Ask Dr. Z

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?

Our patient was hooked up with a 72-hour Holter monitor (CPT code range 0295T-0298T); however, the monitor was worn for less than 48 hours. Should this be coded based on the type of monitor hooked up (0295T-0298T) or the time of continuous monitoring (93224-93227)?

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

What is the appropriate CPT code for an MRI of the lumbar plexus?

The vascular doc exposed right neck external jugular vein, and the harvested saphenous vein graft was transferred to neck, where the anastomosis between the saphenous vein graft and external jugular vein was performed. At that point the plastic surgeon did a muscle flap using latissimus dorsi muscle and eventually attached the thoracodorsal vein anastomosis with the saphenous vein graft. This created a bridge for the gap between the neck and preauricular flap for the cranial defect. All our vascular doc did was the saphenous vein harvest and anastomosis to the external jugular vein. We have no clue how to code this! Help would be appreciated!

If the physician states "mapping using recording of intra-atrial signals" during a PVI ablation, would this be acceptable documentation to report code 93609? Or should they specifically state "intra-atrial mapping of tachycardia"?

Would you use code 10030 with 20500 or 49185 when the physician is draining a post-op chest wall seroma and using betadine sclerosant? The drainage catheter was left in.

Is there a CPT code for left renal vein transposition and inferior vena cava repair? I think it should be an unlisted code, but the provider disagrees. Documentatino states it goes in as an inferior vena cava reconstruction with the left renal vein transposition.

The patient had PVI ablation for atrial fibrillation. The doctor then did a CTI ablation without stating that there was continued atrial fibrillation or any other type of arrhythmia. In this type of case are we able to code for the CTI ablation, or do we have to consider it an empirical ablation and just code the PVI?

Would you still recommend using unlisted code 37799? We would not code cone beam or 3D post processing, correct? "Two pediatric micropuncture needles were advanced into separate sites of the venous malformation. 3 cc aliquots of foam (bleomycin mixed with human serum albumin) were injected through the needles with continuous fluoroscopic visualization using contrast displacement technique. Approximately 2 to 5 minutes were allowed to pass between injecting each aliquot. Direct digital compression of draining veins was performed to reduce systemic exposure of bleomycin. A total of 18 units bleomycin and 3 cc 25% human serum albumin were injected. The needles were removed. A cone beam CT of the head was performed to compare the distribution of sclerosant to the preprocedural MRI. 3D postprocessing was performed on a separate workstation. Multiplanar reformatted, maximum intensity projection, and volume rendered images were archived to PACS."

When the doctor administers Varithena into the greater saphenous vein varicosity and then into multiple adjacent varicosities using ultrasound guidance, would code 36466 (multiple veins) or 36465 (single veins) be used? Does the documentation need to state that multiple truncal veins were infused with Varithena to bill 36466 (multiple veins)?

My provider performed an image-guided lumbar puncture at the L4-L5 level for the purposes of administration of enzyme replacement therapy for Hunter syndrome. "A 22 gauge needle was inserted into the thecal sac at the L4-L5 level. A fluoroscopic image of the needle within the spine was retained within the patient record. 10 mg of Idursulfase in 1 cc of saline was then slowly administered intrathecally." Would this procedure be coded with 62323 or 96450 with 77003? My concern is 96450 is for chemotherapy. Both procedures place the medication into the subarachnoid space. 

Can we bill code 93600 for recording bundle of His when done at the same time as replacing a defibrillator lead?

How do I code a two-vessel stent with rotablation?

"Under CT guidance (77012), a 17 gauge coaxial needle was advanced into the left lower pole, and multiple 18 gauge core needle biopsy samples were obtained from the left lower pole (50200). The specimen was placed in saline. An Avitene slurry was utilized to embolize the tract. Impression: Technically successful CT-guided left medical renal biopsy as described above." Is there a CPT code specific to the Avitene slurry embolization of the biopsy tract (procedure) in this case? If so, what would that be? Code 37244 is the only thing that comes close that I am finding. 

Can codes 77012 and 76942 be reported on the same encounter if one is an US-guided biopsy of the thyroid nodule and one is CT biopsy of a retroperitoneal mass in separate locations? "Under ultrasound guidance fine needle aspiration was performed of the left thyroid nodule utilizing 25 gauge needles x3. Pressure was applied for hemostasis. Sterile bandage was applied. The patient was in the supine position. Left lower quadrant was marked, prepped, and draped in usual sterile fashion. 2% lidocaine used for local anesthetic and a small incision made. Under CT guidance a 16 gauge introducer was advanced into the left retroperitoneal mass. Multiple 18 gauge core biopsies obtained. Needle was removed and pressure. IMPRESSION: 1) CT-guided left retroperitoneal mass biopsy. 2) Ultrasound-guided fine-needle aspiration left thyroid nodule."

During intervention, how do we know the difference between diagnostic angiography and guidance angiography?

On 7/23 patient had tunneled CVC exchange then returned on 7/27 for tunneled CVC for removal because central intravenous access was no longer needed. How do you recommend this case scenario be coded? With a modifier or as 99024?

I have a case where an AICD upgrade was planned, but after venography the upgrade was cancelled until further intervention could be done to allow the lead to be placed due to occlusion. The provider performed a cardioversion that same day prior to leaving the EP lab. I cannot find supporting documentation that this was discussed with the patient. In my opinion that makes this non-elective. Do you agree?

With this documentation could we also report 93567 along with our cath code? To save space I’m only including a portion of the cath report. "ASCENDING AORTOGRAPHY: The pigtail catheter was placed in the non-coronary sinus and in the LAO 12 caudal 4 view, an aortogram was performed. This demonstrated heavy calcification of the cusps with no significant aortic regurgitation."

Patient comes in for check of implanted loop recorder. The nurse checks device, and if there are any recorded events she prints them out and gives them to the cardiologist. Is this reported with code 93291? If there are no events, so nothing is printed out, should we submit code 93285 instead (and only submit 93291 if we do print out events for the cardiologist)?

What code is correct for an ilioprofunda femoris bypass with an "ex vivo" endarterectomized superficial femoral artery? The indication for the procedure was a left femoral hemorrhage and infected femoral artery. My first choice was 35565, but it's not a vein, and I cannot find a code for the use of an artery. I don't think a non-vein code is appropriate since it is an autogenous vessel. I am also assuming the endarterectomy is included since the SFA was occluded. 

Please let me know if 20552 is the appropriate code to bill for this procedure since code 64646 requires surgical exposure or electromyographic needle insertion to the muscle. "INDICATIONS: Ventral hernia without obstruction or gangrene. COMPARISON: None. PROCEDURE: After informed consent, the skin in the mid axillary lines was prepped and draped. A timeout was performed. Prior to each procedure, 8 cc of 1% lidocaine was injected into the abdominal wall. Right abdominal wall injection: Using ultrasound guidance a 20 gauge needle was placed into the right external oblique muscle. It was injected with 50 units of Botox. There are no procedural complications. Left abdominal wall injection: Using ultrasound guidance, a 20 gauge needle was placed into the left external oblique muscle. It was injected with 50 units of Botox. There are no procedural complications. IMPRESSION: Successful bilateral ultrasound-guided abdominal wall injections with Botox."

Is it ever possible to report an ECG before and after an electrophysiology atrial fib, flutter, SVT, or VT ablation? Or is the EKG always included?

I have looked and can't find an answer to this question on your site. If our doctor does a left heart cath and then goes down and selectively cath's the renals (and he had medical necessity to do so), can you bill both 93458 and 36251/36252? We weren't sure you if should bill two cath placements. 

Patient had a dual pacemaker implanted, which the generator only was removed and replaced with a biventricular pacemaker generator. The atrial and ventricular leads were reattached, and a biventricular lead was added. The pocket was relocated to make room for the biventricular device. I'm looking at billing 33228, 33225, and 33222. I do not see a code for the biventricular generator and wanted to make sure I am not missing something. 

Can code 76937 be reported with diagnostic EP procedures? One of your responses to a previous question regarding 76937 was that it cannot be coded with EP ablation procedures... but what about diagnostic?

When a provider is ordering or reviewing an outside x-ray and then independently visualizes and interprets the same x-ray, does the provider get 2 points or 3 points in MDM Table B (they are not separately billing for the XR-26)?

Would you please advise on coding a thrombectomy in the central dialysis segment of an AV fistula? There was also an angioplasty in the central dialysis segment on the same encounter (36901, 36907). "1) Excellent results of clearing of the stenosis in the venous limb of the graft with angioplasty with a 7 mm x 4 cm long balloon. There was resultant thrombus formation in the graft and subsequent draining venous system. 2) Successful pharmacomechanical thrombolysis of the thrombus within the graft and draining central veins using a Trerotola catheter, a cleaner catheter, a Fogarty balloon, a total of 4 mg of tissue plasminogen activator (tPA), and 6500 units of heparin. 3) Successful angioplasty of the central stenosis with a 10 mm x 4 cm long balloon."

"Utilizing CT and CT fluoroscopic guidance, a 3.5 in 22 gauge spinal needle was advanced to the right L4-5 zygapophyseal joint. Contrast injection confirmed communication with the right L4-5 synovial cyst. Next, utilizing CT and CT fluoroscopic guidance, a 12 gauge Bonopty cannula was advanced through the right L4 laminotomy into the right L4-5 synovial cyst. Attempt at aspiration of the synovial cyst through the Bonopty cannula yielded no synovial fluid. Next, disruption of the cyst was performed via injection of the Bonopty cannula. There was contrast opacification in both the epidural space and in the intrathecal sac. Therefore, steroid/local anesthetic cocktail injection was not performed. Next, approximately 0.2 mL of Tisseel fibrin saleant was injected into the synovial cyst via a 15 cm 20 gauge Chiba needle coaxially through the translaminar cannula. The spinal needle and biopsy cannula were removed with continuous aspiration." How would you code this procedure for a L4-5 synovial cyst?

"Patient with left LE critical limb ischemia with gangrenous 2nd toe. Vascular surgeon A performs the upper extremity vein harvest of the cephalic and basilic veins while simultaneously vascular surgeon B performs fem-pop bypass with the spliced veins. Physician A documents the vein harvest procedure indicating that simultaneously Physician B has already started with arterial exposure of LE and then finalizes the procedure once the harvested veins are handed over by Physician A." Physician B also had an assistant (PA-C). Reason for both physicians is reduction of OR time and improved patient safety (documented by Physician A). Since each procedure is distinct and has its own CPT code, how would we capture this, as the vein harvest, performed exclusively by Physician A, is and add-on code and requires a base code which in this case was exclusively performed by Physician B? This scenario does not look to support a true co-surgery (based on 2 distinct procedures/codes and same physician specialty); however, is there a way to capture both physician services appropriately? 

How would the following be reported? Patient had a CTO of the diagonal 2 treated with drug-eluting stent. In addition, the native LAD had an atherectomy with drug-eluting stent and the diagonal 1 had a POBA. Would C9607 be reported for the treatment of the CTO of the diagonal 2, along with C9602 being reported for the atherectomy and drug-eluting stent of the LAD, and 92921 for the POBA of the diagonal 1?

We are having issues regarding when we can and can't charge for unused supplies at a hospital. Would it be appropriate to charge for a device that was dropped on the floor during a procedure? If a coil went in a patient and then was taken out because it was the wrong size and physician didn't deploy it, would it be appropriate to charge for the device?

We have a physician who insists that if an angiogram is performed and there is runoff into a vessel and if he performs angiogram in one of the vessels that the runoff was in that he has completed his basic examination. The only problem is that he is never consistent when using 75774. Can you please explain what would qualify as a basic examination and how it would be appropriate then to bill for an additional angiogram with 75774? I should also say that 95% of the time he states that there are no prior angiograms because he factors this in also when he wants to bill for 75774. 

Several of our cardiologists are using Propofol for sedation on cardioversions. Can they bill code 99152 (all requirements met for the code) for the Propofol sedation even though it's technically a deep sedation? If not, that doesn't seem fair to reduce the RVUs on some of these procedures when we cannot capture the sedation and that's the riskiest part of the procedure. Do you have any recommendations?

Are we able to bill for skin/soft tissue removal during aneurysmal repair of AV fistula? "Separate longitudinal incisions were made over these aneurysmal segments. Cephalic vein was identified and secured with silastic loops. The aneurysmal portions revealed thin vessel wall with compromised overlying soft tissue. Circumferential control was obtained. 5000 units of heparin were administered and allowed 3 minutes to circulate. The cephalic vein was clamped proximally and distally to the aneurysmal segments. A longitudinal venotomy was made over the compromised sites. Redundant compromised vessel wall was excised until a 2 cm residual diameter vein remained. Aneurysmorrhaphy was performed as the vein was then re-approximated using double layer 5-0 proline suture. Vascular clamps were removed. A thrill remained throughout the fistula. Compromised skin overlying the aneurysm was resected with a 15 blade. The amputated skin measured approximately 4 cm x 8cm. Deep dermis was approximated with interrupted 3-0 polysorb suture."

When performing a procedure such as an A-fib ablation or left atrial appendage closure, would the physician be able to bill separately for an angioplasty of the intra-atrial septum? This is performed to make it easier to cross. Would CPT code 92992 be appropriate? If not, would we be able to append a -22 modifier for the extra time involved for performing this procedure? Sometimes, the physician has to perform this angioplasty twice in one session.

Is it appropriate to report code 93451 when an IVUS catheter is used to obtain right heart pressures during an IVC gram and bilateral lower extremity venogram? Indication for procedure: bilateral lower extremity swelling. Excerpt of physician documentation: "I also used the IVUS catheter to measure pressures in the right atrium." Findings: The right atrial mean pressure was 15 mmHg.

Can you please clarify some coding info for dialysis procedures? Patient has small RC AVF, so the physician makes his approach from the distal radial artery at the wrist (no mention of distance from AA). He performs the fistulogram from this arterial cannulation with findings of AA and cephalic vein stenosis. He then inserts an angioplasty balloon to perform the PTA on both stenosis. Would we just code 36902 or 36140 and 36902-52? I'm finding conflicting/confusing info between your book and ASDIN for 2018.

"Transforaminal epidural steroid Injection at the levels of L4, L5. Procedure: Needle was advanced under fluoroscopic guidance using an oblique view just inferior to the pedicle of the L5: right. The final needle position was into the inferior one-third of the foramen. The fluoroscopy view was changed to the AP and lateral views, and the needle position was confirmed to be within the foramen. Then 2 mls of isovue 200mg/ml dye was injected under AP view without DSA and confirmed adequate spread along the nerve root and in the epidural space. There was no evidence of intravascular uptake or intrathecal spread on imaging. A lateral view was also taken confirming adequate epidural spread. This was repeated at the right L4 level as well. At this point, 3mL total volume, consisting of 1mL of 40mg/mL of Triamcinalone was injected along with 2.0 mls of 1% lidocaine per level." Is this considered one level L4-L5 for 64483 or two levels for 64483 and 64484?

I cannot seem to find any coding guidance for the following scenario. Patient had CSF leak following forgery (not lumbar puncture). The physician put a drainage catheter within the intradural space under CT guidance. How would this be coded?

I'm confused on how to code when the left anterior descending artery is treated with a balloon angioplasty and then the branch of the LAD receives a stent. Is this coded as 92920-LD and then 92928-LD?

I am auditing stress echocardiograms with color Doppler. The indication is dyspnea on exertion and abnormal EKG. The physician gives the findings of the resting and stress EKG and echocardiogram and then states the heart contractility was normal and that it was an unremarkable stress echocardiogram. However, immediately below this statement he gives the findings of the color Doppler, which showed mild AI, mild MR, and mild TR (which codes to I08.3). The coder I'm auditing is coding I08.3 as the primary diagnosis on the stress echocardiogram and the color Doppler code due to those color flow Doppler findings. My understanding is that a stress echo is designed to measure the effect of stress on the heart, and since the provider has told me the stress echocardiogram was normal these valvular findings are not a response to stress and are incidental. I would revert to the indication to assign the ICD-10-CM code. What is your take?

If tumor imaging SPECT (78803) is performed along with sentinel node injection (38792), can they both be charged or only the SPECT (78803)?

Is the bypass considered inflow/outflow to 35142? Can both of these be coded together with 1 incision? "Distal dissection revealed a large pseudoaneurysm with multiple lymph nodes. It was decided to open the pseudoaneurysm to repair. A clamp was placed on the common femoral artery. An incision was made into the pseudoaneurysm, which was quite thick wall. At the base of the incision was an area of superficial femoral artery about 5 or 6 cm, which was totally destroyed by infection. This area was resected in its entirety, leaving a stump of distal common femoral and a stump of superficial femoral, which appeared to be good tissue. Cultures were taken from the base of the wound. Saphenous vein was then harvested. It was far enough away from the pseudoaneurysm and appeared free of infection. A sufficient length the proximal greater saphenous was harvested and prepared for use in a reversed fashion. The proximal common femoral and distal superficial femoral were heparinized. The vein was then cut to length and sutured end and each of these arteries using 6 0 Prolene suture."

Could you advise on CPT codes that should be used for this procedure? What do we need to look for in a retrograde cystourethrogram? "Retrograde cystourethrogram was performed via indwelling Foley. Scout imaging and fluoro images of the urethra and bladder were obtained during and following instillation of contrast through indwelling Foley. Fluoro cystogram was performed with contrast instilled in the bladder lumen via gravity flow through patient's indwelling Foley. Total of 225 mL of contrast was instilled into bladder lumen. No extraluminal contrast was visible to suggest postop leak. There was irregularity of the bladder dome near the reimplantation site during filling, which improved but did not resolve on further distention. Large volume reflux of contrast was seen in the left renal collecting system, and small volume reflux was seen into the right renal collecting system. Following evacuation, small post void residual was seen. No residual contrast seen."

Patient presents to cath lab with repaired tetrology of Fallot with absent pulmonary valve syndrome with mixed conduit dysfunction. The physician performs conduit/pulmonary valvuloplasty and then places a stent in the conduit. He states, “The stent is placed as intended across the stenotic conduit valve.” What code would you use for the stent placement?

How would you code this scenerio? "INTERVENTION: A 5 French Sophia catheter was advanced into the distal external carotid  artery. Then, a Headway microcatheter was advanced into the middle meningeal artery without difficulty. During this portion of the procedure, continuos Cardene infusion at 25 mg per hour was initiated via the Sophia catheter. Additionally, slow infusion of nitroglycerin was administered through the microcatheter position within the distal middle meningeal artery just proximal to the origin of the frontal branch. Multiple unsuccessful attempts were made to advance a Headway microcatheter into the frontal branch of the middle meningeal artery using a combination of a 5 French Sophia catheter, a Headway Duo microcatheter, and an assortment of microwires including Traxess, Marathon, and Synchro microwires. Due to the acute angle and diminutive caliber of the artery, the procedure was aborted." Our docs want to report codes 36597, 61624, and 75894. However, I don't think 36597 is correct. Also, I'm wondering if modifier -74 should be appended to 61624. Thoughts?

Would this be 93580-74, 93580 or cath only? "A prograde right and left heart catheterization was performed with a 6 French GL. The GL was advanced across the atrial septum to the LUPV and exchanged over a wire for a 20 mm ASD sizing balloon, which was advanced over the wire and across the ASD to straddle the atrial septum. The balloon was inflated during real-time TEE color Doppler, and the stopflow diameter of the ASD was found. This was found to be 12 mm by TEE and 13.4 mm by fluoroscopy. The balloon was deflated and removed. A 30 mm Gore/Cardioform was selected, prepped, flushed, and loaded. The device/delivery catheter were advanced via the RFV to the RA and across the ASD to the LA. The LA disc was deployed and pulled to the atrial septum, and the RA disc was deployed. Device position was assessed by fluoroscopy, TEE, and gentle push-pull. The mandril was popped deploying the RA locking loop. The patient went into 2:1 AV block with a heart rate of 70 and a normal blood pressure. The device was recaptured with the retention suture and removed."

"Transcutaneous oxygen assessment. Skin was prepped & fixator rings were placed at left chest 2nd intercostal reference site & distributed for 8 sites in a medial & lateral mapping formation of the rt lower extremity. Clarke-type polarographic electrodes were then calibrated at 45 degrees Celsius paced on fixator rings & allowed to equilibrate w/subjacent tissue over 20 min. Measurements performed while patient breathed normobaric room air and again during oxygen challenge. A regional perfusion index is calculated for each site using baseline equilibrated values relative to reference site." There is no mention of ABIs specifically. How would you code this?