Ask Dr. Z

How would you code excision of the popliteal artery with repair by interposition cryovein graft for adventitial cystic disease?

What is the proper code for the scenario below? The patient is a middle aged man with a witnessed cardiac arrest. He was in V-fib, taken to the cath lab, placed on AV ECMO, and underwent PCI. "A 19 French cannula was placed in the right common femoral artery and a 25 French cannula in the right femoral vein. An Impella was placed in the left common femoral artery over a 14 French sheath. I was asked by Dr. X to place a distal perfusion cannula. The micropuncture wire was advanced under fluoroscopy, and a 4 French sheath introducer was placed. The wire was exchanged for a J wire, and the 6 French antegrade perfusion cannula was placed under fluoro visualization. Of note, the SFA appeared to be calcified in fluoro, and an SFA stent was visualized. The wire and cannula were advanced without any complications. The perfusion cannula was flushed and secured to the right groin, then connected to the ECMO circuit, achieving antegrade perfusion of the right lower extremity." Would 33952 or 36140 be the best code, or does it bundle to the ECMO placement?

Would this procedure be coded with 38999? It does not fit the description of 49185. (There is a similar question from 2013, question ID# 5228.) "Ultrasound reveals enlarged left level three lymph node. 1% lidocaine was used to anesthetize the skin and soft tissue around the nodule. Using a 1 cc syringe and 25 gauge needle, ethanol was injected in the node in a stepwise fashion, covering as much area as possible. A total of 0.7 cc was used. IMPRESSION: Successful and uneventful ultrasound ethanol ablation of left cervical lymph node."

We have an ARNP who does device clinic follow -up visits. For nearly every patient with an ICD or pacemaker she adjusts the lead output voltage to a lower setting, i.e.: "The RV lead output was reprogrammed from 3.0 v to 2.5 v to give the patient a safety margin of 2:1." This is the only adjustment that is made. Does this "reprogramming" justify the use of a programming encounter code (93279-93284), or should I be coding these as an interrogation only instead?

I’m coding for hospital cath lab services. We had a patient transferred to us on 7/5 with elevated troponin and had initial chest pain at outlying hospital. Chest pain had subsided, but 2 hours later had CP again and was transferred to us. Patient’s troponin had steadily increased on 7/6 and was taken to the cath lab on 7/6 and had DE stent. Physician reported acute MI-NSTEMI on the cath report. Our question is, when a patient isn’t taken to the cath lab emergently on that initial day being admitted/transfer, but physician dictates it as an acute MI on the cath lab report, do we still code as acute MI or DE stent? Not exactly sure if we should code it as an acute MI because it wasn’t emergent, but had increased troponin.

Patient has a history of prior EVAR with new endoleak. Proximal extension was placed (34710), but they noticed the previously placed iliac limb was maldeployed, so they re-aligned the limb by placing a Medtronic Endurant II stent within the limb. Would this be 34711, even though it's not an extension, or would this be 37221? When closing they couldn't control the bleeding from the large arteriotomy in the left common femoral, so they incised over the left common femoral artery and extended down to the common femoral artery and found large calcified plaque. Localized endarterectomy was performed and then they repaired the artery with a suture, then closed the groin incision. I started with 34812, but since they needed to open it I'm wondering if 34713 would be more appropriate? Since the endarterectomy was localized I do not believe we can code for it; is this correct?

Would you code for the biopsy along with a planned ablation at the same site (for liver, kidney, bone, muscle, prostate, soft tissue, lymph node, etc.) since going into that same site for the ablation? Please add if any sites the biopsy would be included and any that you would code the bx along with the ablation.

We have a neurosurgeon who frequently performs cases in our IR suite. On his reports he almost universally dictates the following statement, and I wanted to get your opinion on if it satisfies documentation standards to bill for additional diagnostic imaging when it is permissible. In some cases his office consult note states that the patient is being brought in for angiogram and intervention. "The prior non-invasive cerebral imaging is inadequate to determine detailed geometry of the vascular lesion for treatment-making decision."

I know that you can code for a separate catheter placement when a catheter is inserted via a different access or a higher degree of selectivity. For the higher degree exception, does the catheter have to be on the contralateral leg? For example: If the doc performs angioplasty on the SFA/POP and then moves the catheter to the anterior tib for thrombolysis (ipsilateral), would this be 37224/37211? Would the catheter be considered higher degree (36247) since he went further down then the angioplasty?

"We brought a patient to the electrophysiology lab for a potential ablation of VT due to multiple appropriate ICD shocks. A NIPS was performed through the patient's dual chamber ICD. The induction of VT or clinically significant PVCs was attempted. Isuprel was infused. No clinically significant rhythm was induced. Procedure was stopped." We rarely do non-invasive studies here. Is this considered a typical NIPS study? Is Isuprel included? Would 93642 be appropriate, or how would you code this?

PA cath placed from right IJ. Mini-sternotomy done and transinnominate identified and isolated. Aortic valve crossed and positioned in the apex of the left ventricle. Delivery sheath brought down thru the aortic valve and valve was deployed. Would this be coded as 33365?

Would we bill code 33363 for this? The main notes regarding approach: "Successful transcatheter aortic valve replacement via percutaneous right subclavian cutdown with 26 mm Sapien 3 bioprosthetic valve. Right subclavian arterial cutdown was performed as described in the surgical note and a 6 French vascular sheath was placed. The subclavian vascular sheath was removed and the subclavian surgical site closed as described in the surgical note."

"Provider performed endarterectomy of the common femoral artery. There was no significant backbleeding from SFA. #3 and #4 Fogarty catheters were subsequently placed down the SFA, yielding a moderate amount of thrombus and small amount of backbleeding. Arteriotomy was closed by means of elliptical pericardial patch and 6-0 prolene. Flow was reestablished. Common femoral was accessed and visualized with micropuncture needle, and patient noted to have patent profunda and SFA with distal irregularities and calcification. No further thrombus was identified." Should I report codes 34201 and 35371, or is it bundled since it is same incision?

If both fiducial marker placement (55876) and hydrogel spacer (55874) in the prostate are performed with US guidance, can the guidance be coded with a modifier for the fiducial marker placement even though it is included with hydrogel space oar (55874)?

Our physician performed a resection of an aortoenteric fistula, removed the previous aortic graft, and performed an axillobifemoral bypass. My thought is to use 34832 for the latter and 37799 for the aortoenteric fisutla. Is the use of an unlisted code correct? I'm also at a loss for pricing this piece. The procedure was 6.5 hours of work. Another physician was brought in to repair the small bowel.

I was wondering if you could tell me the difference between 3D rendering vs. 3D mapping from a coding perspective. I have a physician who imports a patient's MRI or CT into the Carto workstation to create 3D models of a patient's heart prior to an ablation. They then use those renderings during the ablation procedure. So how do I code this, or can I code for this (93613/93609)?

I need help with this case where the PEG tube is not suctioning properly: "The existing gastrostomy tube was injected with 5 cc of contrast, confirming appropriate positioning. I then placed a 12 French Salem sump drainage tube through the G-tube and coiled the distal portion of the gastric fundus for better decompression." Code 49465 is documented, but I can't find the sump or decompression code.

We have done two TAVIs recently, and they have both been denied by Medicare Part B in Florida. We have been told by the maker that it was not included in a clinical trial. There isn't much information out there, and I'm not sure where to go from here. Any suggestions?

"A needle is advanced through the left buttock towards a fluid collection for drainage catheter placement in the CT suite. In the process, the wire becomes buckled in the soft tissues. The wire breaks and the patient is moved to the angio suite for retrieval of the retained portion of the wire using hemostats under fluoro." Is this wire removal separately billable, and if so, what CPT code? Or, is it considered part of the drainage catheter placement?

I was wondering if we would code a CT-guided aspiration of prostatic abscess with codes 10160 and 77012 or if we should use codes 55899 and 77012. I thought 10160 was used for skin, subcutaneous abscess. 

I'm not sure if this should be coded with only 35301, or can we add the selective angio code 36222 (selective CCA with cervical angio) and 36217-59 (select ECA w/o angio) in addition to 35301 prior to the CEA? Patient did have a recent MRA of the neck. "Access was at the right femoral and selective cath of the right CCA with cervical angiogram. The ECA was catheterized, and additional angiogram was performed. Since EPD cath could not cross the stenosis for embolic protection, the carotid stent was aborted. Incision was made in the neck and endarterectomy of ICA was performed." I'm leaning towards 35301-RT only because of the aborted stent procedure, and there was a recent MRA of the neck.

What CPT code can you recommend to report for physician services when billing for a CardioMEMS performed during a right heart cath and pulmonary angiography? I see HCPCS C9741 for the facility billing. Would you recommend unlisted code 93799? If so, what would you consider a comparable code?

Patient comes in for a stereotactic breast biopsy. After performing the biopsy, a radiopaque marker (clip) is placed. Two-view post biopsy digital mammogram is performed on a different machine to view the clip is in the correct position. Would it be appropriate to charge for the digital mammogram (77065)? Is the stereotactic table the same as a mammogram?

I have a physician who did a biventricular ICD implantation, and at the end of the report just states, "Please see Implant Device Record for Implanted Hardware and Thresholds." There is nothing in the cardiology report that gives any information about the details of testing the device with a shock or any threshold information, BUT all of the threshold information can be found on the "implant record" - a separate form that has the parameters, stimulation threshold, device measured info, and pacing threshold, but that form is not signed by the cardiologist (it is scanned into the medical record). Can we still bill code 93641 with this unsigned form and the cardiologist just referring to it in the final signed ICD implantation report? Also, what is the difference with 93641 and 93642? We are not sure what documentation is necessary for either code. 

Physician performed a PTFE carotid-subclavian bypass (35606) at same session as TEVAR procedure (33880). Is bypass 35606 billable on same day of TEVAR? I have seen cases of bypass 35606 performed day prior to TEVAR but not on same day.

Is there anything we can charge for the Brevital injection and functional testing as described in the following dictation, or would we just charge for the diagnostic angiogram and embolization? No EEG was performed during this test. "Following placement of the guide catheter, a Marathon flow-directed catheter was navigated over a Synchro-10 guidewire into the posterior cerebral branch 1 where angiograms were performed. Functional testing was then performed with 5 mg of Brevital. The patient did not pass this and developed a homonymous hemianopsia....The micro catheter was then navigated into the right more medial posterior cerebral branch. Angiograms were performed. A 2nd functional testing was performed with 5 mg of Brevital. The patient passed this neurologically. Onyx 18 was then used to embolize this feeding branch."

I need help coding a procedure that my physician performed. Would an extension be appropriate to billed in addition to the first stent graft placed? "Pt came in with large saccular aneurysm of the proximal descending thoracic aorta involving the takeoff of the LT subclavian artery. 1St step was to place an Amplatzer plug in LT subclavian to prevent this artery from becoming a source of type II endoleak. From LT femoral approach tip of catheter was advanced into the LT subclavian and into the LT axillary. Plug was deployed proximal to the takeoff of the LT vertebral. Now deployment of the thoracic endograft from RT femoral access a 36x100 thoracic endograft was positioned in proximal portion of the aortic arch at the level of takeoff to LT common carotid making it easier to transverse the aortic arch. Then deployed the graft so the proximal edge was positioned distal to takeoff of common carotid. Unfortunately during this deployment the stent graft jumped at the last moment and landed more distal than planned. It was necessary to place a 2nd thoracic endograft." 

This is a diagnosis code question for Sara Wolf. Can you please clarify what code should be used when the physician states "in-stent restenosis" in the record? Even though it is most likely a progression of the disease, restenosis indexes to T82855A in the book, which falls under the complication category. I've found in my 2017 conference slides that you had submitted a question for clarification to AHA Coding Clinic, but I haven't been able to find if your question was answered yet. 

This topic is continually discussed. I'm aware that the question has been answered in the past several times. My question is, has there been any change in correct coding of a procedure that is cancelled because the initial imaging does not find the abnormality expected? If a paracentesis is ordered, but the initial ultrasound does not find enough ascites to aspirate, is 49083 coded for the facility (with modifier -73) and professional billing (with modifier -52), or is it 76705-26 for professional and 49083-73 for facility? If the expected abdominal mass is not found with imaging, is the biopsy billed for both the hospital and radiologist? If following CMS guidelines and other sources, the professional code is what was done the facility may code the intended procedure with appropriate modifier. Yet, others feel the facility and professional codes need to match. Your opinion along with any references you use is much appreciated.

"Endovascular repair of penetrating ulcer of the descending thoracic aorta using a 22 French sheath on the right and a 6 French sheath on the left (33881, 75957, 34713-RT). Because of concern for dissection in the left iliac system, the physician performed abdominal aortography with iliofemoral angiography (75630-59?). Confirmed dissection and stenting of the left external and left common iliac arteries (37221/37223 or 37236/37237?). Perclose deployed right and left. Then patient markedly hypotensive, re-accessed left and right femoral arteries and performed left femoral/iliac angiogram and stented the dissecting left common femoral artery (37226-LT or 37236?). Angiography of the right iliac system revealed dissection of the right external iliac artery followed by stenting (75716-59?, 37221-RT or 37236?)." Do we use lower extremity codes for dissection or 37236-37237 (how many initial and additional codes are allowed per encounter)? How many cath placements with re-accessing both groins? Can we code for lower extremity diagnostic studies?

"Abdominal aortography demonstrates patent renal arteries. Ectasia and calcification of the infrarenal abdominal aorta without evidence of aneurysm. The superior mesenteric is also widely patent. The inferior mesenteric and celiac axis are not visualized. There is atherosclerosis involving the proximal common iliacs bilaterally without significant stenosis. There is evidence of an ulcerated plaque in the left common iliac that is not flow limiting. There is evidence of plaque disruption in the left external iliac. The right common and right external iliacs are widely patent with atherosclerotic plaquing. That is not flow limiting. Both the right and left internal hypogastric arteries are patent. RLE angio + runoff was performed from the contralateral CFA and was outlined in great detail. Following intervention, catheter was pulled back & detailed LLE angio + runoff was performed." I would normally bill 75716 and 75625, but I can't bill for LLE angio after intervention. Since bilateral iliacs were viewed from the aorta, I'm unsure if I should report 75630 and 75774 or 75710 and 75625?

Coding unsuccessful procedures is sometimes confusing to me. Would I code this attempted tunneled cath placement as 36558-53, 77001, and 76937? The doc wants to add 36010. "The right internal jugular vein was punctured under direct ultrasound guidance. A 0.018 inch guidewire was advanced through the needle and was unable to be advanced into the SVC. A small amount of contrast was injected through the micropuncture needle, showing collateral flow without filling of SVC. The procedure was halted, and the right side was further interrogated in the angiography suite later on the same day. IMPRESSION: 1) Technically unsuccessful ultrasound and fluoroscopically-guided placement of Perm-cath via the right internal jugular vein. 2) Patient went on to have tunneled hemodialysis catheter placed in the angiography suite later on the same day."

For a CT-guided retroperitoneal lymph node biopsy, the physician dictated, "A scout CT scan was obtained with a grid system in place on the skin over the area in question. Appropriate CT scan slices were obtained. A window from the surface to the mass was calculated. An incision was made with a scalpel. A 17 gauge coaxial needle system was advanced. This was monitored with CT fluoroscopy until a retroperitoneal lymph node was entered. An 18 gauge core biopsy device was then passed through the coaxial system to obtain a biopsy. Three samples were taken and given to pathology, which indicated that there was appropriate tissue for diagnosis. The needle system was removed, and a sterile dressing was applied." What codes would apply here? Can we code for the scout CT as well as the CT guidance?

When the doctor states "high grade stenosis", is this equal to 50% or more?

Would you code as new graft or extensions? "The common femoral arteries were punctured bilaterally, and an 8 French sheath was followed by Prostar sutures and an 11 French sheath. We used pigtail catheters to advance through the Endologix AFX graft and avoid being in-snared in the 3 internal skeleton. After placing an Amplatz wire on the right side, a 16 French sheath was placed on the right. The pigtail was left on the left side. A 26 x 14 x 180 cm long C3 Excluder endograft was introduced from the right side and deployed below the renal arteries. The top end of the graft was in the middle to the top third of the suprarenal stent, which had migrated now below the renal arteries. The contralateral leg was cannulated with some difficulty from the left side because of tortuosity. The ipsilateral leg was completely deployed followed by an extension with a 20 x 10 to reach the iliac bifurcation on the right. On the left side, we placed a bridge of a 16 x 16 x 10 followed by a 20 x 14 contralateral leg down to the distal iliac artery."

To code and bill for 93922, is the physician required to include the actual measurements in addition to the summary in the finalized report? Or, is it permitted for the physician to reference the document that contains the measurements which is not part of the finalized report?

What would be the appropriate CPT code for hepatic Yttrium-90 radioembolization right hepatic lobe?

Can my surgeon bill thrombectomy of the LV with a CABG (same operative session)?

How should we charge for crossing the left ventricle to do a measurement without doing an angiogram? 

Should we also report the removal of the old grafts, or would this be included in 36832 since it was in the same area? "Once we had dissected out the Hero graft, and also dissected out the old graft that it was also in this area causing confusion for the technicians at the Dialysis Unit, we now brought an 8 mm PTFE graft on to the field and then tunneled medially between the 2 locations. We systemically heparinized the patient, clamped the patent graft and then opened it. We beveled both ends and created end-to-end anastomosis utilizing 6-0 Gore-Tex stitch. This was performed at both ends of the graft. We now released the clamps after flushing the system and they were rewarded with good flow through this. Now, we turned attention to resecting the previously placed grafts. The occluded graft was then removed utilizing electrocautery and blunt dissection. The stumps were oversewn. An additional graft was also noticed at this point and it was also removed utilizing electrocautery and blunt dissection. We copiously irrigated. We obtained hemostasis."

How many catheter placements does code 75625 need?

Physician does a primary thrombectomy of the right fem/pop stent graft using a cutdown procedure in the right common femoral for access and then uses a Fogarty balloon to reach the thrombus. A cutdown access years ago automatically meant an open procedure, but I thought the AHA had clarified that in the past few years, so since he is not accessing the SFA/pop graft directly (probably not a great idea) this would not be considered "open" but percutaneous since he was working further downstream on the SFA/pop graft, right? I could not figure out the specifics of code 35875, as there are not guidelines in the CPT Codebook like there are for 37184. I am trying to figure out which code best describes this procedure, 37184 or 35875. Please enlighten me on this code selection.

For the celiac vascular family, when the physician documents selecting the celiac artery, common hepatic, proper hepatic, and GDA, and then documents pulling the catheter back to select the splenic artery, would 36248 be billed for the splenic artery, even though the physician already selected a third order off of the common hepatic? 36247 would be coded for proper hepatic, 36248 for GDA, and 36248 for splenic artery.

Provider excised a portion of the right common femoral artery and distal portion of the Dacron graft to perform the interposition bypass between the distal end of the Dacron graft to the profunda. The PTFE graft was connected to the Dacron graft, and once completed the distal end was sewn to the profunda. Would this be considered a revision (35881/35883) or new bypass (35647, 35681)?

Can the vertebral artery catheterization be coded after the embolization? After the embolization, the continued drainage is seen into a second pouch adjacent to the jugular bulb/jugular sigmoid junction. I thought the reason for 36226 was to check that overall blood blow was normal after the above finding. Code 75898 indicated 36226 should not be coded.

Patient is on day 3 of venous lysis treatment via popliteal vein access. Patient brought to lab, VENOUS lysis completed, and then patient is flipped and femoral artery access (same leg) is obtained. ARTERIAL lysis is now started, and then patient sent to room for 24 lysis. Question: can I code 37214 for venous completion AND 37211 for arterial, during the same procedure, with modifiers? Or do I only code 37211 and save the 37214 for when they're COMPLETELY finished with ALL lysis procedures?

When the shocking function of an ICD is turned off, would it then be billed as a pacemaker (for programming/interrogations, etc.)?

I have a challenging AV fistula case, and I want to ensure I credit my surgeon with the work involved. The case begins with a cutdown over the fistula. He attempts thrombectomy but says it is unsuccessful (not retrieving much clot and still poor thrill). He then shoots a fistulogram, identifies a high grade stenosis in the venous outflow, and angioplasties. He then sees contrast flowing out of the vein on fluoro and decides to stent the area to try to salvage things, but that doesn't resolve the problem. He ultimately decides he cannot salvage the fistula and ligates it completely. Are we prevented from trying to capture the stent (36903) with 37607 since this is one fistula and it is no longer patent when the case is finished? I'm leaning towards 37607 with modifier -22 plus 36901 for the imaging but it seems insufficient.

"Under US guidance the physician punctured the pleural space, placed a catheter, drained fluid, and then removed the catheter (32555). Then he did a limited US and saw there was still moderate pleural effusion, so decision was made to place a drainage tube. Local anesthesia was applied to same puncture site, then needle again was placed into pleural space followed by placement of a drainage catheter that was stitched into place (32557)." Since the physician removed the first tube and a decision was made to place a drainage tube, would we code both 32555-59 and 32557? Or should we just report the 32557 since 32555 is inclusive of 32557? 

Would the following be reported with code 10035 for muscle wire placement or with unlisted code 21899? "The patient was brought to the interventional suite and was placed in a semi-upright supine position. The patient's left neck was prepped and draped in the normal standard sterile fashion. Ultrasound was used to evaluate left sternocleidomastoid muscle, and an appropriate biopsy site was chosen. 2% lidocaine was used for local anesthesia of the superficial tissues. The 0.9 mm hypoechoic nodule was identified. This was approximately 1 cm deep to the skin surface and 1.5 cm just lateral to the vasculature. These landmarks corresponded to the prior ultrasound. Color-flow imaging demonstrated low resistive arterial waveform within this as well. Under ultrasound guidance, 2% lidocaine was used for local anesthesia. Following this, a wire localization needle was advanced under ultrasound guidance to the edge of the nodule. The wire was then deployed in this location, and the guide needle was removed. The wire was then secured in place. Impression: Ultrasound-guided fine needle localization of the left sternoclavicular nodule with wire placement."