Ask Dr. Z

Patient had filter in place for 13 years. It had fractured into four pieces, all in close proximity to the original placement site. The largest piece of the filter was embedded in fibrous tissue, and a laser was used to free the filter. Should I only report code 37193?

What are the current 2018 CPT codes for sphenopalatine block? Is fluoroscopy included?

We have a patient who has an abdominal abscess catheter in place. They were found to have complex debris within the abscess cavity. TPA 2 mg in 10 ml of saline was injected and left for 2 hours prior to opening JP suction. Should the administration of the TPA be billed with 49185 or unlisted code 49999?

We just received the information about the complexity adjustments codes for 2018. Is this for providers or hospitals? The term "complexity adjustment" is new for us at the hospital. What does it mean for the hospital?

Bilateral pulmonary AVM embolization with 10 catheterization sites of the lobes. Would you report codes 37242 (x 2) and 36015 (x 10)?

Patient had a peritoneal abscess. The doctor did a diagnostic aspiration first (10022), then placed a catheter for continued drainage (therapeutic 49406). I do not see an NCCI edit on these two codes, but I'm not sure if I can bill both same day/same session/same abscess. Please advise. 

We do echos with DEFINITY. Please tell me the correct code grouping: 93306, 96374, Q9957 or 93306, 96409, Q9557?

If a stent was placed in the diagonal branch, and after this was done it was found that the occlusion was in the main LD and so the provider goes back 3 hours later and places a stent in the main LD and also performs a kissing balloon angioplasty in the main LD and the diagonal branch, would we be able to bill for both stents plus the angioplasty on the second attempt?

What would be the correct code for fiducial marker placement in this case? "Patient has metastasis from hepatocellular carcinoma, replacing the T9 vertebrae. He accesses the T9 pedicle, and a gold marker was deposited within the soft tissue just dorsal to the right T9 pedicle and another to the left T9 pedicle." Is this soft tissue or bone or thoracic?

"A Swan-Ganz catheter was advanced into the common iliac vein however it met resistance. The Swan-Ganz catheter was pulled back into the introducer sheath, and the right common iliac venography was performed. No lesions were identified." Is this considered bundled with the procedure?

Our providers on occasion dictate the following for AAA repair: "Amplatz device was used to place surgical staples around the neck, which went quite nicely with excellent seal." For 2018 we have 34712, fixation device (e.g., anchor, screw, tack). Does the staple fall into this category?

Can the vertebral artery stent (0075T) be billed with the basilar artery thrombectomy (61645) during the same session? Would this also be the case for 0075T and 37215 since they are in different territories?

For the following case, should code 36596 or 36593 be reported? The physician is defining as catheter declot, but the "explosive irrigation" is throwing us. "Pre-Op Diagnosis: Catheter dysfunction. Procedure: The risks and benefits of catheter thrombolysis were discussed with the patient in detail. The patient understood, and informed consent was obtained. The ports were prepped and draped in usual sterile fashion. The ports were aspirated and then explosively irrigated using normal saline. 2 milligrams of tPA was then slowly infused into both ports."

I have coded an US-guided lymph node clip placement with 10035, but they also did a post digital mammogram. It does not seem correct to code mammography when only axilla is imaged? Should code 77065 be reported?

Would unlisted code 49999 be used for a pleural tunneled catheter exchange? "A 0.035 stiff guidewire was inserted through the existing tunneled catheter to secure access. The cuff of the existing catheter was dissected away from the surrounding skin and mobilized. The old Aspira catheter was retrieved over the stiff Glidewire. A new Aspira catheter was then advanced over the Glidewire into the loculated pleural collection. The new catheter was sutured to the skin."

This provider did a left AVG with plication. "He did an arterial anastomosis, first applying vascular clamps using a blade and Potts scissors arteriotomy was done. An end-to-side anastomosis was done and noted to have good flow in the graft. Then an end-to-side anastomosis was done on the high brachial vein. Prior to completion all vessels were flushed and hemostasis was noted. Doppler signals above and below the venous anastomosis were noted to be very strong. However there were faint Doppler tones in the radial and ulnar arteries, so two separate areas of plication of the AVG were sutured. Doppler tones on the radial and ulnar arteries were then back at baseline." This was done on a patient with ESRD on hemodialysis needing permanent access. Should they have used the new codes for dialysis circuit (36901-36909)? Or should codes 36830 and 37607 be used instead?

Code 38222 is not listed as an appropriate code to report with 77002, but codes 38220 and 38221 are. Is this an oversight, or should fluoroscopy not be reported with 38222?

What CPT code would you recommend for ReDS Wearable System? The ReDS™ Wearable System is a non-invasive, portable, wearable vest cleared by FDA that uses impedance plethysmography technology to accurately quantify lung fluid volume through a brief, 90-second reading. Measurements of lung fluid volume with the ReDS™ Wearable System, which clinicians use to guide treatment of heart failure patients, have been demonstrated by clinical evidence to reduce the rate of re-hospitalization of heart failure patients by 87%.1 The ReDS™ Wearable System is appropriate for use in multiple settings of care, including hospital inpatient, hospital outpatient, physician office, and home monitoring. 

"Renovo Rx catheter was positioned along the splenic artery adjacent to the adenocarcinoma. The infusion port was injected with contrast to ensure distal and proximal occlustion. Once occlusion confirmed, the infusion of 2000 mg gemcitabine in 132 mL was performed over a 20-minute interval using the power injector. Post infusion splenic artery angiogram was performed, demonstrating no evidence of vessel injury or extravastion." Can I bill anything for the chemoinfusion? I know I can bill for the catheter placements and diagnostic angios. I am billing for the professional side, and the patient is an inpatient at the hospital. Can I report code 96422? Or something else?

Is code 38222 to be used when both bone marrow aspiration and biopsy are performed through the same incision? If aspiration and biopsy are performed though two separate incisions, do we use codes 38220 and 38221?

Patient has a created upper extremity AV fistula for plasmapheresis (not dialysis). They are performing venography through the fistula. Do we use dialysis circuit code 36901 or stay with 36005/75820? You answered a similar question in 2011 instructing to use the non-dialysis codes, but with new CPT codes, have there been any changes in how to view this?

Is there a CPT code(s) for CT localization with methylene blue at T9-T10? A neurosurgeon is to perform a T9-T10 laminectomy with decompression and requested my provider do a CT marking with methylene blue. The report states: "Using intermittent CT fluoroscopy for guidance, a 22 gauge, 3.5 inch spinal needle was introduced into the soft tissue of the back and progressively advanced up to the posterior aspect of the T9-T10 posterior elements. Repeat CT imaging of thoracic and lumbosacral spine was obtained to verify correct needle position at the T9-T10 level. I then injected approximately 1 mL of methylene blue through the spinal needle at the T9-T10 level. The needle was removed." 

We currently use codes 62302-62305 to bill for myelograms performed by the radiologists. They would like to utilize the PAs for the myelogram injections. Would it be appropriate to have the PAs perform the injection and bill under their NPI for code 62284, and also bill under the radiologist NPI for codes 72240-72270?

I have a case where there are two separate lesions, one in the mid left circumflex and the other in the obtuse marginal. One stent was able to cover both lesions. With these two lesions being separate and in the main artery and branch, should I code this as one intervention? Or as two interventions with 92928-LC and 92929-LC?

Can a congenital catheterization code (e.g., 93533) and 92990 be reported together?

Indication for case was an abnormal CTA. Right femoral access used. We have the following CPTs charged. Are they correct? "Procedure Summary: Spinal dural arteriovenous fistula with venous hypertension. Fistula appears to be present at T12/L1 levels: internal carotid left and right (36224 x 2), vertebral left and right (36226 x 2), external carotid left and right (36227 x 2), subclavian bilateral (75716), right thyrocervical trunk (36218, 75774), left thyrocervical trunk (36217, 75774), left supreme intercostal (36218, 75705), intercostals bilaterally T4-T12 (36215 x 18, 75705 x 18), lumbars bilaterally L1-L4 (36245 x 8, 75705 x 8)." Are we close?

Patient receives a new CRT-D with the third lead placed at the bundle of His (as opposed to the LV). For the lead charges we are using HCPCS codes C1777, C1898, and C1898 (instead of C1900). For procedure codes we are still unsure. We have 33249 for the device; what additional procedure code would be best for the His bundle lead placement? 

"The left external iliac artery lesion was stented with a 6 mm x 6 cm self-expanding stent, which was dilated to 6 mm. Catheter positioned in the SFA. A 6 mm x 6 cm self-expanding stent was then placed across the area of occlusion. The catheter was then positioned in the above-knee popliteal artery, and an outflow arteriogram was performed below the level of the knee. Using a straight Glidewire, the peroneal artery was accessed. The occlusion in the mid peroneal artery was crossed and suction embolectomy performed. A 0.018 wire was then placed. A 2 mm x 15 cm balloon was then used to dilate the peroneal artery. Repeat arteriogram was performed. An attempt was made to recanalize the left anterior tibial artery using multiple different wires; however, the chronic occlusion could not be crossed." Would you report code 37186 for the embolectomy with 37228, or 37229 atherectomy peroneal? In addition to 37221 (iliac) and 37226 (SFA)?

Since code 71023 was deleted for 2018, what code do you suggest to report a sniff test?

My provider is placing a stent into the LAD and RCA. He stated there was a mechanical obstruction in the LCX due to the LAD stent, and then he did a plasty on the LCX. Would I bill for this plasty with 92920-LC or just consider that not billable?

Patient had a DVT diagnosed in the PVL prior to initiating thrombolysis. Can we charge for the "confirmatory" venogram done during the thrombolysis encounter?

Does a statement of patency (i.e., "right renal vein, left renal vein are patent") constitute as "venous outflow" and support billing a complete study (93976)? The arterial inflow is equally documented ("no significant stenosis of bilateral renal arteries").

Dr states 34847. Cath advanced into bilateral renals through the renal fenestrations. Then, soft cath, the SMA scallop was cannulated, a wire was advanced down SMA. Balloons inflated for release of constrainment of fenestrated body. Does the scallop count as the third opening? Or is this just a two opening (34846)?

Can I bill EVAR with FEVAR if they are done at the same operative session? Usually these two are done as staged procedures, but in this case they were done concurrently. FEVAR includes proximal extensions, but I do not think that applies to axillary delivery of the thoracic endograft placed before FEVAR device. NCCI does not bundle the two, but I am hesitant to bill them together. Can it be done?

The patient was admitted inpatient and had TEE done. No intracardiac thrombus was seen. ICE catheter was inserted and revealed thrombi on right atrial and ventricular pacing leads. Transseptal puncture was not performed. Since ICE is an add-on code only, what would be most appropriate to bill? 33340-Q0,53?

How would you code this vascular embolization/occlusion scenario? Coil occlusions were done of five collateral vessels: 1) Collateral from left hepatic vein to systemic pulmonary vein; 2) Collateral from innominate vein to the area around the left mainstem bronchus/carina; 3) Collateral from left lateral thoracic artery to left lung; 4) Collateral from right bronchial artery to the right lung; 5) Collateral from right thyrocervical artery to the right apex of the heart. For surgical fields, I see right lung, left lung, heart apex, systemic pulmonary vein, and vein in area of mainstem bronchus/carina. We often report code 37242 twice for coiling of APCs on the right and left sides, but this is way past that. I can't believe we could be billing that many separate occlusion codes. What would you suggest?

Can add-on code 93621 be reported for catheter advanced from the LFV to the CS for mapping of mitral valve annulus? (CPT 93653 is my primary code). "A Bard dynamic decapolar 6 French catheter was advanced from the LFV to the CS for mapping of the mitral valve annulus. A St Jude 6 French Daig quadripolar catheter was advanced to the right ventricle from the RFV. A St. Jude duo-decapolar BDB Livewire catheter was advanced via a 7 French LFV sheath, and the entirety of the right atrium while in the flutter was mapped. The TCL was 220 msec."

I'm looking for some assistance regarding thoracic duct stenting. "Viabahn covered stent deployed across cranial aspect of thoracic duct in area of lymphatic leak." I'm wondering if this would follow the same logic as a lymphatic embolization and be coded as a venous stent, or are we looking at unlisted code 38999?

Would the following be coded as an unlisted procedure? "Patient scheduled for atrial flutter ablation. Patient presented to EP lab in AFL. Due to patient comorbidity, (coincident AF, recent Watchman implant) physician decided (prior to procedure) he would not pursue AFL ablation if circuit was left-sided. J-wire was advanced to IVC. Repeat access, repeat to 1 cm above the last, and 3rd access to 1 cm above, and J-wire advanced to level of right atrium. Sheath was introduced. SRO sheath was advanced into right atrium. Halo cath was advanced and draped across the tricuspid valve. SC cath was advanced into body of coronary sinus. Baseline findings recorded. Physician decided not to ablate. Conclusion: left-side AFL. Unable to pace terminate."

My doc places the catheter in the posterior tibial vein (this is where he starts procedure), goes up to CF, does a venogram of leg, and then goes into the IVC and images the IVC. This is all ipsilateral. Is the catheter placement 36011?

MD placed a stent in the right common carotid with EPD, then performed angioplasty and placed two more overlapping stents all the way to the distal cervical right ICA. Patient had "near occlusive stenosis". All three stents overlap each other, so we are inclined to report code 37215 once, but I wanted to verify that we aren't missing any codes. EPD was used in all three stent placements.

With the new 2017 dialysis circuit codes, when a revision or thrombectomy/revision is performed, can you code an extremity arteriogram or extremity venogram with the open procedures?

I have a physician who is doing selective right and left iliac angiography during a left heart catheterization. "We gained access from the right brachial artery. The left main coronary ostium was selectively engaged with the JL3.5 catheter, and angiograms were taken in multiple projections. The right coronary ostium was selectively engaged with the JR4 catheter, and angiograms were taken in multiple projections. The JR4 catheter was introduced in a retrograde fashion across the aortic valve into the LV, and pressure measurements were made. Selective right and left iliac angiography was performed by injecting the 4 French JR4 catheter. Selective right and left iliac angiography: Both of these angiograms demonstrated a probable proximal total occlusion of the iliac arteries. There was diffuse disease of the distal vasculature. There were prominent abdominal collateral vessels noted on angiography." Would we bill code 93458-26 with 36245-50? I am also finding that code 75716 might be appropriate too. What would be the best way to bill for the angiography?

I am having trouble deciding when it's appropriate to use code 35883 alone or with other codes. What all does this code include? One case - previous iliofemoral bypass, which was aneurysmal. "After dissection and mobilization it avulsed off the proximal anastomosis. The entire graft was removed from operative field, and a new 8 mm graft was placed in the same location, distal external iliac to distal common femoral." Is this reported with code 35883 alone or just removal of graft (37799) and 35665? The other case was similar, ax-fem-fem bypass with aneursym on left femoral artery. "Patent ax-fem on the right, occluded fem/fem. Thrombectomy of right to left fem/fem. Aneursym of left femoral artery resected and interposition graft was placed left femoral artery to left profunda artery after it was thrombectomized." Is this codes 35883 and 35875-59 (for fem/fem thrombectomy)??? Also considered 35876. Can you please advise on these cases and how to determine when to use 35883 alone or with other codes.

How would I code PTEG tube check, and how would I code placement of a PTEG tube? Should the placement be an unlisted code? Should the check to go code 49465?

"Periosteal elevator was used to dissect the femur to a position higher than the soft tissue amputation. This level was at the upper third of the femur. We then used the pneumatic saw to divide the femur. We then trimmed the anterior aspect of the femur so that it was beveled and had a smooth edge. We then divided the posterior flap of soft tissue. As he has become more cachectic, the soft tissue around his prior left above-knee amputation has atrophied. In addition to this problem, he has developed hyperostosis of the distal aspect of his femur. This has caused severe ulceration with exposed bone of the distal aspect of the left above-knee amputation site." The provider used code 27590, and the coder used 27596... can you tell us when it is appropriate to report code 27596? This was done two years after original amputation.

"A patient with pleural effusion and an existing tunneled PleurX drainage catheter is taken for a tunneled pleural catheter check. Subsequently found to have PleurX catheter malfunction. A Bentson wire and subsequently an angled glidewire were advanced into the catheter. These could not be advanced through the entire length of the catheter. Subsequently, a Roadrunner catheter was successfully advanced through the entirety of the catheter length. The catheter was slightly manipulated with the guidewire." Would unlisted code 32999 be the proper coding of the guidewire manipulation of the existing tunneled PleurX drainage catheter of the right pleural space?

If a physician orders and performs, in the same session, an MRV of the head without contrast and an MRA of the head with contrast, is 70546 the correct code to use? 

Can we append modifier -SC to pacemaker implantation claims when we are doing the implantation prior to an AV node ablation?

When our doctors perform an AV node ablation (93650) with pacemaker implant (33208) on the same date, we have been getting denials for code 93650. Specifically because code 93650 was billed in the global period for code 33208. I believe this may be payer specific. Should I append a modifier -78/-79, or should I appeal to the payer?