were placed in his right and left groins, and a CS catheter and ICE catheter were advanced. Through the SL 1, transseptal puncture was performed (ICE guidance was used during the puncture). A 3D model of the LA including the pulmonary veins was created. Mapping of the LA was performed, and there appeared to be activity in all four pulmonary veins. The catheter was advanced into the left inferior pulmonary vein. At this point, a mobile mass was observed on ICE. Several attempts were made to aspirate the echogenic material into the ablation catheter sheath. An aspiration catheter was introduced and aspiration performed several times. The ablation catheter sheath was withdrawn into the right heart while aspirating on the ablation catheter sheath. The procedure was subsequently terminated." Our department wants to report codes 93656-74, 93613, and 93662, but because the ablation was not attempted, I hesitate to submit code 93656-74. What would you recommend?

Can you please advise how to code a CVD catheter check without injection of contrast? The CVD was aspirated and flushed, with fluoroscopy documented. Would code 36598 be billed with a reduced modifier?

Does the Physician Supervision Rule apply to the technical component, the professional component, or both?

"Local anesthesia with lidocaine 1% and Bupivacaine 0.25% was infiltrated above the elbow. Percutaneous puncture of the cephalic vein was performed with a micropuncture needle. A 0.018 wire was advanced through the needle. A microsheath was advanced over the wire. A fistulogram was performed. A 0.035 inch glidewire was advanced through the microsheath. A 6 French sheath was placed. The stenosis in the brachiocephalic anastomosis was crossed with the wire. Angioplasty of the stenosis was performed using a 6 mm x 40 mm balloon. There was a good angiographic result and resolution of the stenosis. The sheath was removed, and hemostasis was achieved with 2-0 Prolene pursestring suture. Successful angioplasty of stenosis in the brachiocephalic anastomosis. Patient with large stealing branch." I reported codes 36901 and 36907. Would that be correct?

The physician's report states: "Under sonographic guidance, two 25 gauge fine needle aspirates (FNA) and two 20 gauge core needle biopsies were obtained. The tissue samples were deemed adequate by on-site cytopathology review." There is no mention that FNA samples were inadequate and that a core was required as a result. I reported codes 38505, 76942, and 10022-XU. Is this correct, or should I have appended the -59 modifier to code 10022? Should I have not reported code 10022 since the doctor did not specifically state that the FNA specimens were inadequate and therefore required core samples as well? This was a submandibular LN biopsy.

Thromboendartectomy vs. thrombectomy vs. embolectomy... What is the difference in the three procedures? I am a bit confused. Here are some details of the case: "This time we then made a transverse arteriotomy at the bifurcation of the femoral vessels after placing vascular clamps proximal distal. There was fresh thrombus within the distal common femoral artery. This was removed. We then passed a #4 embolectomy catheter proximally into the iliac system. No clot was noted within that system, and we had excellent pulsatile inflow. We instilled heparinized saline and then clamped the vessel. Similarly we passed the Fogarty balloon catheter into the profunda femoris artery. There was no clot noted within that system with excellent pulsatile back flow. Heparinized saline was instilled. The vessel was then clamped. We now turned our attention to the superficial femoral artery. We passed the #4 Fogarty balloon catheter distally and removed significant amounts of clot. These were passed off the field as specimen. On her last pass we removed a large piece of firm clot, which was likely the inciting factor."

How would you code the following? Patient with Klippel-Trenaunay syndrome with poor venous flow to the right leg because of congenitally absent external iliac and common iliac veins. The procedure performed was a right common femoral to inferior vena cava bypass with the use of a 12 mm ringed Gore-Tex graft. I was unable to find a suitable code for this, and I'm wondering if codes 37799 and 35681 would be correct.

We are hoping you can dispel some confusion in guidelines for code 37215, specifically angiograms of contralateral sides during procedure. Specifically, p285, #13 guideline (15th 2018 15th edition): The last statement states “DOES NOT APPLY”. Prior to purchase of your reference series, we were using OPTUM interventional radiology coding companion (2017 ed. P 163) guidelines 7 and 8 state that if prior studies (as AMA CPT guidelines direct as well) were performed and no clinical changes have occurred, angiographies are not permissible under these guidelines. My physician states that follow-up angio’s on contralateral sides are necessary in his opinion to prove stent deployment success, and to assure adequate and proper placement of stent(s) so that he may evaluate adequate flow through collateral vessels. As a result, he feels he should receive credit for these follow-up angio’s. May we have your official interpretation, please?

I have read in different places some of the requirements needed for doing a PCI. Would you detail the percent stenosis to be documented to meet medical necessity for doing an AV fistula intervention, venous interventions, lower extremity interventions, renal/mesenteric interventions, and coronary interventions?

For the following case example, can I report codes 64490-LT, 64491-LT, 64492-LT, and 64450-LT? "Left C1/2, C2/3, C3/4 facet joint injection. Needle directed to posterior surface at the level of Left C1/2 facet. Needle advanced into facet joint. Needle position verified. After negative aspiration, 0.25 lohexol contrast was instilled, documented joint filling, followed by physiologic solution, 0.5ml 0.125% bupivicain containing 2 mg betemethasone. Repeated px at C2/3, C3/4. ARTHROGRAM: Abnormal. Capsule intact. Margins irregular. STIMULATION: Slow injection into joints did not provoke pain at any level. PROCEDURE TWO: LEFT THIRD OCCIPITAL NERVE BLOCK: Posterior approach. .25 gauge needle under fluoroscopic guidance to the lateral surface of the C2/3 facet joint. .025ml lohexol contrast slowly instilled documenting dispersal. Solution spreads in the immediate peri-articular region with no vascular filling. Injected 1 ml 0.25% bupivacaine." 

My physician states all aortic stent graft delivery systems are larger than 12 French... is this accurate, and would it be appropriate to bill code 34713 if the operative note does not clearly specify the size of the delivery sheath? I queried the physician and he stated that he utilized a 22 French stent graft, but this is not reflected in the operative note. Should he addend the note, or should I submit 34713 based on his statement?

"B/L iliacs were found to be too diseased to use. Aorta was transected excising aneurysmal segment and thrombus removed. Aorta anastomosed to synthetic graft. The right and left limbs of the graft were tunneled to each groin, and end-to-side anastomosis was created to each common femoral artery. Thrombus was also removed from the RCFA." The debate is between code 35091 and 35646. Code 35091 describes graft connection between the aorta and iliacs... Can this code also be used for connection to femoral arteries? Or would code 35646 be more appropriate?

For the following, can codes 36901, 36907, and 37248 be billed? "Left brachiocephalic AV fistula with multiple areas of high-grade stenosis in upper and mid cephalic vein, extending into a previously placed metallic stent in shoulder region. Left basilic vein fistula fistulogram and central venogram with sequential balloon angioplasty of three stenoses. Two of the cephalic veins measure greater than 95%, and in-stent stenosis measures greater than 80% with 6 mm x 2 cm cutting balloon and 8 mm x 6 cm balloon."

It is said that aspiration thrombectomy is included in stent placement. The only code for stent placement I can find that says aspiration thrombectomy is included is 92941. Will you please show where in the CPT Codebook it says aspiration thrombectomy is included in code 92928?

Our clinic physicians will perform lap band adjustments in the fluoroscopy suite here at the hospital. For facility coding, are we to use codes 43999/77002 for Medicare and codes S2083/77002 for non-Medicare? Code S2083 is still a valid code. Problem is, code 77002 is now an add-on code only for certain sets of codes (per the CPT Codebook), so we aren't sure. Neither code S2083 nor 43999 are included as appropriate to be used with add-on code 77002. We are aware of the Coding Clinic for HCPCS, Second Quarter 2017, that states to use 77002 with 43999. 

It is my understanding that radiofrequency ablation and microwave ablation are both thermal ablation interventions, which belong to the same spectrum and would therefore be coded the same. Example: 47382, liver ablation percutaneous RF. Will you please provide clarification?

When a VDD lead is used and connected to a dual chamber pacemaker can I use code 33208? "Blunt dissection was used to fashion a pocket for the implantable device. Using the modified Seldinger technique, one subclavian venipuncture was performed. A J-tip guidewire was advanced to the IVC without difficulty. Over the J-tip guidewire, a peel-away sheath was inserted A passive fixation VDD lead was inserted and advanced under fluoroscopic guidance to the right ventricular apex. After 10 Volt pacing was tested without diaphragmatic or chest wall stimulation and ensuring adequate lead parameters including adequate P-wave sensing, the lead was secured to the underlying muscle using two non-absorbable suture ties. The lead was affixed to the dual chamber permanent pacemaker. Successful VDD permanent pacemaker implantation."

An IVUS was performed to check the leads prior to extraction of PPM RV lead and upgrade to CRT-D with implant of CRT-D, His lead, and new RV ICD lead. What code should be used for the IVUS? "An IVUS catheter was then advanced through the SR0 sheath into the SVC, and the lead lead was visualized at many junctions including the SVC/innominate junction, SVC/RA junction, mid-RA junction, and low-RA junction. There was no suggestion of lead adherence to vascular wall along the high SVC as well as SVC/RA junction, and the lead appeared intraluminal at all levels. IVUS was removed, and a pacing quadripolar catheter was positioned in the RVOT for back-up pacing."

The procedure is removal of the LAAC Watchman device. The only code that seems appropriate is the unlisted code. Is this correct?

"Patient had AVF graft placed 4 days prior and was unable to receive dialysis. Patient was noted to have high grade stenosis of the right brachiocephalic vein, which did not respond to angioplasty by other physician. With a small incision near arterial anastomosis, the graft was dissected out, and incision was made with Fogarty catheter placed and advanced through graft. Clot was extracted but could not traverse the venous anastomosis. Dye was injected, but a large filling defect within the axillary vein was noted, and could not inject enough dye to see beyond that point centrally. Incision over the venous anastomosis through old scar was dissected out but because venous thrombosis was quite deep, and we were never able to get safely around the vein. The procedure was aborted." I'm unsure as to which code to use. If the patient had an attempted angioplasty does this mean we append modifier -52? I'm unsure what it means when a catheter-based arterial access is performed? Would we use 36831-52 or 36901-52, or 36005?

If elective cardioversion is done via an AICD, what CPT code would you bill?

Because the physician was unable to get optimal right arm venous access at the beginning of the procedure, access for the right heart catheterization was through the right common femoral vein. Physician then had trouble with the Swan-Ganz catheter adhering to the sheath, so he switched to the right radial artery for the coronary angiography. Can you bill for the second access?

Can codes 33883 and 33886 be billed together for a Zenith Alpha 32 mm x 155 mm stent placed proximal to an existing thoracic stent with a second Zenith Alpha 36 mm x 113 mm stent placed distal to the same existing thoracic stent? The patient has "contrast extravasation/pseudoaneurysm" seen both proximal and distal to the existing thoracic stent. Reason for exam documents sentinel bleed manifested as frank blood from esophagus.

Can you bill both codes 37191 and 37193 at same time? There is no code for filter exchange. Here is report: "Patency of RIJ vein confirmed with US and image saved in the record. After prep and drape the internal jugular vein was accessed with US. No thrombus seen in the IVC. A snare catheter was then advanced through the sheath, and filter was retrieved. A new retrievable Denali filter was then deployed infrarenal. No complications." If we can code both, is it the 37191 with the -XU modifier? 

We have billed codes 36832 and 36902 together in the past, and sometimes they are paid together and sometimes not. We were advised by insurance that we can bill together if we append modifier -59. There is some confusion, and we want to bill this properly because the CPT Codebook states that they should not be billed together. Can you shed some light on this, as it has been causing great confusion and debates with conflicting information from different places?

Can code 75736 be billed for different arteries in the same body area during the same encounter?

Would both codes 37236 and 0075T be reported for the following case? "We then brought an 8 x37 mm LD express stent into the left subclavian artery and stent to the left subclavian artery just distal to the takeoff of the left vertebral artery. Following stent placement and angioplasty, repeat angiogram demonstrated widely patent flow in the left subclavian artery with persistent orificial stenosis of the left vertebral artery. From the right femoral access we brought a 018 wire into the left vertebral artery. We stented the orifice of the left vertebral artery using a 4 x 15 mm SD express stent. There was minimal overhang of the stent into the left subclavian artery. Following stent placement and angioplasty, repeat angiogram demonstrated widely patent flow through the left subclavian artery into the left vertebral artery."

"Contrast was injected through the existing drainage catheter, and sinogram was performed. Findings show no residual fluid. Catheter was removed." Can you bill for the sinogram (49424/76080), as there is no charge for the drainage catheter removal?

If the needle localization is performed by the radiologist and then the surgeon performs a partial mastectomy, can we not report codes 19281 and 19301 together? The 2018 CPT Codebook states, "Intraoperative placement of clip(s) is not separately reported."

When reporting code 76937, must the documentation state "saved images in permanent record"? Is this inferred or understood?

CPT states, "Do not report ultrasound guidance, i.e. 76937 for percutaneous vascular access, in conjunction with 34713 for the same access." What about a smaller than 12 French catheter on the contralateral side? Should we be able to capture 76937? There is an edit with no modifier allowed. Thank you for your assistance with this new 2018 coding.

Code 37216 has a 90-day global to all but Medicare, so if an office visit is performed within the global period, can we bill it to Medicare since Medicare doesn't accept code 37216?

The physician states he did a CT-guided percutaneous pubic symphysis bone biopsy. Would the pubic bone be considered a superficial bone (codes 20220 and 77012)? Or is it considered a deep bone biopsy (20225)?

"Patient has a self inflicted stab wound to left neck. Incision was extended along the sternocleidomastoid. Internal jugular vein was completely transected, and both ends were able to be identified and ligated. (I did verify with the surgeon – he ligated both ends, not sutured/repaired.) Sternocleidomastoid was nearly completely transected and was repaired with a series of U stitches. Platysma and skin were approximated with sutures incorporating the initial stab wound." My coworker and I are going back and forth with coding this surgery. She feels that repair of blood vessel of the neck is accurate. I don't feel like this is a "repair" since it is only being ligated. She is leaning towards 35201, and I am leaning towards 37565 ligation of neck vein. (Also code 24341 for the muscle repair.) We also discussed code 20100, which includes repair of minor blood vessels, but the IJ vein seems more important than "minor". What specifically makes a blood vessel "major" vs. "minor"? And how would you code this? 

The debate lives on, we changed from coding “once congenital always congenital” for echoes and caths after transplant about 8 years ago. We have new physicians that have come from other institutions where the “once congenital always congenital” coding is still occurring. I have not been able to find this published by a regulatory body such as CMS or AMA. Is there such a publication that I can use to support only billing congenital when there is residual anomaly after transplant?

Can you tell me if the bovine angio can be separately coded (36215) in this scenario for aneurysm follow-up? Findings for all vessels are documented. "Catheter advanced right femoral sheath to the ascending aorta for arch aortography. Catheter removed. A Cook vertebral catheter was advanced from the right femoral sheath to the right vertebral artery with angio performed. Catheter placed first in the right common carotid artery, next the right ICA: cervical right carotid angiography and right carotid cerebral angiography, respectively, with the right carotid cerebral angiogram including 3D rotational right carotid cerebral angiography. The vertebral catheter was retracted/advanced into the bovine left common carotid artery to perform cervical left carotid angiography, next advanced into the left ICA to perform left carotid cerebral angiography. Vertebral catheter was retracted and placed in left vertebral artery with angio performed."

"Patient with left femoral neck metastatic lesion seen for embolization of tumor prior to hip replacement surgery. Entry via the right, up and over into the left common femoral where extremity angiography was performed. Next the catheter was advanced into medial circumflex with angiogram done, followed by embolization of the distal medial circumflex. Next the lateral circumflex was selected, and the catheter was placed in the distal lateral branch with angiography done. Finally, catheter placement and angiogram was performed in the 'more medial distal branch' of the lateral circumflex." Is the medial distal branch of the lateral circumflex considered an additional selective? What are the catheter selection codes? How many additional 36248s, one or two?

Patient has idiopathic intracranial hypertension and possible thrombus of the transverse sinus. First catheter access common femoral to right and left internal carotid with angiography. Second catheter access right femoral vein to right jugular with venography. There was no significant steonosis or pressure gradient in the right transverse sinus. Venous phase demonstrates no drainage through left non-dominant sinus. I used codes 36224-50, 36012, and 75870-26, but I'm wondering if there is a code to capture the venous manometry performed in this case?

I have not seen this procedure performed before by the IR physicians, and I am not sure what codes would be correct for it and would appreciate your thoughts. "Patient with post-operative bile leak from the cystic duct. Liver was accessed, right hepatic bile duct was injected, and cholangiogram was performed to opacify the remaining right lobe bile ducts. Needle was used to target an opacified right segmental hepatic duct. This duct was cannulated, and then a glidewire and glidecatheter were used to select the small bowel. The sheath was exchanged and tip was positioned in the proximal hepatic duct. Cholangiogram was performed, demonstrating the cystic duct stump. Cystic ductogram was performed, which demonstrating an active leak from the gallbladder remnant. The microcatheter system was positioned in the mid cystic duct, and the duct and gallbladder remnant were glue embolized, which showed significant residual flow. Embolization was repeated, and post-embolization cholangiogram demonstrated no residual leak. Catheter was left in place in case further intervention is required."

Patient presented for planned dual pacemaker insertion with indication of intermittent 3rd degree heart block per ECG, with greater than 5-second pauses. Unusual for this provider's routine, the electrophyisiolgist performed atrial pacing prior to the start of the dual pacemaker insertion procedure. Should code 93610-XU be billed in addition to 33208 for this service?

"Voltage mapping confirmed that a line of block had been created across the LA roof and also mid-posterior LA to connect the LIPV and RIPV. There was also a semi-vertical line that traveled from this horizontal line to the mitral annulus by passing posteriorly and centrally reaching the midposterior mitral annulus.  From a posterior view this was a somewhat diagonal-shaped line slanting from right to left as it traveled from the posterior LA to the mitral annulus.The roof line seemed to be intact, but there were some locations with more amplitude and fractionation, and these were targeted. The mid-posterior line from LIPV to RIPV was mostly intact but had a few sites with moderate voltage that were also targeted. The line from posterior LA to the mitral annulus definitely had breakthrough; these breakthrough sites were targeted. All posterior wall ablation was done with 20 watts and FTI of 200 g-s. Most other atrial sites were ablated with 30 watts." Are these breakthrough ablations considered 93657?

We are confused as to the coding of an open thrombectomy in the external iliac artery. The only code we can find is 34201, but that is for "aorto-iliac". 

Our neuro interventionalist is performing a cerebral angiogram perfusion study for stroke. At this time, I have recommended they bill the intracranial angiograms and the 3D reconstruction he is doing on a separate system. Since 0042T is for the CT perfusion study, do you have any recommendations for the angiogram equivalent?

Do you have any details related to the CMS final decision memo for ICDs? Most specifically, an explanation of the shared decision-making provision.