Ask Dr. Z

When our doctor does a Permcath exchange (36581), he uses fluoroscopy (77001-26) and says, "Contrast was then injected through the secondary catheter port under fluoroscopic visualization to perform an SVC." I have been only coding 77001-26 because there is only one access (the port exchange site). Is this correct? In this case, there was extensive fibrin sheath in the SVC, and a balloon catheter was used to remove the fibrin sheath (36595-52, 75901-26). Should I bill the SVC-gram? Also, there is an edit on codes 77001-26 and 75901-26. Is a -59 modifier appropriate?

I have a provider performing a plug-assisted retrograde transvenous obliteration where a 22 mm AVP 2 was advanced to the choke point on day 1. The gastro-renal shunt was embolized. They allowed a "dwell" of sclerosant and Gelfoam slurry overnight. In the AM of day 2, the provider used fluoroscopic guidance for AVP 2 vascular plug deployment. It appears the sheath was left in overnight also. This is the note for day 2 procedure: "Using direct fluoroscopic guidance the AVP 2 was released and was noted to be stable in position. Then, the right neck sheath was removed and hemostasis achieved at the right neck puncture site with manual compression." Can we bill for the work done on day 2? Or is that included in the charges billed for the procedure performed on day 1? 

I have a question regarding code 36620. We do intra-arterial hemodynamic monitoring with our complex EP cases (such as 93656 and 93654). Is code 36620 bundled with these two procedures, or is it appropriate to separately bill this service as a physician?

What are the correct codes for CardioMEMS? I was told to report codes 93451-26, 93568, and 93799 (unlisted code)... and then, in block 19, I was told (by the CardioMEMS company) to enter a code that is comparable to 33216. This is for physician billing. 

Is it allowable to bill heart cath codes (93453 - right/left pressure measurement or 93451 - right heart pressures) with PVI (93656)? I could not find any documentation in the CPT Codebook or your Q&A. (Other billed CPT codes are ICE and 3D mapping.)

What would be the correct billing for the scenario below? With the new 2018 38222 code, I am unsure what codes and modifier to use. "Procedure: The left posterior iliac crest was cleaned with betadine solution and draped sterily. The area was injected and anesthetized with 12cc 1% lidocaine solution. The procedure was performed using a standard Jamshidi bone marrow needle. First, an aspirated was obtained. Second, a biopsy was attempted, but unable to be obtained despite two attempts due to patient intolerance of procedure." Would 38222-52 be correct?

My physician is doing a AAA repair. Can you also charge out for the angioplasty and stenting of superior mesenteric artery (37236) with a -59 modifier?

What would be the appropriate coding for "conversion" of a Vena Tech Convertible Filter? My understanding is that the entire filter is not removed, just the head of the filter is snared and removed, allowing the remaining filter to open and remain in the vena cava. Just had my first one of these, but I am sure I'll be seeing more in the future. Currently with only codes for filter placement, repositioning, and removal, I'm not sure how to handle these.

Once the coil is deployed, would imaging always be 75898? What if they just document the position of coil as seen below? 75894 or 75898? Then the coil was placed proximal A2 segment and a slowly deployed from the right A2 segment to the proximal right A1 segment. At that point of the coil was completely deployed, reaching the proximal A1 segment and covering the aneurysm neck. Follow-up DSA AP and lateral demonstrated adequate wall apposition.

How would you bill the DynaCT? Should I use 74150-52 or 76380 (CT limited)? "There were multiple attempts to re-access the stomach through the pre-existing abdominal wall access. These included advancing the Amplatz guidewire, an attempt using a Glidewire, and positioning of a Kumpe catheter to aid in wire placement. The decision was then made to perform a limited abdominal CT utilizing DynaCT. This demonstrated the Kumpe catheter to be intraperitoneal in location, located immediately anterior to the spleen, with intraperitoneal contrast."

"The patient presented to the cath lab with ascending aortic pseudoaneurysm. Thrombin injection through anterior chest wall with micropuncture needle (3000) was performed with partial thrombosis of the pseudoaneurysm. 2000 units of thrombin were injected into the pseudoaneurysm. Angio of the pseudoaneurysm was performed." Would you use code 33999 or 37242?

"Ultrasound was used to evaluate the left arm. Then, under direct ultrasound guidance, the AV fistula was punctured just distal to the arterial anastomosis. Hard copy ultrasound was saved and sent to PACs. A 4 French antegrade sheath was placed in standard fashion. Left upper extremity venograms were obtained. Then, the 4 French sheath was exchanged for a 7 French sheath over a Bentson wire. The Bentson wire and KA 2 catheter were then used to cross the venous outflow stenoses and the wire was placed centrally. Then, the venous outflow was angioplastied in two focal areas of stenosis with a 10 mm x 40 mm balloon. Final venograms were done after prolonged balloon inflation of the MultiHance focal stenoses. The final venograms demonstrate improved flow through the fistula with no significant residual stenoses. The fistula is slightly aneurysmally dilated. The images were reviewed. The sheath was then removed and hemostasis was achieved with manual compression." Would correct coding be 36901 and 37246? Or 36902?

We are a hospital based radiology practice and recently received multiple refund requests from a Medicare Adv Plan on breast needle localization codes 19281-19286 for 2017 due to Medicare's new OPPS payment system. These were billed along with codes 78195 and 76098. Can you confirm if this is an accurate "packaging" of codes, and, if so, why do they recoup on the higher RVU? I've researched Medicare's website and can't find anything relating to this particular procedure.

My provider did heart catheterization with femoral angiogram. What is the proper coding: 93458/75710 or 93458/G0278?

The neurovascular surgeons I code for see a patient emergently, and after reading the CTA they decide to perform neurointervention right away. Okay, not a problem. But then they will see that patient post-procedure on the same day and will charge an inpatient E/M, some even using the critical care codes. The diagnosis is for the same problem that they performed the intervention for. I think this should be post-op care, even the 0-day global procedures if seen on the same day. But what about the critical care? Can they still bill critical care on the same day, even after a procedure done while using the same diagnosis? I'm confused.

I am having difficulty finding guidelines for tilt table test (93660) and autonomic nervous system test (95924). One of my cardiologists performed both services, but I am not sure if I can code/bill for both. Thoughts?

Patient had percutaneous IABP and LAD atherectomy with DES stent in the cath lab. Patient left the cath lab and went to bed, and IABP was removed at the bedside on the same day. Next day, patient was discharged. Should I report code 33968 along with C9602-LD, and not report code 33967? On page 183 of Dr. Z's Diagnostic & Interventional Cardiovascular Coding Reference, it says, “Be sure to code for this device removal.” Does this mean that we should code removal even if it was done at the bed side? This is facility coding.

Patient with significant pacemaker pocket protrusion came in and had pocket revised into the subpectoral plane. In your 2017 cardiovascular book, page 480, coding instruction #17 advises that code 33222 can be reported for moving to a submuscular location for "twiddlers", erosion, or potentialerosion of skin. "Ask Dr. Z" question #5377 advises if new pocket via same incision but to a deeper SUBpectoralis location, this may be a gray area... but you still thought the deeper location would be appropriate for 33222. Have there been any changes on this subject? Is code 33222 still reportable for relocation to a deeper submuscular level?

OP facility question. Let's say imaging of T5-T12 intertcostal arteries bilaterally (36215-59 x 16, 75705, 75705-59 x 15), L1-L4 spinal arteries bilaterally (36245-59 x 8, 75705-59 x 8). When abstracting, would you line item list them out OR list the first one and use the quantity feature with -59s? I'm looking for official guidance reference if possible.

Please help us clarify when it is appropriate to report code 93318 vs. 93355. We have been using code 93355 for TEE performed during TAVR procedures. We have been using code 93318 for TEE performed during CABG procedures and open valve repair/replacement procedures. Is this correct?

Is documentation of "severe pulmonary artery hypertension in the setting of high ventricular filling pressures" sufficient for left ventricular pressures? Under his description of procedure heading, the physician also states, "Left heart catheterization was performed using a pigtail catheter, along with a ventriculogram from a single plane ROA projection."

When performing cryoablation of the medial and lateral superior and medial inferior genicular nerve, would we charge 0441T three times or once?

I know that there are several guidance CPT codes that can only be charged once per date of service. However, I cannot find clarity on code 75984. If a patient comes in and has two tubes changed, can I report code 75984 x 2 with 49423 x 2?

What is the correct code for the following example? Is code 10035 appropriate? "Procedure and findings: Informed consent was obtained following discussion of procedure risks and benefits with the patient. The patient was positioned prone on the angiographic table. The left T7 rib was fluoroscopically identified, and 1% lidocaine was administered into the subcutaneous tissues overlying the T7 rib head. A Seldinger needle was advanced under fluoroscopic guidance, making contact with the rib head, and two 2.5 x 3 mm pushable platinum fiber coils were deployed through the Seldinger needle on top of the T7 rib. The needle was withdrawn and access site covered with a bandage. The patient tolerated the procedure well and was discharged to the observation room in stable condition. Opinion: Successful fluoroscopically-guided marking of left T7 rib head with two pushable platinum fiber coils."

Please help clarify the following documentation coding. "Duplex arterial imaging was performed of the abdominal aorta and iliac arteries with the following results: The abdominal aorta is normal in size with no evidence of aneurysm or elevated velocities. The stent at the proximal anastomosis of the aorto-bi-femoral bypass graft was identified and appears patent with no areas of stenosis. The aorto-bi-femoral bypass graft appears patent with no elevated velocities to suggest stenosis. Technically difficult exam due to shadowing from abdominal gas." If a complete study is attempted, but not all portions of the vessel can be identified due to shadowing from abdominal gas, obesity, surgery, etc., would it still be considered complete? And how would you determine what is the entire course of a vessel? For example, if the iliacs were viewed bilaterally, would it have to include the common, external, and internal, and how much of the aorta would be considered complete? Would an evaluation of an EVAR graft be considered a complete scan?

When you do a cutdown, extremity and abdominal lymphangiogram, and embolization of the cysterna chyli and thoracic duct all in the same procedure, which codes should be used?

When coding for IVUS, I have requested that my physicians report the vessels, the reason why, the findings, and that hard copy images were saved. They are fighting me on the last point of hard copy images saved. I thought I had read it somewhere back in 2016, but I can't locate a rule. So my question is this: is it necessary or mandated that the physician report indicate that hard copy images were saved?

What is the most appropriate CPT code(s) that replaced 35475/75962-26? My physician is performing a percutaneous transluminal arterial angioplasty of the right cervical carotid artery critical stenosis with the balloon angioplasty, restoring luminal patency for atherosclerotic stenosis/occlusion. He is also trying to charge for selective catherization/angiograms of the following: 1) Right subclavian artery. 2) Bilateral common carotid artery (which I know I can't bill). 3) Bilateral internal carotid artery. 4) Left vertebral artery. He is trying to also bill for the following: QTY 2 for control angiograms from RICA existing guiding cath. QTY 1 for where he entered at left CFA (which I know is included and can't bill for it). Not sure what is the best code. I'm leaning toward 37246. Thanks for your time and helping me with this difficult MD.

Is the angioplasty billable in the following case? It seems that it is being done to deploy the filter completely. "A guidewire was placed through the micropuncture sheath, and the access site was sequentially dilated. The sheath was advanced into the inferior vena cava over the wire. Digital substraction angiography was performed to evaluate the IVC and locate the renal veins. A non-retrievable VenaTech filter was advanced below the renal veins and deployed. The superior aspect of the filter did not appear to be fully deployed. Additional venography demonstrated apparent narrowing of the IVC at the superior aspect of the filter. Gentle angioplasty was performed at the level of the filter using a 12 mm x 40 mm Atlas balloon. Subsequent venacavogram demonstrated persistent narrowing of the IVC at the superior aspect of the filter. The filter appeared to be positioned adequately for prevention of further pulmonary embolism."

Would the following injection be reported with code 62323? "Under fluoroscopic guidance, the needle was inserted and advanced to a periarticular location between the first and second coccygeal segments. Periarticular injection of cortical steroids around the first and second coccygeal articulation was performed."

Can a patient have peripheral vascular disease (PVD) and not have claudication? Is PVD always coded in claudication? My confusion is that sometimes the physician says "PVD with claudication", and sometimes we  have a patient with PVD only and no mention of claudication. Can you please clarify if these are two separate diagnoses? Are the physicians using these terms interchangeably? I am just not clear on this.

If we open for femoral access to close or to check something after the procedure is done, say on an EVAR, does that change it from a percutaneous procedure... losing 34713 and adding 34812?

I have a case where a cardiologist and CT surgeon worked together to remove an infected biventricular ICD as well as epicardial pacing leads. I have one note from each surgeon detailing his portion. The patient has a "biventricular ICD with two previously known LV epicardial pacing leads". Cardiology takes out the generator and does a transvenous laser lead extraction of endocardial leads in the right ventricle and the left ventricle (four leads in total). Then CT surgery performs a thoracotomy, takes out the epicardial LV pacing leads and "stays to help the cardiologist with his laser lead extraction". How would you suggest coding for both physicians?

If tube pericardiostomy (33015) was performed, and two days later 360 cc fluid manually aspirated at bedside, would you report code 33011?

I'm looking for clarification on billing for reconstructed image exams. For example, if the patient has had a CT of the abdomen and pelvis, and images are reconstructed from that exam for a CT pelvis, can that CT pelvis be billed separately by a physician or is it included in the CT abdomen/pelvis exam? Your book explains that a CT thoracolumbar spine can be billed from reconstructed images for a CT chest and abdomen (for physicians only, not the technical component), but it also states not to bill for additional planes imaged or reconstructed since these extra views or 2D reconstructions are included in the base procedure... or does this statement only apply to the technical component as well? I want to make sure that we are coding reconstructed image exams correctly.

When a generator exchange is done for a biventricular ICD and is followed by shock impedance testing with a commanded shock, would the shock impedance testing be reported with code 93641? Or would there be no additional code because the shock impedance would be included in generator exchange code 33264?

The guidelines following CPT codes 61630/61635 indicate that the stenting or PTA are all-inclusive and we should not code for the diagnostic work unless we do not stent or angioplasty. But there are no NCCI edits to stop this from happening. Am I misinterpreting the guidelines?

The EP physician wants to bill code 36620-59 with every EP procedure since he documents the following in his report, "5 French SideArm vascular sheath was placed in the artery and was used for intraoperative arterial blood pressure monitoring." He doesn't document any more information after that as to why, etc. Is this sufficient to bill in addition to an EP procedure?

PT. PRESENTS FOR DIALYSIS CATHETER ACCESS. UNDER US GUIDANCE THE DIMINUTIVE RT YNTERNAL HUGUKAR VEIN IS ACCESSED. A WITE IS UNABLE TO BE ADVANCED CENTRALLY. A 3-FRENCH CATHETER IS PLACED INTO THE VEIN AND A VENOGRAM IS PERFORMED SHOWING THE JUGULAR VEIN IS QUITE DIMUNITIVE AND OCCLUDES AT THE SUPRECLAVICULAR LEVEL. INNUMERABLE COLLATERAL VESSELS ACROSS THE CHEST AND NECK EXTEND INTO LARGER COLLATERAL VESSELS WHICH APPEAR TO OPACIFY THE SVC. AT THIS POINT OPTIONS FOR CATHETER PLACEMENT ARE QUITE LIMITED. THE PROCEDURE IS ABORTED. SHOULD THIS BE CODED AS 75860 AND 36299 FOR THE VENOGRAPHY OR 36556-53 FOR THE ATTEMPTED CVC PLACEMENT?

How would we code for a MRN of the lumbosacral plexus? We have two scenarios (if it makes a difference): 1) Symptomatic patient has MRI lumbar spine and also an MRN same day, which is dictated as a separate report. 2) Patient has MRI lumbar spine and subsequently undergoes several weeks of therapy with no relief. Patient comes back a few months later and has the MRN alone.

"A patient came to our department with a non-functioning right upper chest tunneled dialysis catheter and a non-healing ulcer of his left second toe. The doctor started with a diagnostic left leg angiogram via antegrade stick into the left femoral artery (75710, 36140). The findings were a high-grade stenosis of the tibioperoneal trunk. A PTA of the tibioperoneal trunk was performed with a good result (37228). We then turned our attention to the non-functioning perm cath. The right upper chest and neck was prepped. The catheter was injected finding a fibrin sheath. We used a balloon via the same access to disrupt the fibrin sheath (75901, 36595). A new tunneled dialysis catheter was then inserted via the same access with a new tunnel (36581, 77001)." Our coders are telling us that we cannot charge code 77001 because it is bundled with the other codes. Please help us with this situation.

We are questioning if we should bill a revision or an unlisted code for the following pacemaker procedure. "A 4 cm incision was made on the skin overlying the infraclavicular fossa with a #15 blade. Dissection was carried down with electrocautery to the pre-pectoral fascia until his chronic DCPM was identified. Further dissection was performed and the device extracted from the body. Hemostasis was obtained as needed with electrocautery. The generator was seen in a vertical position. The generator was then removed, and a deeper caudal pocket was made using blunt dissection. Hemostasis was obtained with electrocautery. The lead and device were then placed in the pocket and sutures with 1-0 silk suture."

Is it appropriate to bill code 93352 if in the physician's interpretation he does not mention the use of Definity? It is listed in the report as a medication administered and signed off by the physician, but he does not personally refer to it at all in his interpretation.

Patient had a biventricular pacemaker with a malfunctioning left ventricular ENDOcardial pacing lead. Physician performed, by thoracotomy: 1) Placement of EPIcardial lead left ventricle, 2) Removal of ENDOcardial lead left ventricle, 3) Removal of current pacemaker generator with replacement of new pacemaker generator and reattachment of the existing right atrial and right ventricular leads. I know the placement of epicardial lead is 33202, but I can't locate a code for removal of an endocardial lead. I would assume the generator exchange is 33229. Would CPT code 33238 be appropriate for the endocardial lead removal?

I code for neuroendovascular physicians, and I recently attended a coding seminar and was told that we cannot bill for ultrasound guidance for vascular access. Could you please clarify this statement for me since all the research I have done does not confirm this?

I was reviewing a question from 2013 in regards to insertion of single transvenous electrode connected to external pacemaker. Is 33216 still accurate, because the description states permanent pacemaker or implantable defibrillator?

Would the following example be reported with codes 34201 and 37186? "We made a transverse incision in the distal common femoral artery. We inserted an 11 French sheath. Angiogram demonstrated thrombus in the popliteal artery and distal superficial femoral artery. There was single vessel peroneal run-off with chronically diseased and occluded anterior tibial and posterior tibial arteries. We brought a NAV6 filter into the tibioperoneal trunk. We performed over-the-wire thrombectomy of the superficial femoral artery and popliteal artery. We removed a lot of thrombus. Repeat angiogram demonstrated patency of flow in the popliteal artery with irregularity and debris in the tibioperoneal trunk. We performed mechanical thrombectomy with a Penumbra CAT8 catheter of the popliteal artery and the tibioperoneal trunk."

The documentation states: "Under fluoroscopic guidance, an 18 gauge coaxial Temno biopsy needle was advanced into the posterolateral aspect of the L2-L3 disc. With the guiding needle in the disc space, no fluid could be aspirated. Four core biopsies were then obtained." I have referred to Q&A #6963 and #8906; however, the information is conflicting between 64999 and 62267. Please clarify the appropriate CPT code for this procedure based on the documentation provided.

This patient had left heart cath with selective right and left coronary angiography (93458-26-59) along with PCI with stent to the LAD for STEMI (92941-LD) and stent to the RCA (92928-RC). In the recovery room, while undergoing echocardiography, he developed ventricular fibrillation and was returned to the cath lab, suspecting another cardiac event. He underwent right and left coronary angiography (93454) at this time but no stent. What modifier do I require on the 93454? I do not believe it would be -76 because it isn't the same CPT code. I am now debating between -78 and -59. 

Ultrasound is included in the RFA, but can be billed separately with sclerotherapy. We receive an edit on the RFA code stating that no modifier is allowed. Can ultrasound be reported in the same session for these two procedures?