Ask Dr. Z

Right cervical and cerebral (36223) selective views of the carotid artery, and catheter was placed into the origin of the right vertebral (36226). Left cervical and cerebral (36223) selective views of the carotid artery, and catheter was placed into the origin of the left subclavian (36225). It was realized at this time that the left vertebral arose directly from the aorta, so a vert catheter was placed in the left vertebral (36226). Would this be billed 36226-50, 36223-50, and 36225-59? If not, why? Seems like I read that the anatomy does not matter as it did in the past.

Can you please give us a complete list of congenital cardiac anomalies that would qualify the billing of code 93303 or 93304?

A patient had pre-op and post-op EKG with atrial flutter ablation. Hospital wants to submit two units of 93005 before and after atrial flutter ablation with 93613 with 3D mapping, 93653 with atrial flutter ablation, and 93621 for coronary sinus recording and pacing. Is EKG bundled with atrial flutter ablations? If it's allowed, can we bill it pre-op or post-op?

At times I struggle with the documentation needs for a diagnostic exam prior to an intervention when a prior study was done. This patient had an MR angio runoff done one month prior to the insertion of stent in this common iliac artery. At the stent insertion the provider states, "Pelvic arteriogram was performed to better characterize the findings on the MR dated 8/29/18 and aid in operative planning." Would this be enough to re-charge the angiography portion of at the intervention? Of note the MRA dictation did not mention anything not being well visualized.

Right arm brachiocephalic fistula. RT common femoral vein is accessed with US guidance, and image saved to PACS. Stenosis in mid-cephalic vein is reached and treated with angioplasty. Then, “due to delivery sheath and stent delivery system length discrepancies, unable to safely stent the lesion from the right femoral approach.” Second access is made in upper arm cephalic vein and then stent is placed across the same stenosis. My codes: 76937, 36903, and 36012-XS for the remote access. How did I do?

Does the use of code G0278 require that permanent images be present in the record? If it does, and we do not have these images in the chart, would we then code the procedure using the appropriate CPT code from the 7xxxx series?

I was wondering how you would sequence an encounter for thoracentesis, with the diagnosis of pleural effusion due to lung cancer? I know that there is a "code first the neoplasm" note for J91.0, but if the encounter is to treat the effusion, does this still apply?

When a dobutamine stress echo (TTE) is performed in addition to a TEE, and TTE portion of stress echo is limited but full TEE is performed, will this be coded as 93312 and 93350 with modifier -52?

I am needing some guidance. I'm unsure how to code this case. Are codes 36831 and 37799 correct? "Longitudinal incision made in graft, #4 Fogarty catheter placed both proximal and distal and antegrade bleeding was established. Retrograde bleeding could not. Fistulogram obtained and noted total occlusion of venous outflow and brachial artery proximal to the anastamosis. After multiple failed attempts to cross the total occlusion of the venous occlusion it was elected to address arterial inflow. Further exposure obtained of brachial artery, control obtained proximal and distal to the anastamosis. Anastomosis was open and noticed patient had significant fibromuscular hyperplasia. Patient had friable artery with an area of small disruption. It was elected to remove that portion of artery and treat with an interposition 5 mm Gore-Tex graft. Brachial artery was transected proximal and distal to previous anastamosis. An end-to-side was accomplished both proximal and distal with a running 6-0 prolene. Flow established, patient had palpable pulse, wound irrigated and closed in double layered fashion." 

Should we bill code 93351 with modifier -52 appended if the procedure is stopped due to patient knee pain and fatigue?

I have a strange scenario, and I'm not sure how to code. Patient was in for a CABG. Vein bypasses were sewn to the RC, OM1, OM2, and then to the LAD. Next the doctor sewed the LIMA to the vein graft that went to the LAD. So would this be four veins and one artery (33533 and 33521), or would this be three veins and one artery (33533 and 33519)?

The patient came in with a dual pacemaker and was upgraded to a biventricular pacemaker with new LV lead (of course), but also had the old RV lead extracted and a new RV lead inserted. I am wondering what the codes would be for this procedure.

POSTOPERATIVE DIAGNOSIS: Severe bilateral lower extremity rest pain, with diffuse aortic and iliac occlusion. PROCEDURES: 1. Endovascular repair of abdominal aorta with the following endovascular devices. a. Gore iliac limb 16 x 12 x 7, followed by 16 x 10 x 7, followed by 8 x 59 Visi-Pro stent. b. Bilateral common femoral endarterectomies. c. Left to right femoral-femoral bypass with 6 mm Propaten graft. I am not sure if I would use the endograft codes for this since we are not treating aneurysmal disease.

How would you code a stent-assisted angioplasty in the proximal cervical segment of the internal carotid artery for a Medicare patient?

Would you code the subclavian angiography, or is it considered inclusive to the temporary pacemaker insertion? "Indication: Complete heart block. The options of IJ and right subclavian access were examined, and decision was made to pursue with the placement of pacemaker through the right subclavian vein. Right subclavian vein angiography: Subclavian vein angiography was performed through the 6 French sheath placed in the right subclavian vein. Right subclavian access was obtained with the micropuncture system and sheath was placed, but the temporary pacemaker was not floating to the superior vena cava and instead was going to the left subclavian vein. At this time right subclavian vein angiography was done, which did show no obvious venous abnormality, and the sheath was pulled back slowly to get the wire across to the superior vena cava, but sheath came out and it required a additional access to the right subclavian vein followed by his successful placement of temporary pacemaker."

I'm totally excited about coding vascular. what book would you recommend for a beginner?

Our office and hospital coders need clarification on the billing of an intracardiac echo. Do you consider ICE (93662) an integral part of an ablation/EPS? Or can ICE be billed in addition to the primary code as long as supervision and an interpretation is documented? There have been conflicting opinions, and I wondered what your recommendation was regarding this code.

RHC (93451) done in cath lab by the heart failure docs. MedGem (94690) is done in the pre-post area. 94690 is a “separate procedure” and edits with 93451. The question is, would 94690 be considered part of “hemodynamics” of a RHC and not be reported separately?

We have a trauma case with multiple deep lacerations of the arm/forearm. The doctor harvested the saphenous vein for segmental interposition repairs of the brachial artery and distal radial artery (35236-59 x 2). The ulnar artery was unsalvageable – it was ligated (37618). Multiple veins and smaller muscle bleeders were sutured (35206). Please advise.

I can bill 37197 when a wire is fractured during a coronary intervention, correct? Physician had just finished doing intervention on patient having AMI. Patient became restless and pulled back guide, balloon, and wire back into the aorta. Physician removed all devices. Went back in with guided to do angiogram and saw a fraction of the wire in the subclavian. Then went in with a snare and removed the wire.

I recently learned that code 93571 would need a -52 modifier if the physician does not dictate the administration of the adenosine in his report. Dictating only the results would need the "Reduced Services" modifier. Would this be applicable to both the facility and the physician? Please advise. I do the Invasive Cath Lab.

Would you please clarify if it is permissible to bill code 76937 with 61645?

When the place of service is 11 (office), can I code for a peritoneal catheter HCPCS A4301? The note that follows the code listed in the HCPCS book states: "Service not priced by Part B." But when I checked the Medicare, NGS Medicare, they are showing A4301 under Jurisdiction Part B MAC. Can it be billed to Part B? If so, how should it be priced? NGS is not showing an amount.

I am confused with when to use 36005 vs. 36140. Doctor accesses the right CFV and does an injection for right leg venogram only. We have been coding this as 36005 plus S&I. Now I am told that on a different case where radiologist accesses the right CFV and gets to right iliac vein, does a venogram of right leg, and then sees a stenosis and does a plasty, that the catheter placement is still 36005. Is this correct, or is the catheter placement 36140 instead? What instance is 36140 used over 36005?

We had a case where the physician inserted a subcutaneous array during an ICD generator change. Is the following still correct?

"Question ID 2625: We have this scenario, the procedure was removal of ICD, revise the ICD pocket, added a new ICD, tested the defibrillator threshold, and added a subcutaneous anterior chest coil array was added to the vector after the new ICD and old leads weren't providing optimal results. This is what we coded 33249, 33241, and 93641 with device codes C1894, C1721, and C1896. Is there something else that you would suggest? Answer: I agree with your codes. I might add 71090 if fluoroscopy was used to place the array though."

I feel that codes 33249, 33241, and 93641 (if performed) are still accurate. Is this advice still relevant? Please advise.

What code would we use for XCOIL? The XCOIL is not an infusion device. So would we use code 34421? This was used in the iliofemoral vein. 

How would you code this new procedure? Our thoughts are unlisted code 37799 with coil embolization code 37241. Help!! "Began with retrograde arterial access. Duplex U/S of brachial artery done-normal caliber. Using a guide catheter & guide wire, we selected the ulnar artery. Right arm angiogram performed demonstrating normal & patent brachial, ulnar, radial and interosseous artery on right. Brachial vein identified and punctured, then selectively cannulated ulnar vein. Rt arm venogram done demonstrating normal ulnar and brachial vein flow. 2 magnetic catheters placed into arterial and venous sheaths. Catheters were aligned to one another and magnets held artery & vein together. Radiofrequency electrode placed into venous cath & ceramic backstop placed in arterial catheter. Radiofrequency electrode energized for 2 seconds creating an anastomosis between ulnar vessels. Fistulogram done showing excellent flow. Brachial vein coil embolized at level of antecubital fossa with 2-8mm nestor coils. Good flow thru fistula on angio. Sheath removed & pressure held." 

How would you charge ureteral stent removal then nephrostomy placement via same access? Should I report codes 50384 and 50432? Or would it be codes 50384 and 50435 because of the already established tract they would be going through. I am leaning toward codes 50384 and 50432.

This was one surgery. The provider indicates that all three procedures need to be billed out. What is correct? 1) Thromboembolectomy left common femoral artery, profunda femoral artery, and superficial femoral artery with Fogarty balloon catheter. 2) Left common femoral endarterectomy and proximal superficial femoral artery endarterectomy with completion bovine pericardia] patch angioplasty. 3) Right to left femoral-femoral bypass with 8 mm ringed polytetrafluoroethylene graft.

Patient is past type A dissection repair with ascending tube graft. He subsequently had TEVAR for residual dissection repair during the same hospitalization. He is being followed for chronic residual dissection, and on CT scan was noted to have persistent endoleak with perfusion of the lumbar vessels in the false channel where the majority of this aneurysmal enlargement is. Patient now comes for embolization and thoracic stent graft extension to the celiac artery. “The celiac artery was marked on IVUS, and a CTAG Gore stent graft was then advanced and deployed just above the celiac artery. Access was obtained into the false lumen, and non-selective aortography showed endoleak from intercostal vessels, which is keeping the retrograde flow in the false lumen intact. We catheterized the endoleak channel and the nidus and deployed several 8 x 4 mm Tornado coils and then deployed an additional 12 mm Amplatzer plug within the endoleak channel.” Is this initial 33881 or extension 33886 for the residual dissection? Also what’s the code for cath for embolization? Is this 36200?

The following is an example of how my vascular/IR doctors dictate. Would you code this as diagnostic imaging, or is it considered roadmapping? Should I have the doctors remove "roadmapping" when dictating? "Initial roadmap images were obtained of the abdominal aorta. Angiographic imaging demonstrated a widely patent left renal artery. The images occurred below the other visceral vessels. There was fairly focal region of complex stenosis involving the mid abdominal aorta over a distance of several centimeters. There was a large lumbar collateral arising from the posterior aspect of this region. The inferior mesenteric artery was patent but diminutive in caliber. There were recurrent stenoses in the proximal aspect of the common iliac stents bilaterally. Using this magnified roadmap image, I decided to place an LD stent."

If patient has a fem-tib bypass but surgeon decides to do an lower extremity angiogram to find the right area for the distal anastomosis, would the angiogram be reportable with 75710? I feel this is not diagnostic and is considered intraprocedural mapping so therefore code 75710 could not be reported. Is this correct?

When a cryopreserved vein is used for the bypass graft, would you use the "bypass graft, with vein" CPT codes, or should we be using "bypass graft, other than vein" CPT codes? Is there anything in print to support your answer?

Is code 76937 billable with pacemaker insertion code 33208? One of our coders attended the recent Dr. Z conference and was told that 76937 is considered "roadmapping" when done in conjunction with heart cath procedures and is not billable due to the S&I portion of 76937 being included with the procedure. The coder was under the impression that it is now not billable with any of the percutaneous "heart" procedures. Per the NCCI edits, pacemaker insertion code 33208 and ultrasound guidance code 76937 do not bundle. Can you please provide advise/guidance as to when ultrasound guidance code 76937 is and is not billable for percutaneous cardiac cath procedures, in particular, pacemaker insertions?

What ICD-10 code would you use for elevated troponin? I've seen R79.89, R74.8, R77.8, but I don't know which one is correct.

Can code 50389 be used if there is no stent in place or mention of a stent? From what I'm reading from other questions asked about this code, on several other sites, only the fluoroscopy is a must to be mentioned. Is this true? So, a nephrostomy tube removal under fluoroscopy with no mention of stent can be coded as 50389?

My provider does most ablation procedures without using fluoroscopy, relying only on 3D mapping. Is this enough to qualify for a complex procedure modifier?

Does the left heart cath procedure need to be diagnostic in order to bill code 93458? Or can the provider report 93458 if just used for the placement of 33990?

How should the professional portion of a 1-view humurus be coded and billed? We receive films from facility that only include one image, but the only CPT code states “minimum of 2 views”. Do we automatically bill with a -52 modifier?

Doctor implanted a dual chamber pacemaker including a coronary sinus pacing lead in the RV port and a right atrial pacing lead in the RA port. He chose to avoid the transvenous right ventricular lead due to the presence of a mechanical tricuspid valve. I thought it would be coded as 33208, but the doctor wants to code it as 33206 and 33225. How should this be coded?

Can we bill an antibiotic pouch (11981) along with code 33215 in the same pocket? "Example: The patient was in atrial fibrillation. The patient underwent cardioversion. The patient was prepped and draped as sterile field. 20 mL of 1% lidocaine was used for local anesthesia. Then, using incision made in the left infraclavicular area where the prior incision and a pocket was opened and the device was explanted. The atrial lead was released from the sutures. Then, the lead was revised with new positioning. The patient had excellent sensing and threshold and lead was secured using 2-0 Ticron suture. Appropriate maneuvers were performed to document the absence of movement of lead with deep inspiration or coughing. Then, the lead was connected to the generator, placed in the pocket header side up. The generator was placed inside the antibiotic pouch after pocket was irrigated copiously with antibiotic and saline solution. The pocket was closed in 2 running layers of absorbable suture and third layer of Steri-Strips."

"Butterfly needle was inserted in a lower large varicosity that was visualized by ultrasound. 1 cc of polidocanol was then injected into the varicosity. This was imaged and massaged into place. The first one was done on the right lower extremity. On the left lower extremity, the same process was repeated with visualization of the large varicosity with ultrasound, and using a butterfly needle, access was obtained in real time with 1 cc of polidocanol then injected into this left lower extremity." Is it correct to report codes 36470-RT and 36470-LT? Since 36471 is multiple veins in the same leg? Please advise.

Is it appropriate to bill code G0463 for facility charges when a patient comes to the IR department holding room for a port site dressing or G-tube pull performed by a PA or NP with note documenting the service?

We have a dilemma and need help. How do we report a percutaneous angioplasty with an open thrombectomy? We see 36905, which includes both angioplasty and thrombectomy, but we cannot report this code because our thrombectomy is performed open. I queried the physician, and the reason why it's been done this way is because the facility does not have the equipment to perform percutaneous thrombectomies. Is it okay for me to report codes 36831 and 36902? There are NCCI edits stating that code 36831 is bundled into 36902; however, modifier -59 can be used to unbundle it. Would the application of modifier -59 be warranted in this case?

Can code 37211 be reported twice if done in two separate areas on the same day at different times?

1. Left lower extremity angiography. 2. Ultrasound-guided right common femoral artery access. 3. Selective left external iliac artery catheterization and angiography. 4. Superselective peroneal artery catheterization and angiography. 5. Superselective posterior tibial artery catheterization and angiography. 6. Initiation of catheter-directed thrombolysis of the arterial embolus involving the popliteal artery, tibioperoneal trunk, and trifurcation.

1. Ultrasound-guided right internal jugular vein access x2 2. Selective main pulmonary artery catheterization with PA pressure measurement 3. Bilateral superselective lower lobe pulmonary artery catheterization, angiography, with placement of bilateral thrombolysis catheters 4. Initiation of catheter directed thrombolysis bilaterally with tPA.

"A 10 French drain was introduced into the hematoma using Seldinger technique. 175 ml of liquid was removed. It was irrigated. It was then instilled with 10 mg of Retavase and allowed to dwell for 30 minutes. We were able to get an additional 50 ml on top of 50 ml of Retavase. At this point, it was still noted to be semisolid and clotted. The drain was removed. We will give the patient a trial of one week and try to repeat aspirating in one week's time to see if we can get additional fluid off, but it is still predominantly clotted at this time." The patient did receive Retavase a week later, and another treatment was performed shortly after that. Could you provide some suggestions on how this should be coded? I can see billing 10160 for the catheter placement. I am stumped on how to bill for the thrombolysis. If I need to bill unlisted, what would be the best code to compare this to?

Which modifier would be appropriate for this situation? On some of our adult congenital heart patients, we frequently will have an adult cardiologist and a peds cardiologist in the cath lab performing separate portions of the procedures. Both employees of the same hospital, just one is adult cardiologist and one is pediatric cardiologist. Are these considered two separate specialties? Also, which modifier would I use on each of their portions of the procedures (-62, -80, -82, etc.), and which physician would receive the modifier? Example: Adult cardiologist performs the congenital heart cath, and the pediatric cardiologist performs the angio, etc. Also, how should this be documented? Should the adult cardiologist do his/her documentation and the pediatric cardiologist do a separate note for his/her portion of the procedure? 

We have a third party company looking for additional reimbursement on outpatient facility cardiac caths. They are telling us that we can bill for an attempted stent in an artery with a -74 modifier when it was not completed; however, they went on to successfully complete an angioplasty in the same artery. So the billing would be coronary angioplasty (no modifier) and coronary stent with -74 modifier. My concern is that the angioplasty is bundled in the stent code. In the past we billed for the successful procedure only. They are using guidance HCPCS, 3rd Quarter 2011, page 7, to justify this type of billing.

What code should we use for venous sampling? The provider only has 36500 and 75893. "Thereafter, I used high resolution real-time ultrasound, identified the right common femoral vein, infiltrated 1% lidocaine, and punctured into the vein under ultrasound guidance during a permanent image. I advanced a guidewire, then exchanged the puncture needle for a 6 French vascular sheath. I used a series of diagnostic catheters to sample multiple venous sites, including the right and left subclavian and brachiocephalic veins, right and left internal jugular veins, superior thyroidal veins, right and left vertebral plexus, azygos vein, left internal mammary vein, thymic vein, superior vena cava, and right atrium. All samples were sent to the lab for analysis, and the results were reported before the end of the day."

Are codes 36595-52 and 75901 correct for PTA of a fibrin sheath through the same access site during a replacement of the existing CVC without port? The NCCI edits as of July 1, 2018, have a bundling issue with codes 36581 and 36595. It states modifier -59 is allowed with the 36595, so do I charge 36595 with a -52 modifier and a -59 modifier?