Ask Dr. Z

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?

This is for physician coding. It is unknown who originally placed the midline or where the tip of the midline terminated. What CPT code would we use when they exchange a midline for a PICC line through the same access site? What CPT code would we use when they exchange a midline for another midline through the same access site? "A left-sided midline catheter was in place prior to beginning the procedure. The LEFT upper arm was prepped and draped in the usual sterile fashion. A stainless steel straight wire was advanced through the midline catheter, and exchange was made for a 5 French double-lumen power PICC catheter. The PICC catheter was positioned at the superior caval-atrial junction. Fluoroscopy was used to confirm final catheter position. The catheter was secured in place. IMPRESSION: Successful LEFT arm PICC line placement (midline catheter exchange)."

A stent is placed in a femorofemoral bypass graft for revascularization. Which artery is the bypass replacing? Iliac and code with 37221? Or code with femoral 37227?

The physician stented an iliac aneurysm with a Bard covered LifeStream stent, not an ilio-iliac stent graft. Is it okay to use code 37236 instead of 34707?

Our doctors want to start performing MRI-guided elastography. I know there is a new CPT code for the elastography for January 2019, but how would we code now until then? I'm thinking it should have to be an unlisted code 76498, as there is currently no CPT for MR elastography.

Our provider tried to do a vein ablation (36475) for a patient, but due to excessive scarring he couldn't do the procedure. This was performed in the clinic setting. We had to use a kit (which runs about $500+) for the procedure. Although the procedure was incomplete, is there a code we can charge for the kit? Or is this not allowed? I would hate to go back to the provider to tell him that we'd have to eat the cost of the kit. Please help clarify what we can do in this situation.

Patient had stenting in the upper extremity previous day and had an angio seal break and developed an occlusion in the leg. When removing parts, the vessel ruptured and bled out, requiring ballooning and stenting to tamponade off the bleed -- it was not placed for a stenosis; however, the patient also had atherectomy performed in the vessel prior to stenting. Would this be reported with code 37227 or 37236? The confusion arises with the atherectomy portion of the procedure for coding if 37236 is the correct stenting code to use.

If you have a charge that has positive finding but no reason for exam, and you are billing for the radiologist or the pathologist, can you assign an ICD-10 code to this? Or do you need to send it back to the client and ask why he/she saw the patient?

The patient presented to the cath lab for planned iliac vein stent placement. A sheath was inserted into the left femoral vein, and angiography was performed in the external iliac vein. The stent was placed in the left external iliac vein. What catheter placement code would you report along with 37238?

One of our doctors is asking about the location of her cutdown vs. how it is coded. She says the location of the cutdown on the cephalic is still central. She states that she is about an inch away from the subclavian and it’s still on the trunk, not on the extremity. Our concern is that the codes specifically state either central or peripheral, and the cephalic vein is peripheral no matter what part of the vein you access. We have been coding these as 36571. She has asked us to research/review that the cephalic cutdowns for venous access would, in this circumstance, be considered central since she’s not cutting down on the extremity. Can you please advise us of your thoughts on this?

We have a patient that has been undergoing thrombolysis, on one of the follow up visits the physician places a stent to treat the thrombus and areas of extravasation. Can we bill anything for the stent placement? "THE RIGHT FEMORAL ACCESS SITE WAS PREPPED AND DRAPED IN THE USUAL STERILE FASHION. A GENTLE HAND INJECTION OF CONTRAST AGENT THROUGH THE EXISTING INFUSION CATHETER WAS PERFORMED WHICH DEMONSTRATED ACCUMULATION OF THROMBUS MATERIAL WITHIN THE DISTAL FEMORAL POPLITEAL SEGMENT. ADDITIONALLY, 2 AREAS OF EXTRAVASATION OR IDENTIFIED FROM THE DISTAL SFA AND POPLITEAL ARTERY. I ELECTED TO COVER THE THROMBUS AND TREAT THE AREAS OF EXTRAVASATION WITH A COVERED STENT GRAFT. A 6 MM X 15 MM GORE VIABAHN WAS DEPLOYED. A POST TREATMENT ANGIOGRAM DEMONSTRATED RESTORATION OF INLINE FLOW. MINIMAL DISTAL THROMBOEMBOLI WERE PRESENT WITH 2 VESSEL RUNOFF VIA THE PERONEAL AND ANTERIOR TIBIAL ARTERIES. I ELECTED TO TERMINATE AT THIS POINT. THE INFUSION CATHETER WAS REPOSITION WITHIN THE SFA. TPA INFUSION WAS RESUMED."

If a physician performs mechanical thrombectomy of both the left circumflex and obtuse marginal, would you report code 92973 twice?

One of our physicians created a right posterior tibial artery to tibial vein graft for plastic surgery free flap using the GSV. The patient had a large open traumatic wound of the right lower extremity requiring reconstructive surgery with a large free flap. We were asked to created a graft to provide inflow and outflow to the flap. The documentation is pretty clear; he harvests the GSV and does an anastomosis to the tibial artery and tibial vein when he was done there was excellent thrill in the graft. I have requested to bill an unlisted code for the procedure to my QM department. They have said no, that I should bill 36825. I disagree... that code is for renal disease, which is not the case here. I believe an unlisted code with the appropriate dx code for the wound is how this procedure should be billed. What would your recommendation be? If you think it is appropriate to bill 36825 I will go with that.

Physician is stating "bilateral lower extremity angiogram with runoff performed" and "additional images of fem-pop and tibioperoneal vessels were obtained". I know about the catheter placed in the aorta for runoff, but don't I need dictation stating which vessels he placed catheter in for fem-pop and tibioperoneal to obtain those additional images? Or is that statement enough?

One of our physicians would like to treat a radial artery pseudoaneurysm with 6-8 hours of compression with a TR band. Have you had any experience with how to bill this and if it will be paid?

How would you code a needle localization of a breast lesion with CT guidance?

My provider is trying to bill 36228 for the angiogram done of the choroidal aneurysm after first doing angiograms of the LCC and LIC (36224). This is what he documents: “A scepter XC 4 x 11 mm balloon was advanced into the MCA followed by advancement of an echelon 10 microcatheter into the aneurysm. An aneurysmogram was performed. The aneurysm was now sequentially coiled with Codman coils. Left anterior choroidal artery aneurysm: Superselective aneurysmogram better delineates the size and shape the aneurysm.” I do not feel that this is a true diagnostic angiogram, and he does not give us any detail of what was seen... he only says the aneurysmogram better delineates the aneurysm. Do you agree with billing or not billing the 36228?

Can we report 92990 together with 33477?

I am new to vascular coding, and I am unsure how to code this. Our vascular surgeon was called in to assist with patient that underwent a nephrectomy and was found to have significant retroperitoneal bleeding from the renal vein. Per the op note: "Patient had bleeding from gonadal vein inferiorly and the adrenal vein superiorly. Clamps were in place controlling renal vein. Hemoclips were utilized to ligate the left gonadal vein, and left adrenal vein was oversewn by means of a running 4-0 prolene. Clamps were removed from renal vein, and interrupted 4-0 prolene sutures were utilized to completely control the bleeding renal vein. Wound was irrigated, and hemostasis obtained. At this point in time, closure and completion of surgery were to be completed by primary surgeon." How would I code this? Do I need to add a modifier since the opening and closing of the incision was not done by our surgeon?

A patient was brought in for planned intervention on CTO of mid right coronary. Attempts were made, but it was unable to be crossed. However, the physician was able to angioplasty the proximal right coronary. Should this be billed as 92920-RC or 92943-52? I do not think billing both would be allowed since they are the same artery.

Patient is status post EVAR, now with type I endoleak. Balloon expandable stent grafts were placed in the right and left renal arteries with successful exclusion of type I endoleak. Are the correct codes for this procedure 37236 and 36237? Along with 36245, for bilateral catheter placement in the renals?

"Patient has a brachiocephalic fistula. The left cephalic vein fistula was accessed antegrade. The sheath was used to inject contrast to perform fistulogram. Retrograde injection was performed with a balloon occlusion of the fistula, which revealed ~90% stenosis of the proximal fistula vein ~2 cm distally to the AV anastomosis. Left radial artery was then accessed at the wrist under local anesthesia and ultrasound guidance. Wire and catheter were unable to access the fistula from this location. Therefore retrograde fistula access in the proximal upper arm was obtained under ultrasound guidance and with local anesthesia. The stenosis was angioplastied with a balloon with good result." Can we code for the radial artery attempted access? Would 36140-59 be correct in addition to 36902?

How would you bill the following scenario? Patient had lysis initiated (36904) on day 1. Patient returned on day 2 for angioplasty with subsequent lysis from existing catheter (36902). On day 3, the patient returned for imaging and termination of lysis (36901). Can each day be billed separately, or would they all be included in one code? Specifically, since separate dates of service, would we bill the aforementioned codes individually or 36905 one time? Looking for clarification on the term "encounter" in regards to this. Trying to decipher if encounter means each day, or if the entire inpatient stay would be considered "one encounter."

Can you please help me with the following case? "CT guidance for needle placement within the intradural space. CT-guided placement of drainage catheter within the intradural space. The patient presented with CSF leak following surgery."

Please clarify: Coder's Desk Reference indicates a fourth catheter should be moved into the left ventricle. Can you report this add-on code 93622 if provider documents the catheter is moved into the CS and pacing/recording performed? When I queried, provider indicated both left atrium and ventricle were paced/recorded from this position. Is this sufficient to bill the additional add-on code?

I don't see any coding information for coding VenaSeal (36482) in the same vein (great saphenous vein), but segmental treatment - meaning two separate accesses, but same vein. Would you report code 36482 one time, or would you add 36483 for the additional access even though it's the same vein?

If the doctor does an ultrasound and fluoroscopically guided placement of a percutaneous gastrostomy feeding tube, can the ultrasound guidance be billed? We have two separate opinions: 1) The procedure includes fluoro and CMS only allows one unit of these guidance codes for a service, and 2) code 76942 does not bundle and the procedure only says it includes fluoroscopic guidance.

I'm not sure how to code for this. We were thinking perhaps 37799 and not 61623 because a "balloon" is not mentioned. The doctor calls it an embolization, but we're not sure it's really an embolization. Please advise. "Utilizing a Headway dual 167 microcatheter, the radicular artery carry into the dural arteriovenous fistula was superselectively catheterized with the micro-catheter tip at the C5-6 foramen. Additionally, with the micro-catheter injection, DynaCT was obtained. Through this system, 10 mg of intra-arterial lidocaine was injected to mimic the occlusion effect of dural arteriovenous fistula with SSEP and motor-evoked evoked potential monitoring. There is no change of the neurophysiological finding. However, the superselective microcatheter injections revealed the presence of a posterior spinal artery from the arterial pedicle. Therefore, no further endovascular treatment was carried out. Multiple control angiograms were performed to monitor the embolization procedure, and no complication was encountered."

Is 0075T a global physician charge, or should it require a -TC/-26 split?

Case where a patient had a transplant kidney off of the right iliac system. Initial access of RLE provides angiography of iliac and renal artery, but due to the angle of renal artery a contralateral approach was then utilized for the intervention. Stent was placed in the renal artery from the second access. Would you use the standard renal artery codes for the transplanted kidney, and would you code for a separate access?

An angiogram in the aortic root was done prior to an EP ablation study (SVT) by a different cardiologist. Should I report code 93567 in addition to the EP study? Echo (prior the procedure) stated: "Left coronary artery is less clearly visualized. Will perform angiography at time of ablation. The angiogram was done to evaluate the coronary artery anatomy. The results were normal."

The pacemaker pocket was opened, and the existing pacemaker was removed from the pocket. The pacemaker pocket was revised in order to allow a more inferior placement of the device upon completion of the procedure (33222?). Existing RV and RA leads were extracted and removed from body (33235?). Brand new leads were implanted (33217?). The leads were connected to the previously placed generator, which was placed into an antibiotic sleeve then placed into the pocket. Can we charge for pacemaker generator removal (33233), or is this included in the other procedures charged?

"LCF artery punctured w/ 6 French sheath. Aorta was catheterized and angio obtained, no stenosis. Rt common iliac, external iliac, common fem, superficial and popliteal were catheterized and angiogram of each segment obtained. Vessels patent except superficial fem that had 60% stenosis. Distal runoff revealed patent anterior tibial to the foot. Rt tibioperoneal was catheterized and angiogram revealed 60% stenosis, distal runoff was peroneal artery only to the foot. Pt given 6000 units of heparin and sheath place up and over to the rt fem. Angioplasty of the tibioperoneal trunk and superficial fem performed with 3.5mm and 5mm balloon and post angioplasty both vessels were patent. Catheterization of lt external iliac performed and was patent. Sheath removed and puncture site closed." Billed as 37228, 37224, 75710, 75625, 75774. I'm confused with the angiograms. Can you explain why these are correct? Our clinic struggles with 75625/75630 and 75710/75716 and 75774 is always an issue.

Do you have any guidance on diagnosis code selection if "lumbar facet arthropathy" is documented? My question would extend to the other regions of the spine as well.

When 3D is used in an MRI-guided breast biopsy, can code 76376 be reported? "A dedicated breast coil was used. Localizing images were obtained of the left breast. Axial T1 weighted 3D images with fat suppression were obtained both before and after the uneventful IV administration of 20 mL of Multihance injected at a rate of 2 ml per second. This study was acquired both before and after the IV administration of gadolinium contrast material. An MRI biopsy was performed for the focal area of non-mass enhancement located in the left breast at 3 o'clock middle depth. This was described on the previous MRI report. The abnormality was approached from the lateral aspect. A 9 gauge biopsy needle was placed adjacent to the abnormality under MRI guidance. Additional MRI images were obtained to document needle placement. Once the needle was documented to be in the correct location, eight specimens were obtained using the Suros ATEC system. A dumbbell-shaped biopsy marking clip was inserted into the biopsy cavity. No immediate complication."

I know typically a cardioversion is only billed prior to the beginning of a procedure (EP, LHC, PM), but occasionally our EP doctor is doing an elective cardioversion after placing the PM and leads for safety reasons since these patients are bradycardic and it's safer to have the RV lead in prior to cardioverting them. Would it be okay to bill code 92960 in this scenario since it was elective (consent on chart), but it wasn't safe to perform the cardioversion at the beginning of the procedure?

We know that a dobutamine stress test with TTE would be reported using 93350, 93351, or 93352 if contrast is used in addition to the charge for the dobutamine. How should a dobutamine stress test with a TEE be reported?

Would the following be coded as 36830? "Patient with left arm radiocephalic AVF presents for placement of hybrid graft. The left axilla was inspected with US. The previously placed axillary/basilic vein stents were ID'd. The axillary vein was punctured under US guidance. A small incision was made over the puncture site, and a short sub-q tunnel tract was created. A sheath was passed into axillary vein. The hybrid graft/Viabahn stent was passed through the sheath and into the axillary vein beyond the previously placed stents/known stenotic lesions. The stent portion of the graft was deployed. Venography of the graft/stent and axillary vein/central runoff was performed via the sheath. Severe stenosis was noted within the axillary vein stents. Balloon angioplasty was performed. The graft was flushed and clamped at the axillary incision. A tunneler was passed between the two incisions along the tunnel tract. The graft was pulled back through the tract. An arteriotomy was made on the anterior aspect of the brachial artery. The graft was sutured end-to-side to the brachial artery."

We sometimes see procedures in which a lower extremity artery is being treated for stenosis, and on repeat angiography dissection or extravasation is seen, and this is then separately treated with stenting. The dissection or extravasation is not described as being occlusive. Would it be appropriate to add code 37236 in these scenarios? Or would only a code from 37220 - 37235 apply? Can you explain?

Regarding Ask Dr. Z question ID #3482, do you still recommend 93799, or does 37248 apply here? Example 1: The fenestration was crossed and was balloon test occluded for 10 minutes. The Fontan pressures rose to 16 mmHg, and we decided not to close it. Example 2: Test Occlusion: The fenestration was easily crossed using a 4 French JR4 catheter over a 035 Tureumo guidewire. The catheter was exchanged to a 4 French wedge over a 018 V-18 wire. The fenestration was temporarily test occluded for 10 minutes by inflating the wedge catheter, and repeat hemodynamic evaluation was performed using the LFV catheter. There was mild elevation in his PAp=15 mmHg and arterial saturation increased from 95 to 96%. However, his overall Qs decreased to 2.9.

Can we charge for just the catheter placement when a patient has a non-chargeable angiogram? Example: Patient had stent placement into the proximal left internal carotid with distal protection (37215). On previous CTA, patient had bilateral internal carotid imaging. At time of intervention, the physician re-images the non-treated right internal carotid artery. I will not be charging for that angiography, but would I be able to charge 36217 for catheter placement into that artery?

If my provider indicates in his conclusion the patient has trace or mild valvular disease, would it be appropriate to code? I have heard to only code valve disease that is moderate or severe.

I didn't see any previously answered questions regarding coding for a RVAD and LVAD. "Prior to an angiogram, a right- and left-sided Impella device was placed. The patient was in severe right-sided failure, the left common femoral artery was accessed, and a JR4 cath with a glidewire was advanced across the TAVR valve into the LV and placed the CP Impella device. Once that was completed, they went up from the right side, accessed the right common femoral vein, and angled the balloon cath and guide wire with a J in it all the way distal as we safely could and advanced the device with the tip in the left PA until we were adequately positioned. We had good numbers, and everything was peeled away on both sides and sewn into place. Mattress sutures were done on the right side. At that point we were ready for an angiogram." What would the coding be for this?

The CT department had a question for me today, and I have no idea how to tell them to code these. Please help. "We are currently charging a CTA aorta with runoff for the CTA renal donor protocol. They have changed the protocol. It now requires us to scan an abdomen/pelvis without, CTA abdomen/pelvis with runoff, abdomen/pelvis venous phase, and delay abdomen/pelvis. We are all doing multiplanar reformats, volume rendering, and MIPS of all the contrast phases. Is charging the CTA aorta with runoff the correct charge for the updated protocol?"

For the following I think codes 37236 and 36246 are correct, but I would like to be sure. Patient has a non-functional pancreas transplant, and the physician placed a stent to occlude the transplant artery. This was done preoperatively so they can removed the transplanted pancreas. "Procedure: Angiogram was performed and demonstrated the transplant pancreas artery to be originating from the proximal third to mid portion of the right external iliac artery. OmniFlush catheter was exchanged for a Bern catheter, which was positioned in the proximal external iliac artery. Angiogram was performed. Exact location of the origin of the transplant pancreas artery was determined. Roadmap was created. SupraCore wire was placed. Balkan sheath was used to cross over the aortic bifurcation and placed into the external iliac artery. Appropriate measurements were made for stent placement on angiogram and prior CT. A 9 mm x 29 mm Viabahn VBX stent was then placed in the right external iliac artery centered on the origin of the transplant pancreas artery."

We are hoping to get clarification on when it would be appropriate to report add-on code 47544 (percutaneous removal and/or destruction of calculi from biliary duct) vs. 47554 (biliary endoscopy via existing tract with removal of calculi). The two codes seem very similar. Does code 47554 include the lithotripsy/stone destruction when done? And can code 47544 be used when done with choledochoscopy? Our scenario is a choledochoscopic lithotripsy through the sheath with a biliary drain exchange.

What would you recommend coding for the facility side for the following? "REASON FOR EXAM: Elevated PSA. DISCUSSION: Sonography provided for the Urology service for the purpose of a fusion-directed biopsy. Prostate measures 4.9 x 3.5 x 4.7 cm, giving a volume of 42 mL. IMPRESSION: Sonography provided for the Urology service."

My practice is wondering if we can report the 93793 with code Z79.01 as diagnosis along with the secondary code (ex. AFib/AFlutter) when the patient has just started use of Warfarin and requires monitoring. Is it enough to meet the definition of "Long (Current) Term Use" if we are anticipating the patient will be on the anticoagulant for the long term?

Do you have insight on how to code for the new technology of intravascular litotrispy treatment for PAD in the lower extremities?

A Medicare patient has a Micra inserted for dx of R00.1 and I48.1. Patient is not part of any clinical research study. Does the claim qualify for modifier -Q0 and dx of Z00.6?