Ask Dr. Z

The CT physician first did: placement of endocardial right ventricle and right atrium defibrillator and pacemaker leads by direct cannulation of the right atrium and placement of defibrillator pulse generator in the left chest wall pectoral location with tunneling of leads across the midline to the right thoracotomy incision. After the CT surgeon was finished, the EP physician did the CS lead: "After placement of a 9 French SafeSheath into the right atrium, a Medtronic right-sided guide and sheath were delivered to the low right atrium. A St. Jude 7 French CSL inner catheter was used to cannulate the coronary sinus. Tributaries of the coronary sinus were interrogated/search with a 0.018 guidewire. Once appropriate coronary sinus tributary was identified, a Medtronic, quadripolar, LV pacing lead was delivered there without difficulty." Codes 33224 and 33225 don't seem to work for the EP portion. Any suggestions for coding the CS lead placement?

Is there any requirement that a facility wait for the radiologist report when coding/billing x-ray, CT, MRI, US, etc.?

"Patient was placed supine on the fluoroscopy table. The right arm was prepped and draped in sterile fashion. Local anesthesia was administered with 1% lidocaine. The venous outflow of the AVG was accessed under ultrasound guidance in antegrade fashion using a micropuncture needle, wire, and sheath. Over a guidewire, a 6 French introducer catheter was advanced and positioned within the venous outflow. Contrast was administered, and a right upper extremity AVG venogram was performed in successive stations centrally. The cephalic venous outflow demonstrated long segment of stenosis involving the cephalic vein graft near the axillary vein venous anastomosis. The central venous outflow including the right subclavian vein, right innominate vein, and superior vena cava appeared patent." The physician stated she used the ultrasound guidance for access only. Can we report code 76937?

In reference to question ID #10267, does the new code description 76881-76882 for vein mapping for CABG change in 2018? If we are doing vein measurements only for a pre-op CABG with NO color flow and spectral Doppler, and the descriptions for codes 76881 and 76882 state “other soft tissue structures”, do you consider a vein to be soft tissue? 

What makes the following 75625 and 75716 and not 75630? "LCF accessed w/US guidance, 6 French sheath inserted, angiogram of LCF, 10% stenosis w/plaque. Performed angiogram of LPF, found 10% stenosed with plaque. Angiogram of LSF, found 20% stenosed w/plaque. Catheterized the LT external iliac, performed angiogram with noted stenosis and plaque. Catheterized the LT common iliac, performed angiogram, noted stenosis and plaque. Catheterized infrarenal aorta, performed aortogram which was stenosed w/plaque. RT common iliac was stenosed. LT common iliac was stenosed. RT external iliac was stenosed. LT external iliac was stenosed. RT internal iliac was patent. LT internal iliac was stenosed. RCF was stenosed. LCF was stenosed. RPF was stenosed. LPF was stenosed. RSF was stenosed. LSF stenosed. RT popliteal was stenosed. RT anterior tibial was occluded. RT tibioperoneal trunk was stenosed. RT posterior tibial was occluded. RT peroneal was occluded. RT dorsalis pedis was occluded."

It is my understanding that coronary IVUS is a diagnostic procedure used to assess the size and integrity of the vessels. I realize that this code may be reported during or following an intervention, but what if its purpose is not to evaluate the coronary vessel itself but to evaluate the adequacy of the intervention? For example, "Intravascular imaging was utilized to evaluate the adequacy of the intervention and stent deployment. An IVUS device was threaded into the proximal to mid RCA. The cross-sectional area was 8.2 mm. The stent was expanded the optimal amount, and there was good strut apposition."

"Patient with small veins with stenosis in brachial/cephalic fistula. Wire passed and 6 x 20 cutting balloon over wire; balloon angioplasty with excellent results. A wire was passed into the branch, and a small incision to dissect the vein and perform ligation. Bleeding was noted where branch had been ligated. There was a slight tear where branch joined main vein and stitch and pressure applied and bleeding stopped. Weak thrill noted and some clot noted at site of angioplasty. With wire in place, AngioJet thrombectomy was performed, but area had already restenosed. A 7 x 7.5 stent was deployed and ballooned. Following stent placement, excellent thrill was noted and good flow. Wire was removed and pursestring 3-9 nylon placed." Code 36906 doesn't seem to correct because the incision was made for ligation and thrombectomy. If 36833 is correct for ligation and thrombectomy, there is a PTP with 36903. Thoughts?

If the physician accesses bilateral femoral veins, then over the wire, a Volcano PV IVUS catheter is placed and intravascular ultrasound evaluation of the bilateral iliofemoral veins and IVC is done, would this change the catheter placement to 36010-50? Or is it still just 36005-50?

I looked through your knowledge base and saw that you recommend using code 33216 when a permanent pacemaker lead is used instead of a temporary lead. However, I’m unsure of using it for the following situation. "Day 1: Patient with WPW was brought down for an ablation. A complete EP study with left atrial recording and pacing, 3D mapping, and Isuprel was done. An ablation was performed with abrupt termination of the pathway, and complete heart block occurred. Conduction returned via the accessory pathway. Any attempts at further ablations were discontinued. Because of concern that the ablation may have affected the conduction via the AV node, a temporary pacemaker was placed, although this was actually a permanent pacemaker lead." Can we report code 33216 here, or should we code nothing since we caused the problem? Also, should we append modifier -74  on the ablation code since it was not successful? The same thing was repeated three days later. The ablation was successful, but the patient had a junctional rhythm and another temporary pacemaker lead (again a permanent lead was used).

LHC with abdominal aortogram and bilateral femoral run-off from two cath positions above and below renals performed to evaluate chest pain, syncope, and bilateral LE claudication worse on the left. Findings are given for abdominal aorta (no aneurysmal dilatation), renal arteries, and aortoiliac/SFA/infrapopliteal segments. Selective left popliteal angiography is then performed with findings describing the left pop, AT, PT, and peroneal arteries. How would this be coded? The department has 93458, G0278, and 75625. Are infrapopliteals included in G0278?

Per Ask Dr. Z question ID #9706 dated August 7, 2017, the MD stented LVAD graft with VSD occluder device. What would you bill if physician put a Palmaz XL stent in an existing LVAD graft? Would you still suggest unlisted code 33999... or 92937 and 93455? "MP catheter and supracore wire advanced into outflow graft of LVAD, MP replaced with pigtail catheter and baseline angiography hemodynamics were assessed. Amplatz wire advanced into outflow graft to assure wire remained outside the pump housing, stators and motor. Palmaz XL was hand mounted on a 16 mm x 5.5 cm BIB balloon and advanced over the wire positioned in the proximal segment of the outflow graft. Optimal position achieved. Stent deployed with the pump speed reduced to 6000 rpm. Balloon was removed, and a second Palmaz XL stent was hand mounted. Balloon was advanced and positioned stents overlapped. Second stent was deployed with the pump speed reduced to 6000rpm. Stents then post-dilated balloon was removed. Pigtail readvanced over the wire, and final angiography and hemodynamics assessment were performed. Catheter removed."

Can I code a stress echo (93351) as well as a cardiopulmonary stress test (94621) for the same DOS done by the same physician? I know if a regular stress test (93016 and 93018) is done with a stress echo, the charges bundle into 93351, but I am not sure if the same rule applies to 94621.

What CPT code is recommended for endoscopic harvest of a radial artery? I am finding conflicting information regarding using 35600 or an unlisted code.

"Catheter crossed the occlusion in the right upper axillary artery. Sheath was advanced into proximal subclavian, then embolic protection filter was placed. Percutaneous directional atherectomy of the right axillary artery was performed, followed by angioplasty." What is the CPT code for percutaneous axillary atherectomy? Is it a category III code for unlisted? I believe the angioplasty code is 37246 for axillary. Can that be billed in addition to the atherectomy?

Can we report code 93015 with 93924 for the stress testing portion of 93924? Does code 93924 include stress testing, per description? Is code 93015 not appropriate for extremity testing?

When a doctor performs AAA repair with the delivery of an endograft prosthesis via femoral artery, sometimes he/she will perform a brachial artery cutdown. We've noticed that from this they will catheterize the renal arteries for stent placement into the renal arteries during a fenestrated graft placement, or sometimes they will do it to have through-and-through access to help them place the endograft. 1) Can we report code 34834 for the stent placement in the renal arteries for the fenestrated graft? 2) In the case of a normal endograft placement (not fenestrated), if the actual endograft itself is not placed via the brachial artery cutdown, can we still report code 34834, as the brachial cutdown was performed to help them place the endograft in some way, regardless of whether or not anything was passed through other than a catheter?

Would it be appropriate to bill code 99152 (physician documented 26 minutes) in the following example? "General anesthesia with intubation and mechanical ventilation was already in place from the OR. Continuous monitoring consisting of continuous ECG, pulse oximetry, and cardiopulmonary monitoring was performed by a dedicated RN and documented in the procedural flowsheet."

If a patient is having an angiogram as a pre-operative procedure for kidney transplant (for example), and they happen to find CAD, would you use Z01.810 as the first listed code with the kidney disease? Or use I25.10 without using the Z01.810?

Is it appropriate to report codes 37607 and 36830 in this case? Or is this revision? "There is an AVF in the antecubital space that never matured. An incision was made over the cephalic vein, and the cephalic vein was circumferentially dissected. Sutures were used to ligate the cephalic vein. Then a 3-inch longitudinal incision was created in the axilla overlying the brachial artery pulse, and the proximal brachial vein and artery were dissected free. The vein was ligated distally, clamped proximally, and transected. The artery was encircled with a vessel loop and dissected free. Accuseal PTFE graft was tunneled in a subcutaneous fashion forming an upper arm loop. This required a 1-inch counterincision a few fingerbreadths above the antecubital fossa. A 7 mm end of the graft was cut and anastomosed in an end-to-end to the draining brachial vein. The brachial artery was then controlled with clamps, and arteriotomy was performed with an 11 blade and a Potts scissors extending 4 mm. The end of the graft was then anastomosed in an end-to-side to the brachial artery."

In a congenital cath case where they put coils in the RIMA and in a collateral of left subclavian, would you consider that two surgical fields or one?

We are having a debate in our office on coding the following: "The 10 French SL 1 sheath was advanced containing a 25 mm Gore Helix left atrial occlusion device. The device was deployed at the ostium of the left atrial appendage. A second transseptal access was obtained using Torflex 90 sheath. Angiograms were performed utilizing the Torflex 90 sheath to evaluate the Gore Helix. Device position, size, compression, seal, and stability were assessed. All criteria were met and the device was released from the delivery catheter." Is the correct coding 33340? There is debate that the Gore Helix is an ASD device and 93580 may be coded.

I know you can use CPT code 76882 for vessel mapping for a graft. Can you use this code for any vessel mapping not just for grafts? Also, what documentation does it require besides permanent imaging?

Our physician performed an ultrasound-guided therapeutic and diagnostic needle aspiration of a hepatic cyst with abdominal pain. A total of 350 cc of chocolate brownish fluid was manually aspirated and sent for laboratory evaluation. This was originally coded with 10160/76942, but the diagnoses did not support this procedure coding. Would it be appropriate to code this with 10022 and 76942?

"Procedure: Removal of bilateral upper quadrant temporary pacemaker wires placed in a coronary artery bypass grafting approximately year and half ago. These were protuberant and causing pain. I previously marked the location of the protuberant temporary pacemaker wires while she was in same-day surgery. I made an incision over each of these in the left upper quadrant and also one in the right upper quadrant spanning approximate 1 cm in length with a 15 blade scalpel. I was able to dissect bluntly with Crile forceps and grasp both the left upper quadrant ventricular pacemaker wire and the right upper quadrant atrial pacemaker wire with gentle pressure and was able to remove these. She had no rhythm disturbances and had no hemodynamic instability." Would this be reported with unlisted code 33999?

"Patient presents for TEVAR for distal arch and descending thoracic aortic aneurysm. With an 8 French sheath, the surgeon places TEVAR at the level of the left common carotid artery. Continues placing distal TEVAR extensions covering the left subclavian artery origin and ending at the origin of the celiac artery (33880). Through micropuncture access of the left brachial artery, a 1.7 mm laser is delivered to the level of the newly placed TEVAR. A fenestration is created and ballooned. A stent is then placed into the left subclavian artery." Can the stent be reported with code 37236? Or would I use a -22 modifier on 33880?

Would you advise separate reporting of a diagnostic right heart catheterization (93451) in addition to 93799 for CardioMEMS recalibration for the facility and/or the physician? Would the right heart catheterization be considered part of the recalibration service?

Can we code and use 76937 with ablations if vascular guidance access is used?

Would you be kind enough to clarify reporting the new anticoagulant management codes for 2018 (93792, 93793)? Our understanding is that these codes may be provided in either the home or office place of service, based on the narrative description of the CPT codes. We have a physician who wants to bill for these services with place of service inpatient. The CPT guidelines for code 93793 state: “Do not report 93793 on the same date of service as an E/M service." However, they also have the following parenthetical note: "(Do not report 93793 in conjunction with 99201,99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245)." We assume the guidelines only specify outpatient E/M codes because these are considered outpatient services, so listing the inpatient codes wasn’t necessary; however, we need confirmation. Do you agree that CPT codes 93792 and 93793 should only be used with a place of service of home or office/outpatient? 

I have a difficult Y90 mapping that required 100% additional time, and the physician is asking for modifier -22. This is a non-Medicare patient. I found that for codes 36247, 36248, and 75774 the -22 modifier is allowed on the professional side. Per Medicare guidelines (https://med.noridianmedicare.com/web/jfb/topics/modifiers/22) modifier -22 can only be reported with procedure codes that have a global period of 0, 10, or 90 days. Other procedures are ineligible for modifier -22. Codes 36248 and 75774 have a global period of XXX. Can we still bill these with the -22 modifier since this patient is not Medicare?

Please explain how to bill when radiology does the lumbar puncture (62270) with fluoroscopy, and oncology administers the chemotherapy drug.

Can remote evaluation of interrogation device code 93294 be reported with in-person evaluation of interrogation device code 93288?

The physician exchanged the bilateral nephroureteral stent to a nephrostomy over the same tract. Would the correct code be 50435? And is there a removal code for the nephroureteral stent?

A patient had an alcohol septal ablation done, and a temporary pacemaker was placed at the same time. I know that the temporary pacemaker is included with the ablation procedure, but can anything be billed if the temporary pacemaker is removed a few days later? A different physician placed and removed the temporary pacemaker.

Can we use code 33363 for the following procedure? "Transcatheter aortic valve replacement using Medtronic Evolute R Pro 26 mm percutaneously from left axillary approach, balloon angioplasty of left subclavian artery at area of dissection just opposite the vertebral, second order catheter placement and angiography of the left subclavian, additional vessel after basic ×2."

When we do MRI of multiple joints on the same extremity, do we charge these individually or change this to an extremity?

We periodically receive reports where our IR doctor is requested to place an IV under ultrasound guidance. This is typically due to poor IV access. When is it appropriate to bill this service? Sometimes this may be the only procedure that day. Sometimes the patient has a "with contrast" imaging study following the placement.

If the patient has never had a diagnostic angiography done before and the provider performs one, then decides based on the findings of the diagnostic angiography to perform a therapeutic/surgical procedure [i.e., revascularization of the femoral (37224) and also a selective renal angiography (36251)], can you code for the diagnostic angiography (75625)? Or is it always bundled into the renal angiography?

I am being told you can never bill code 75630 with 37225. "You can’t bill diagnostic when intervention done on lower extremity on the same date of service." In my procedure, the diagnostic 75630 was performed (B/L as indicated in the description), and a decision was made for intervention. The intervention was performed only on the right SFA. Can you advise if diagnostic code 75630 would be appropriate to add?

Our protocol for a bone density (77080) is to perform the measurements of the L-spine and both hips. When the patient has metal in the spine or one hip, we substitute a wrist view. When we substitute the wrist view, we have been charging 77081 in addition to 77080. We have had some denials on this from Medicare. Should we not be charging 77081 in addition, or should the referring physician code the order a particular way that justifies this charge?

Our physicians have started performing urosonography procedures, and we aren't sure about the coding. Our code choices are 51600 and 76700 without 74455 because the dictation states: "Initial grayscale sonographic images were obtained of the bilateral kidneys and bladder. 0.5 mL of Lumason was mixed in 250 mL of saline. 40 mL of contrast mixture was infused by gravity into the bladder during sonographic observation." Please advise.

I have reviewed old questions about CPT code 93286, but I am wondering if this is just for the MD billing or if it can be used for hospital billing as well?

Which CPT code, 37236 or 33881, would used for the following intervention? "Given the unexpected finding of the aneurysm, it was necessary to perform a covered stent angioplasty of the proximal thoracic descending aorta. This served the dual purposes of endovascular repair of the aneurysm as well as treatment of the residual coarctation. The right femoral artery was noted to be stenotic, and not large enough to accommodate the required sheath. An 8 French sheath was therefore placed in the left femoral artery under ultrasound guidance. After serial dilation, a 12 French sheath was advanced through the LFA without any resistance and positioned in the transverse arch. Next, an Amplatz super-stiff wire was positioned in the right subclavian artery. A 2.8 cm long CP covered stent was mounted on a 12 mm BIB balloon. The covered stent was advanced to the proximal descending aorta, within the previously placed stent and spanning the broad-based aneurysm. The stent was implanted without difficulty and post-dilated with a 12 mm x 2 cm Opta balloon. The aneurysm is completely excluded."

"Infrarenal abdominal aneurysm with very short neck requiring bilateral renal and suprarenal extension, aortoiliac graft, Ovation iX graft. Accessed both brachial and femoral arteries and 12 French in the LT and 14 French in the RT (34713-50) femoral. Aortogram - marked angulation of suprarenal aortic neck, RT/LT renal is filling and RT renal is somewhat lower than the LT. Large fusiform aneurysm w/ 1cm neck below the LT renal and extend to the aortic bifurcation, common iliacs with moderate luminal irregularity. Catheter placed in RT/LT renal, selective injection and placed stent (37236-37237). Sheath across on the RT and wire on the LT, placed the Ovation graft (34705) and deployed it above the renals. Put polymer in and cannulated the gate from the contralateral side, IVUS aorta and both iliacs (37252, 37253, 37253). Polymer cured then deployed the limbs into the common iliacs." One doctor would like to bill 34705, 34842, 34713-50, 37252, 37253, and 37253, while the other doctor would like to bill 34705, 34709 x 2, 34713-50, 37252, 37253. Any help and explanation is greatly appreciated!

We performed a 36905 with Q9967 (contrast material) along with J2997 for the alteplase injection to dissolve the blood clot. Now the insurance company is wanting the money back on the J code. Should we have billed it in the first place?

Patient came in with existing epicardial LV lead with no other leads or generator. Physician implanted a right ventricular lead, a right atrial lead, and a generator, and then connected the newly implanted leads and previously implanted LV lead to the newly implanted generator. Would you code this as an initial insertion (33208) or as an insertion with existing leads (33212)?

What CPT codes would be billed for myocardial viability SPECT with immediate imaging and 24 hour delay imaging? Thallium 201 chloride was administered. Day one and day two were images were both at rest.

Ruptured abdominal aortic aneurysm, status post EVAR with type 1A endoleak. Percutaneous access with proximal extension cuff Endurant II with intentional coverage of the left renal artery in order to obtain maximal seal. Is 34710 the appropriate code for this procedure?

"Patient hx of same side endarterectomy, embolization, and stent. DSA done 1 week ago shows new pseudoaneuysm just distal prior endarterectomy and stent. I was then able to advance my VTK catheter and the neuron Max sheath and positioned them just proximal to the stent. Although I wanted to use a filter device for the stenting and angioplasty, the stent corresponding to use was not a monorail. As there were no filter device with a 300 cm exchange length wire I was unable to use any filter device for the stenting and angioplasty. I then measured the size of the carotid artery within the stent, and based on that I decided to use a 6 mm x 2.5 cm by a band covered stent. I then performed an angiogram with cervical views, which confirmed satisfactory deployment of the stent across the area of the pseudoaneurysm with the stent completely covering the whole extent of the endarterectomy." Do we report code 37216, or should we report an unlisted code? Dx pseudoaneuysm?

Patient with bone lesion rib. Soft tissue component is biopsied along with bone... chest wall... anterior rib... through chest wall, soft tissue component was biopsied. Then, bone biopsy needle through chest wall to anterior rib. Can we code for both? Which codes?

A RUE DVT is determined to be caused by the PICC line, and the PICC line is removed. How is the DVT coded at the follow-up visit a week later, now that the PICC has been removed? A year later, the DVT (initially provoked by the PICC line) is now carrying a chronic status per duplex scan. How should this be coded?