Ask Dr. Z

Please advise what you would recommend coding for both the procedure in CT for a wire placement under CT guidance prior to a G-tube placement in the IR dept. Would you recommend the CT guidance only for the placement of the wire in CT under CT guidance prior to the G-tube placement that is placed in the IR dept., or would you recommend coding both the CT guidance and an unlisted for the wire placement along with the G-tube placement code placed in IR?

I have a TEVAR procedure coded as 33881, 75957-26, 36200, and 34812-LT. However, they also removed previously placed stents from the iliac and femoral arteries on the left side due to re-stenosis and dissection and placed new stents in the left common iliac, left external iliac, and the CFA. I am going to omit 34812 and 36200 and bill codes 37221, 37223, and 37226. Is this how you would code this procedure? I was a little concerned that the extremity stents had to be removed just to perform the TEVAR and are bundled, but there was a dissection, so would that show medical necessity? No mention of the % of re-stenosis. They also tried to access the right femoral and could not, but left a 5 French sheath there and decided to go through the left brachial artery. I am thinking that is all bundled too but am not sure. I am new to coding these and any help would be appreciated.

Patient had a full comprehensive EP study performed (93620) and also LHC by transseptal puncture (93462) for monitoring left atrial pressures, as well as ICE (93662), LA pacing and recording (93621), and IV drug infusion (93623). Craneware shows no edits with all of these codes. However, Revenue Cycle is stating that 93462 is hitting an edit because there is no primary code. We are unable to find any reference that states 93462 cannot be added to 93620. Please advise.

How would you code RFA of medial branch nerves at transverse processes at L3, L4, L5, and sacral ala (all right side)?

Patient had a congenital bicuspid aortic valve, which was corrected in 1994 with the replacement of a prosthetic aortic valve. The patient has been followed on a routine basis, but recently has dyspnea, therefore, a TEE was performed for dyspnea. Would you report a congenital TEE code (93315), or would you report a normal TEE code (93312) for both institutional and physician charges since the initial diagnosis was congenital, even though the surgery has corrected this congenital condition?

How do you code a discoblock? "INDICATION: Axial lower back pain. Severe degenerative disc disease with Modic type II endplate change at L5/S1. Procedure: Using fluoroscopy, the appropriate skin entry site was localized and anesthetized with 1% lidocaine for the L3/4 disc space level. Using intermittent fluoroscopic guidance 7 inch 20-gauge Chiba needle was advanced until the correct trajectory was obtained. The fluoroscope was then turned into the Lateral position. The needle was then advanced in small increments the needle tip was inserted into the central aspect of the L5/S1 disc space. AP and lateral confirmed the centrally located needle tip. At this point approximately 0.5 mL of Omnipaque-180 IV contrast was injected to confirm intranuclear needle tip position. This was followed by 0.75 mL of 0.5% bupivacaine. The needle was removed. After the procedure, the patient described only 10% relief of back pain. IMPRESSION: Technically successful L5/S1 discoblock."

Have they put out a new code for removal of a non-infected AV graft, or should we still be using the unlisted code?

We have a pain clinic that is currently doing facet joint injections. The pain level that is being reported is a level 2, but per Medicare criteria the pain level needs to be a 3 or higher. Can we still bill for the procedure? Also the pre and post pain is not being documented on the procedure note; it is being notated on a separate nurse note. Is that documentation acceptable to use, or does it need to be noted on the procedure note?

One of our surgeons is wanting to bill a venogram only (75820) for an attempted pacemaker insertion. To summarize the note, he makes the incision between the clavicular angle and the delta-pectoral groove, does not see the cephalic vein, does a venogram of the subclavian vein, makes a few attempts at access, and is unsuccessful. The patient has COPD and HR was over 110, so the procedure was stopped and wound was closed. Could we still do the PM implant with modifier -53? I'm hesitant to bill this since it didn't seem like very much was done here. Also, if we can bill for the PM placement with modifier -53, should I just do the 33207 since the provider doesn't indicate whether he planned to place a single or dual chamber device?

Can you tell me if the -Q0 modifier is still needed in 2018 on 33249 when the AICD is placed for primary prevention?

Is there a special modifier that we need to get reimbursed for the removal of the AICD during the heart transplant? We have denials coming in when we billed 33945, 33980-51, 33944-51, and 33241-51. The denial is for 33241-51 with “Px inconsistent with modifier/required modifier missing”.

Would it be appropriate to code this as 50387? The Expel nepthroureteral stent has a C-code of C2617, which confirms that this wasn't a catheter being used for drainage rather this seems internal and a true stent. "The indwelling catheter and left flank were prepped and draped in the usual sterile fashion. Contrast was injected through the indwelling left nephroureteral stent with antegrade pyelography performed. The catheter was then cut and, over an Advantage wire, exchanged for a new 10 French 22 cm Expel nephroureteral stent. The distal and proximal loops were formed within the bladder and renal pelvis respectively."

When access is made in the brachial artery (remote access) with subsequent procedure performed in the AVF/AVG such as a (PTA/stent/percutaneous thrombectomy), would it be correct to report code 36140 for the brachial artery access along with either 36902-52 for a PTA, 36903-52 for a stent, or 36904-52 for percutaneous thrombectomy?

Patient with an ileal conduit with current nephrostomy tube comes in for internalization to a double-J ureteral stent. Nephrostomy is removed and replaced with the stent coiled within the ileal conduit. Would you consider this 53899 for initial stent placement via ileal conduit, 50693 for stent via pre-existing nephrostomy tract, or 50688 for replacement even though the tubes were two different types?

Is it appropriate to bill 74022 when only the 2-view AB and 1-view CXR are completed? Does the timing matter within the same 24 hour period? Some sources we found state that specific views must be used in order to bill 74022 but CPT does not.

What CPT code would you use for SI joint aspiration?

Texan Plus is requesting anatomical modifiers on cath codes 93451 through 93459. They want us to put an RC, LC, RD, RI. How can this be possible?

Could you provide guidance on when to code open vs. percutaneous vs. central ECMO cannulation on the CPT side?

I am looking for changes to the NCD 20.4 Implantable Cardioverter Defibrillators. Since learning of the announced changes at your seminar in February 2018, I've watched for a specified date and my organization has implemented the "Shared Decision Making." It appears Medicare and other payers are paying for the implants if we use the -Q0 modifier and Z00.6 as secondary diagnosis or not. I can't find any information stating this is necessary or is no longer required. Nor can I find any specified date on the decision memo (CAG-00157R4). Do we still need this information on the claims? Could there be a sunset period? Any suggestions would be most appreciated.

I was wondering if you have any info on using 0439T during a TTE 93306-26 / 93308-26 when Definity contrast is used. I know we use 93352 when Definity is used during a stress echo 93350, 93351, but I'm not sure about when used with a TTE. These are for professional reads. 

Would you assign 35266-59-51 in addition to 33984 and 33952? "I reopened the right axillary artery wound, placed a Henley retractor. There was diffuse oozing from the entire surface of the end-to-side graft with multiple areas of bleeding along the arterial edge. I attempted primary repair with a number figure-of-eight and pledgeted 6-0 Prolenes. However, I was not able to adequately control the bleeding. Therefore, I felt at this point, our only option was to reapply our clamp. The patient's ACT was greater than 200. Therefore, I placed a Satinsky side-biting clamp, removed the graft. The artery was very small and thin-walled and was quite diffusely injured, likely from the force of the ECMO cannula and flow. At this point, I elected to repair the artery in order to ensure good perfusion to her right arm, I sewed a bovine pericardial patch using a running 6-0 Prolene."

There are no CPT codes that describe non-invasive vascular procedures with contrast. The Noninvasive Vascular Lab wants to do vascular imaging with contrast enhancement (Lumason) to evaluate for: abdominal aortic stent graft leakage, renal artery/stent stenosis or occlusion, portal hypertension and portal thrombosis, etc. Should we report:

• Vascular duplex scan codes 93975-93981 with Q9950?
• Abdominal US limited code 76705 with Q9950?
• Unlisted code 76999 with Q9950?

One of our physicians has started performing a transforaminal epidural steroid injection (64483), followed by an interlaminar epidural steroid injection (62323). I know you can’t code both of them, so which one should we use and why? "Uneventful lumbar epidural steroid injection under fluoroscopic guidance and moderate IV sedation, as above described. Today's procedure was performed via a left-sided L5 transforaminal approach, as well as via left-sided L5-S1 conventional interlaminar approach."

I would like to get your advice on coding tomosynthesis-guided breast biopsy. Would it be appropriate to use CPT code 19081? Here is the copy of report: "Left tomosynthesis core biopsy: The patient's left breast was positioned in the digital breast tomosynthesis device, and images of the calcifications in the upper outer quadrant were obtained. The breast was prepped for the procedure, and the area was anesthetized with a local anesthetic. Using a vacuum-assisted biopsy device and a lateral approach, six specimens were obtained. A micromarker was placed at the site of the core biopsy. Specimen radiographs showed calcifications in some of the cores. The patient experienced no complications during the procedure. Total anesthesia used during the procedure was 10 cc of 1% lidocaine and 20 cc of 1% lidocaine and epinephrine 1:100,000. A post procedure unilateral digital mammogram obtained to confirm clip location demonstrates the clip is at the biopsy site. IMPRESSION: Left tomosynthesis-guided core biopsy completed."

Can you tell me if there is a way to bill for extra work that may come up during procedures? The example I have now is the patient was in for a declot of dialysis shunt. "The patient was noted to be in atrial fibrillation with left bundle branch block. He was also mildly tachy with rate in 110's. Cardiology was consulted and we decided to give 10 mg of labetalol prior to the procedure. Patient remained asymptomatic throughout denying chest pain, discomfort, lightheadedness." Normally we don't bill an E&M on the same day as the procedure, but would this be a case that an E&M with a -25 modifier would be appropriate? Seems like extra care/work involved prior to the procedure.

Since 93462 is bundled into 33340 when transeptal puncture is done, can we report 93662 for the ICE? No primary code to report. We are wondering if we can show 93799 for that since the ICE is not a stand-alone procedure.

When coding diagnoses for peripheral atherosclerosis, should I code all pertinent diagnosis (like in diabetes), or just the highest level of severity? For example, patient has claudication with rest pain (I70.221), but also a nonhealing ulcer of the toe (I70.235, L97.519). Should I code all three diagnoses, or just the ones pertaining to the ulcer?

What CPT code is used for sartorius muscle mobilization? Should this be coded with 15738 and 14020 or is it bundled into redo fem-fem bypass? "The right groin incision was debrided, removing all necrotic tissue, and the sartorius muscle was freed up on the anterior aspect, allowing for transposition of the sartorius muscle over the anastomosis. The muscle was not transected at the anterior superior iliac spine as one would for complete flap coverage. This wound was then closed in multiple layers with the necrotic skin and soft tissue removed, leaving a small open wound along the prior suture line. A wound VAC was placed, allowing for complete coverage of the wound. Wound VAC in a hockey stick configuration measured 10 cm in length and 1 cm in diameter."

We have a doctor who performs additional ablation on the Carina post complete PVI. Due to its anatomical location we are wondering if this qualifies for the 93657 charge and if the patient has to be in A-fib in order to charge 93657 at all or if the additional ablation needs to be in a different region. Please advise.

How many times can code 93657 be charged if during an AF ablation the MD states: "Additional RFA lines in the left atrium, which include left atrial roof, left atrial septum, SVC, and right side intraatrial septum. These areas are ablated to address the extra pulmonary vein origination of AF." Should we report 93656 and 93657 x 4?

"Endovascular repair of aortic iliac disease with the following Gore devices: 1. Main body aortic limb 16 x 12 x 7, followed by left IVE extension limb 16 x 10 x 7, left side. 2. Right side extension 16 x 10 x 7 IVE extension limb followed by a 16 x 12 x 7 external iliac limb. 3. Intravascular ultrasound of abdominal aorta." How would you code this being that the grafts were placed for aortic occlusive disease with bilateral claudication not for aneurysmal disease?

Office visit: Generally all the histories from the VAD are downloaded by our nurses, and a physician reviews them during the clinic visit and nurse documents them in the chart. Physician personally makes a reference to the nurse's note that he/she has reviewed those numbers, and I also co-sign the nurse's note. Is that enough to code/bill 93750, or does the physician have to perform the interrogation in person? Do the same rules apply to inpatient setting?

When a patient has a TAVR procedure (i.e., 33361-62-Q0) along with CPB (i.e., 33367), do I also need to append the -Q0 modifier to the add-on code as well? Or only the primary procedure? Or should I consider the -Q1 modifier for 33367?

Our cardiologist performed an adenosine challenge infusion only and monitored by EKG for changes. Would this code be reported with unlisted code 93799 for the adenosine challenge, or would you use code 96365 (intravenous infusion, for therapy, prophylaxis, or diagnosis)?

Would 36000-59 be correct to add in addition to 37241 when a butterfly needle was placed directly into the lesion, DSA performed, followed by injection of ethanol and then a second, more anteriorly and deeper lesion was directly accessed, and additional amount of ethanol injected?

If during a cardiac cath the physician suspects aortic insufficiency (I35.1) and proceeds with an ascending aortogram (93567), is code 93567 still billable if the results show that there is no aortic insufficiency? Code I35.1 would get 93567 paid, but what diagnosis would we use if the aortogram came back normal? Or would this procedure code just be included in the payment for the cath in this case?

What would be the appropriate ICD-10 codes for left ventricular dysfunction, ventricular systolic/diastolic dysfunction, or Grade 1 diastolic dysfunction? Would these conditions listed under the summary of echo reports require valid diagnoses?

"Surgeon created a brachiocephalic AVF. After the AVF was completed, clamps were released and immediate swelling of the distal upper arm was noted, clearly a hematoma. Clamps were placed and incision made over the area. The cephalic vein was disrupted and was unrepairable, so the surgeon ligated the cephalic vein at the origin of the anastomosis." Do you code for the AVF (36821) since it was completed and the ligation (37607), or should we just use the ligation code?

"Via indwelling feeding tube, the stomach was insufflated with air. Under fluoroscopic guidance and 18 guage trocar, the stomach was percutaneously accessed. 7 French sheath was placed, and access to the esophagus was obtained in a retrograde direction with a wire and catheter. The wire was advanced out the patient’s mouth, and a 20 French Ponsky type gastrostomy tube was placed over the wire. The tube was guided through the patient’s mouth while performing gentle traction on the wire, resulting in advancement of the tube into the stomach. The gastrostomy tube disc expanded against stomach wall, and the gastrostomy tube exited the percutaneous tract." As the catheter was inserted via the mouth, would this still be supported by CPT code 49440?

Question about 93583 alcohol septal ablation. Our physician performed ablation of septal 1 and septal 2. Code 93583 has an MUE of 1. Can we charge an unlisted code for the additional ablation? 

For 2019 two new HCPCS codes came out that represent percutaneous fistula creation (Ellipsys). However, there is no information available as to whether the two new codes can be billed together (IN hospital OPPS or ASC Facility as it meets the pass through). Do you happen to know any extra information about these two new codes and how they are to be used?

I am trying to get information on how you would code radiofrequency ablation of the S and I joints? We have interventional radiology doing this, and there are questions on how you would code this. I'm wondering if it would be an unlisted code?

Patient had a thrombectomy and revision of aorto-bi-femoral graft. After patch angioplasty the patient had exposure of graft, and physician did a sartorius muscle flap to cover the graft. Would this be coded as 14021 or 15738? See op note regarding this enclosed: "Because of the redo nature and the significant amount of prosthetic in the groin, I proceeded with a sartorius flap. This was done in the usual fashion by freeing up the sartorius muscle from the anterior superior iliac spine and turning the sartorius on top of the previously endarterectomized and patched repair. I placed a drain in the lateral portion of the wound. Closed the drain in multiple layers after securing the sartorius flap to the groin."

"Physician accesses right basilic vein and DSA is performed, demonstrating occlusion of basilic vein centrally with multiple collaterals. Physician then accesses right brachial vein and through inner 3 French catheter hand injection of contrast is performed, demonstrating stasis centrally with collateral washout." Is this reported with codes 75820 or 36005? Or codes 75820, 36005, 36005-XS? I am unsure whether I can code for both access/injections performed on the two veins, both on right side.

If the doctor attempts (breaks skin) for a para or thora, should this be coded as 49083-74 or 32555-74, or should it be coded as US abdomen limited (76705) or US chest (76604)? This is for hospital billing.

Patient presents with severe venous stenosis and occlusion in both legs. Bilateral caths were placed, and bilateral venograms and pullback IVUS were performed. “At this point, balloon angioplasty followed with placement of a pair of 14 x 6 Atlas balloons into the inferior vena cava filter and simultaneous balloon angioplasty for opening the filter and smashing it against the wall of the inferior vena cava, and this was successful. We then proceeded to treat down to the level of the femoral vein with balloon angioplasty.” After the destruction of the filter, bilateral stents were placed in the legs. How would you code this deliberate smashing of the filter? Would it be considered repositioning, angioplasty, or unlisted? There was no mention of a return to the OR for removal of the filter.

Please help with angiograms done with embolization of AP collaterals. "AP collaterals from right lateral thoracic artery were engaged. This vessel splits into two collaterals, one posterior. This one was engaged, and a second angiogram was performed to delineate the position of the cath in relation to the right axillary artery. Hand injections in right lateral thoracic were performed after deployment an MVP-5Q. No obstruction of the flow of the right axillary artery. Using same catheter to engage left subclavian artery, hand injection was obtained showing at least three large AP collaterals, the largest one arising directly from left axillary artery and directed more anterior. After occlusion of collaterals from left axillary artery, a hand injection was performed demonstrating no obstruction of left axillary artery flow. To delineate the origin of the AP collaterals arising from the abdominal aorta, hand injection using the catheter injecting in the abdominal aorta just below the diaphragm. The collaterals in fact arise from a single large vessel from the celiac trunk and split into two small ones to fill the lower lobes bilaterally."

When utilizing moderate conscious sedation, must the physician always utilize two drugs (one drug for the reduction of anxiety and one for pain relief), or can moderate conscious sedation be billed if only a single drug is administered for calming effect? In other words, does a single drug administration "count" for moderate conscious sedation, or must there always be both a calming agent as well as pain relief agent administered in order to bill for the moderate conscious sedation?

We have a new hybrid OR room that has its own staff (x-ray techs) and is run by vascular surgeons and cardiologists. No radiologist is present. I've been asked if they can bill for procedures on the facility side and the surgeon still bill for the professional side. When staff from our imaging dept were sent to provide flouro prior to the hybrid room, that was all we billed for. They now want to charge like we do in our Interventional radiology lab that is staffed with IR physicians. Currently, I add the facility charges based on the dictation, and the radiologists have their own coders who add the professional component. I may be over-thinking this, but I cannot find the answer anywhere and the OR is asking me. Can you please help?

How do we code Sapien Edwards Transcatheter valve in the tricuspid position?