Ask Dr. Z

We have a physician who will be using the NavX mapping system to map the coronary sinus and its branches for CS lead insertion for his Bi-Vs. Can we bill anything for his, or would it just be considered guidance during the procedure?

Our physicians are doing fat pad biopsies of the abdominal wall to rule out amyloidosis. Sometimes they use a core needle, and other times they make a small incision for this. There is a lot of debate regarding the correct CPT for this. Some think it should be 22900 for the incisional biopsy and 20206 for the core. Others have said it should be 22999. Can you help with this? I have looked all over the internet for help and can't find any consistent guidance.

The long description for code 76937 describes US assistance for vascular access. CPT Assistant, December 2004, describes assessment of venous patency and needle passage to the venous lumen. My question is whether this code can be reported for assessment of arterial patency and arterial passage to the arterial lumen. Or, is this code limited to venous line placements?

The physician performed T5 vertebroplasty under fluoroscopic guidance and T9 kyphoplasty vertebroplasty under fluoroscopic guidance. Can you report codes 22510 and 22513 together with modifier -XU appended?

Is it appropriate to report code 35876 for the procedure that follows? "Extensive clot was noted and removed. Some old hyperplasia was also removed. A 5 Fogarty was passed into the graft and pulled a large plug out with significant return of inflow. The fem-fem was flushed and occluded. The profunda was reopened with excellent return of back flow. A Fogarty was passed down the SFA with thrombus removed and good return of back-bleeding. A Gore-Tex patch was cut to fit and sewn in place with running Gore-Tex suture."

Would you use code 49180 or 20206 for soft tissue biopsy of the abdomen?

Our office had a remote interrogation come into the office over the weekend, and we are not technically open on the weekend. The interrogation was recorded on Saturday and interpreted the following Monday. The codes assigned were 93294 and 93296. What date of service should be assigned for these CPT codes, particularly when the remote interrogation (93293-93299) is received on one day and the interpretation is signed on another day? Going one step further, for the in-person interrogations (93279-93292), we are using the date of the encounter/interrogation/reprogramming as the DOS as opposed to the date the interpretation was signed. Is that correct? 

My doctor states he is doing an in-situ femoral-distal popliteal bypass. He documents the end-to-side anastomosis at the tibial/peroneal trunk. In this case, would you consider the tibial/peroneal trunk as part of the popliteal (35583) or the posterior tibial, anterior tibial, peroneal (35585)?

Can we have more than one stent coded in the cervical carotid, for two distinctive lesions, in common and internal? Would there be times when multiple stents can be coded individually?

This patient has an occluded aorta resulting in non-viable left lower leg. The plan was to perform an axillary-femoral-femoral bypass prior to performing the AKA in the near future. In prepping the patient he had an ischemic ulcer high on the left thigh therefore they performed an femoral to iliac vs. femoral to femoral. This is my dilemma... because it was a planned procedure, should I code it as an incomplete axillary fem-fem 35654-52 or should an unlisted procedure code 37799 be used?

In the "Case of the Month" for December, you state that no code should be reported for the imaging of the left ovarian vein done after the left renal venogram. But your previous advice has been to use code 76496 for additional selective venograms in the same family (renal, pelvic, and internal iliac branch veins). Why is code 76496 not appropriate in this instance?

What would be the correct CPT code for sclerotherapy of aneurysmal bone cyst?

What is the code for this new procedure? "The patient had a severely calcified SFA and was going to be treated with lithotripsy at this intervention. Patient was given 10,000 units bolus of heparin, and then shockwave lithotripsy was performed with a 5mm balloon at the SFA. There were two tandem lesions separated by 6 mm. These were treated first with inflations of 4 atmospheres and then 6 atmospheres with shockwave therapy at each inflation. Then the balloon was carried more proximally and was treated in a similar fashion. There was a mildly resistant area in the SFA, which was treated with two more cycles. There was a nice angiographic result. I obtained a 5.5 shockwave balloon and treated the proximal SFA lesion and the common femoral artery. I treated the proximal lesion at 4 atmospheres, retrieving the balloon into the common femoral and inflating this to 6 and then 8 atmospheres, and treated with 2 more cycles. Follow-up angio revealed persistent disease, which was successfully treated once at 4 atmospheres." Would this new technology be reported with an unlisted code, or would I use current codes?

I'm having a disagreement with my auditor. Per MLN Matters, I think I should only append modifier -KX to a pacemaker code if I see the blurb "non-reversible symptomatic bradycardia" somewhere in the chart. She doesn't think that is needed and believes you can add the -KX as long as the claim contains one of the following diagnosis codes: I44.2, I44.1, I49.5, or Q24.6. What is your interpretation please?

What would be the correct code for a PTFE bypass graft from CFA to the mid SFA? The only code that I can find that is close is the femoral to popliteal PTFE bypass (35656), but that is not what was done.

Left heart cath is ordered for patient with unstable angina. Operative report reads that the patient also has a small ulcer on foot, history of arthrectomy to SFA, reassuring ABI. Cath is done through right radial access, then catheter is moved down to right CFA and runoff of right leg with digital subtraction at 2 levels is performed. CFA is normal and arthrectomy site is patent. Would this be reported with codes 93458, 36247, and 75710?

When coding for EP studies/ablations, is it appropriate to assign ICD-10-CM codes for provoked arrhythmias?

Example 1: Patient presents for successful ablation of SVT. Should AV block be coded from the following?

“There were no inducible arrhythmias with ventricular pacing protocol. Adenosine 9 mg resulted in AV block with no ventricular pre-excitation but eccentric VA activation persisted”

Example 2: Patient presents for ablation of ventricular preexcitation, none was found. AV/VA block and RBBB noted as below. Should these be coded separately?

“Ventricular extrastimulus was performed with no inducible arrhythmias or eccentric VA conduction. Adenosine 12 mg was administered resulting in both AV and VA block with no ventricular pre-excitation. There was intermittent junctional rhythm at baseline. There was development of right bundle branch block due to His/RVA catheter. There were intermittent wide complex beats noted during atrial pacing that were found to be due to His/RVA catheter movement.”

For this case we are not sure how much needs to be documented to code for interrogation of pacemaker and what code would be best with this documentation. "Right femoral region was prepped and draped. See cardiac cath log sheet for sedation. The patient's device was interrogated and programmed to a lower rate of 30 BPM. An 8 French sheath was placed in the right femoral vein using modified Seldinger technique. Radiofrequency energy was applied to the AV node with an 8 mm tip ablation cath, resulting in complete heart block. Sheath was removed, and the device was then programmed to a lower rate of 80 BPM." I am thinking of code 93650, but I'm not sure what to code for interrogation of pacemaker. Is there enough documentation to report codes 93286 and 93286-59? Or is code 93288 or 93279 best? We are confused on when to use the interrogation device codes and what is supposed to be documented for each code. Can the cardiology nurses report code 93279 the day after a pacemaker is put in? 

I know the embolization codes include guidance, but I wanted to make sure that means CT guidance as well. I am wondering if a limited CT could be separately reported if CT is used to identify a specific area of endograft leak prior to embolization (same patient encounter).

Would there be a separate code when Valsalva maneuvers are done during a right and left heart catheterization? Or is that included in the diagnostic cath codes?

"Access in the right brachial artery with fistulogram. Second access in the common femoral vein through the IVC, right atrium, SVC to the AV fistula and then advanced into the brachial artery with PTA of stenosis in the fistula." I would code 36120 and 36902-52 for the brachial access and PTA. Would the catheter placement code for the common femoral vein access through the fistula to the brachial artery be 36012 and 36215, or just 36012?

When doing subclavian venoplasty, if upper extremity venography was performed and then the catheter was advanced to the IVC, can both codes 36005 and 36010 be reported? Or is code 36005 inclusive to 36010? Do we not code the injection, along with radiological supervision and interpretation code for extremity venography?

We have neurosurgery using our MRI machine to perform Visualase procedures. They are placing neurostimulators for Parkinson's. Right now we are billing the MRI with the brain MRI code, but when I found some info on the Medtronic website they recommend using 64999. These are hybrid procedures done in conjunction with neurosurgery that can take up to 6 hours. Should we be billing unlisted 64999 code instead of an MRI scan?

My question is basically the same as the one in question ID 9329, specifically the CPT code for cryoablation of a venous malformation. I was confused that your answer seemed to address the sclerotherapy CPT code but not a cryoablation CPT code. 

I understand code 75726 is with or without flush aortogram. But would there be a situation where code 75625 can also be reported? Example: "An aortogram was performed to delineate the anatomy, as pre-operative CT scan was not adequate in defining the extent of spill-over disease into the celiac and SMA." Then a catheter was advanced into the SMA and imaging was done." Can we report both codes 75625 and 75726, or would only code 75726 would be allowed?

Can PA angiography (93568) be coded also if performed with PDA device closure (93582)? In the CPT book it states that code 93568 can be used as appropriate with 93582, and recently a physician shared a letter with the facility from SCAI that stated this could be coded together and that we could begin to receive reimbursement for PA angiography (+93568) if performed with PDA device closure (93582). Coding these together, however, creates an edit that the add-on code 93568 is reported without base procedure code. Can these two CPT codes be coded/billed together?

New IR coder here. Can you please explain why the right atrium pressures are not coded if the intent of the procedure was to do the liver biopsy?

My provider did angioplasty on the left tibial artery (one on the mid posterior and another on the proximal posterior tibial artery). Can we report code 37232 with 37228? I'm thinking it has to be another artery like the peroneal or anterior tibial in order to use 37232. 

Is it appropriate to bill code 50432 x 2 when PCN catheters are placed in the same kidney, one in the upper pole and the other in the lower pole (no duplicated collecting system), same session? If so, would you append the -59 modifier to the second? 

Do you have any info from CMS regarding intraoperative x-rays? I'm working on creating orders that are statistical only so we at least get the productivity. We have a statistical only fluoro charge as well since we cannot charge for the use of the c-arm. This would be for facility billing only. I need resources so radiology gets credit for productivity that can't be charged due to CPT codes being bundled into the main procedure. Your help is deeply appreciated.

Should we bill for Verapamil administration performed for prophylaxis of vasospasm during neuroembolization?

"Patient presents with end-of-life biventricular ICD, no longer requiring the ICD. ICD generator is removed and leads checked. The LV lead requires repair using a portion of lead cap and medical silicone adhesive tied on with silicone. A biventricular pacemaker was then implanted." Is the correct coding 33241 for ICD generator removal, 33218 for lead repair, and 33221 for placement of pacemaker generator?

Would it be appropriate to report codes 93451-26 (right heart catheterization) and 93568 (for the pulmonary artery angiography) in addition to 93799 for the implant of the CardioMems for physician billing?

Can you please help me understand this report. The patient has erythrocytosis. The "order" was for "BMBX" (all done same needle path/location). My doctor goes back and forth with his terminology, and it's confusing me. He says at the beginning of report he is doing a "CT-guided bone marrow aspiration of right posterior iliac crest and a CT-guided core needle biopsy of the right posterior iliac crest". In the body of the report, he says, ".20 mL of bone marrow aspirate was obtained and sent to lab for analysis. In order to obtain adequate bone marrow sample, a core biopsy was required. Next a single core bone biopsy sample was collected in formalin using the 11 gauge introducer needle. Impression: Successful CT-guided bone marrow aspiration. Successful CT-guided bone marrow core." I want to bill codes 38221, G0364, and 77012-26 because he keeps going back and forth with "core bone" and "bone marrow core", but I'm not sure.

I'm seeing denials for missing "qualifying procedure code" when reporting codes 93042 and 99223 together. Payer is Medicare. Error code is B15. What is the qualifying procedure code for this scenario? Or what is missing from this scenario?

Our patient already had a biventricular ICD in place with LV lead failure. Physician is documenting that we changed out the generator, capped the LV lead, and placed a new HIS bundle pacing lead in what is documented as across the tricuspid valve and positioned in the lower right atrial septal wall. So I believe this means I now have one RV lead and two RA leads. Provider is requesting to bill codes 33264 and 33216. I know that typically when we replace the generator and add a lead at the same time we switch to the insertion codes. I am wondering if code 33206 is appropriate in this case or if we should be using unlisted code 33999. I know we capped the LV lead, but I do not feel that the new lead is trying to take the place of the LV function, but stimulating the atria. 

Surgeon performed thoracoabdominal aneurysm repair and removed old infected stent on the same site. Is the stent removal separately billable? If so, what is the appropriate CPT code?

The physician performed an AngioVac thrombectomy with extracorporeal veno-veno bypass from the suprarenal IVC to the level of the iliac bifurcation. Is the bypass separately reportable, or is it included or bundled with the thrombectomy procedure code? If separately reportable, would it be an unlisted code?

LP with Spinraza Injection is very similar to 96450 (intrathecal chemo injection), but Spinraza is not a chemotherapy drug. What CPT code would you suggest for this injection? "CLINICAL INFORMATION: __ days old girl with spinal muscular atrophy presents for Spinraza administration spinal muscular atrophy, spinraza injection. The anticipated puncture site was anesthetized with lidocaine. A 20 gauge spinal needle was advanced into the thecal sac via the interlaminar space of the L3-L4 vertebrae with fluoroscopy and ultrasound guidance. The stylet was removed, and spontaneous flow of clear CSF was observed. A short catheter was attached to the spinal needle, and 4 ml of CSF was collected. 5 mL of Spinraza were then injected. The needle was then removed and the puncture site dressed. IMPRESSION: Successful fluoroscopic and ultrasound guided lumbar puncture with Spinraza injection."

Occluded right hepatic and migrated bifurcation stents both replaced. Selective cannulation and stenting are done on the second right hepatic duct branch and a replacement of the bifurcation stent. Should I use 43276 x 2, as this is the “same anatomical area”?

If a patient presents in the morning for a thrombolysis recheck and has a thrombectomy performed with continuation of thrombolysis and returns later in the day for recheck and additional thrombectomy, what is billable for the second visit to the lab on the same calendar day? Thrombectomy and thrombolysis have an MUE of 1 per day. Are we able to bill thrombectomy each additional vessel for the second visit to the lab?

If we are doing vein measurements for CABG, what code is used for this? Do you consider veins to be soft tissue structures (76881-76882), or is unlisted code 93998 more appropriate?

I'm billing the following to Medicare: 36903, 37186, and 76937-26. Medicare denied code 37186 because its "parent" code was not billed with it; however, the provider did it after the initial angio of the HeRO showed thrombus and the end result was a placement of a stent within the AVG, which justified the 36903 coding. Code 76937-26 was also denied, but the claim didn't identify the AVG site as failing, I'm sure I could add that info, but I don't understand the Medicare denial of 37186... do they bundle it all with code 36903? The secondary commercial plan's claim checker allowed all 3 lines, but when it crossed to them they denied it as failure to follow the primary payer rules. How should mechanical thrombectomy be coded when done with codes from the dialysis circuit?

Is a temporary pacemaker included in the procedure when you bill an aortic valvuloplasty?

Can you report code 76937 multiple times for the same access site? For example, our EP physician puts two sheaths in the right femoral vein and uses ultrasound guidance for each access. Do we submit code 76937 once or twice? There are also situations where ultrasound is used to place an access in the right femoral artery and again for the right femoral vein. Would we bill 76937 once or twice for that?

The CPT Codebook states for percutaneous needle biopsy other than fine needle aspiration to use code 62267 for intervertebral disc. However, in your book (Dr. Z's book), it states to use an unlisted code for core biopsy of disc (64999). Am I confusing "aspiration biopsy" with "core biopsy"? How would you code the following report? "Fluoroscopy was used to localize the L1-L2 intervertebral disc space. An appropriate access site was selected on the skin. 1% lidocaine was used for local anesthesia. The trocar was advanced until the tip was at the margin of the intervertebral disc. The trocar tip was pushed slightly into the disc, and the core biopsy needle was advanced to the anterior margin of the disc space. Fluid and core material were aspirated. A second pass was made with the biopsy core needle. Some additional bloody and pulpy fluid was obtained. Needle was removed. Hemostasis was obtained with compression."

Patient had upgrade from VVI pacemaker to biventricular pacemaker, with old LV lead capped and new LV lead inserted. No lead in the RA or RV. Since there is no RA or RV lead, what code do I use for the upgrade to biventricular? 33208 & 33225 or 33229 & 33225? I am confused on what to code for the generator when there are no right-sided leads.

We have a stab wound case where our surgeon placed a temporary vascular shunt in the femoral artery to allow flow to the distal leg. Once flow was reinstituted into the patient's leg, our surgeon then called a vascular surgeon (not associated with our practice), who then repaired the artery with a vein graft. Are we allowed to code for the temporary arterial shunt, and, if so, what code would we use for that? The vascular surgeon billed code 35256.

I need help coding this case. "Patient is having pacemaker system removed due to infection. A temporary pacemaker was placed via the right femoral vein, and an active-fixation (screw-in) lead was attached to an externalized pacemaker via the right IJ vein. ICE was performed during the procedure, visualizing the right ventricular lead during the extraction. Leads were clearly adherent to the subclavian/innominate veins. After removing the right ventricular lead, contrast was injected in the innominate vein, demonstrating a tear in the distal third of the vein. Atrial lead was then removed. I elected to place a covered Wallstent covering the entire innominate vein. Pocket was irrigated with antibiotic solution, and wound VAC was applied." I was thinking about reporting codes 33233 pacemaker removal, 33235 lead removal dual system, 33216-59 fixation (screw-in) lead, and 97605 for wound VAC. I don’t think ICE can be reported due to no primary procedure code associated with it being billed. Also, I'm thinking that the stent placement would be inclusive with procedure due to perforation created by physician, but I'm not sure. Thoughts?

If the patient has a fem-tib bypass, and there is a stent placed near the proximal femoral anastomosis in the graft and a PTA in the distal tibial anastomosis, how do you code for this graft revascularization? Do you report code 37226 or 37230? Do you code for the most distal vessel replaced?