Ask Dr. Z

Hello - I am trying to determine the correct replacement code for 35475 & 75962 for angioplasty of the subclavian artery that was performed with a heart cath. Your thoughts are appreciated. ASCENDING AORTOGRAPHY AND UPPER EXTREMITY ANGIOGRAPHY The ascending aorta was angiographically normal there was no aortic insufficiency. The brachiocephalic trunk was widely patent . The right vertebral artery was a large vessel with antegradeflow. There was prompt retrograde flow in the left vertebral artery with filling of the left upper extremity. The axillary artery and distal subclavian artery appeared to have mild disease. The subclavian artery was occluded at the ostium and reconstituted just before the takeoff of the internal mammary artery. I eventually performed left carotid angiography given potential need for a bypass from the subclavian artery. The left common carotid artery had 30% ostial stenosis. There was 30% s:enosis at the bifurcation. The rest of the vessel was angiographically normal.

As a cardiology clinic our docs do a lot of Echo interps at the local hospitals. Some of the echos are ordered by our docs some are ordered by the various docs that see the patient while in the hospital. My question is; can we code out an echo interp on the same day as a hospital E/M if our doc did the E/M and the echo interp? If no, would it make a difference if the doc that ordered the echo was not from our practice?

During the Watchman or CABG, an intraoperative TEE is performed. What codes can we bill for the physcian doing the intrepretation and report of the TEE only? We have been billing 93312 and 93325. Is this correct, or should we be billing 93318?

In 2015 (question ID 6584), you recommended the use of 33999 for transcatheter repair of the mitral valve procedures that did not specifically use the Mitraclip device. Does that still hold true? We are seeing transcatheter mitral valve repairs performed using the Edwards Lifesciences Pascal device. Unlike the Mitraclip, the Pascal is a larger/wider device designed to treat mitral valve regurgitation in patients with anatomy not amenable to use of the Mitraclip system. The procedure fits the description of code 33418, but are the AMA and societies still holding with the belief that codes 33418 and 33419 should only be used for Mitraclip insertion?

I understand the rule for angioplasty outside the dialysis circuit states in order to code for a native arterial angioplasty it must be "substantially" away from the arterial anastomosis. Can you provide guidance on what is considered substantially? 2 cm, 5 cm, 8cm, more?

Our facility is in the process of implementing the start of a new procedure, MRI cardiac stress test. My question involves EKGs. Is it appropriate to perform a pre and post EKG for this particular test? We are being told that there will be a need for a pre EKG and one to show patient returned to baseline post stress. Do you have any further input?

Our dept is having workflow issues with documentation. Preventice sends an "End Result Report". Would this generated report suffice for documentation? Physician would comment with signature on the Preventice "End Result Report".

R00.2: Palpitations Summary: The patient's monitoring period was 06/04/2018 - 07/03/2018. Baseline sample showed Sinus Rhythm w/Lead Loss with a heart rate of 91.0 bpm. There were 0 critical, 0 serious, and 1 stable events that occurred. The report analysis of the critical, serious, stable and manually triggered events are listed below. Manually Detected Events: 1 Stable: Sinus Rhythm w/Lead Loss • Baseline Automatically Detected Events: End of summarized findings--------------------------------- . Physician Comments: Agree with findings: Interpreting Physician: I have personally reviewed and interpreted this report. Signature:______________________________________

What code would be used for this pacemaker implant? Would we use 33207 or 33208 for this procedure? "The intention was to implant a multi-lead pacemaker. An RV lead was attached to the low RV septum. Next they attempted to place the LV lead, but were unsuccessful and ultimately abandoned placing the LV lead. They then attempted to place a lead in the His bundle region, which was also unsuccessful. Finally, they fixed this lead to the high RV septum. Thus, the patient ended up with two RV leads, one in the high RV septum and one in the low RV septum."

Have there been any changes to the sacroplasty codes? Our rep is now saying that the coding has been changed to the vertebroplasty codes. I haven't seen any information regarding this.

I work for a hospital where we are being asked to code for moderate sedation based on the nursing record of drugs administered. As a coder I do not feel it’s appropriate to review medications given or determine a time-based CPT code off only drug injection times. I don’t feel this is enough documentation to meet CPT guidelines for the moderate sedation CPT codes. Do you think coders should be adding moderate sedation CPT codes based on drug injections documented by nurses? If not, do you have any advice on how to address this issue?

According to the physician's documentation in his progress note, he documented: "Unsuccessful in placing PICC RUA, unable to fully thread catheter, cut to 12 cm and made midline." The coder in these instances usually rely on the radiologist report based on the image at hand to determine final cath tip placement, but the physician did not take a shot of the final placement. In this instance, would it be appropriate to code this procedure within ICD-10-PCS as 05HY33Z?

Received this with a large quantity of codes and am feeling lost: "Femoral approach, angiogram on right femoral artery and then: Subsequently, initially a 5 French Mickaelson catheter and then right gastric catheter were advanced through the sheath into the distal aorta. Subsequently each catheter when used was reformed into its shape and then used to catheterize the following vessels: right bronchial; left T5 intercostal; left T6 intercostal; bilateral T7 intercostals; bilateral T8 intercostals; bilateral T9 intercostals; bilateral T10 intercostals; bilateral T11, T12 intercostals; bilateral L1 and L2; left L3; and right L4 artery. After each catheterization, digital subtraction angiography was performed."

Our provider is starting to provide these interrogation services in the clinic and would like to know what is required for documentation. I've looked at multiple sources but nothing is really clear. Could you help assist us in guiding us with what is recommended for documentation for interrogations for the ICD/CRT-D devices with OptiVol technology?

We are looking for clarification regarding the appropriate coding and reporting of a new cryotherapy procedure for pain control – specifically the iovera° treatment. Per Myoscience, the iovera° device applies cold to a target nerve to cause a temporary peripheral nerve block based on a process called Wallerian degeneration (2nd degree axonotmesis) without disrupting connective nerve tissue. CPT Assistant gives conflicting information. What is the difference between cryoablation and cryoanalgesia, and what would we code for either service and specifically the iovera° treatment listed above?

We have a physician who assisted an echo tech in the performance of a transthoracic echo in an inpatient setting. The physician remained at the patient's bedside for 4 hours during the performance of the prolonged echo study done while weaning the patient off ECMO. Is there a way to bill for the physician's services beyond just the charge for interpreting the echo report?

The physician performed a thrombectomy and balloon angioplasty on the left posterior cerebral artery and then performed a thrombectomy on the left middle cerebral artery. It appears only one code per vascular territory (which, in this case, is only one, the vertebral territory) can be used according to the CPT Codebook. If that is the case, should we use code 61630 since it is the higher weighted code? Or, are there exceptions to using both?

If the catheter is placed at the artery ostia, is that considered selective for angiography? The catheter was used to obtain access at the celiac ostia. An angiogram was performed utilizing carbon dioxide, which revealed conventional anatomy.

Is it appropriate to code both 32555 (thoracentesis) and 71045 (chest x-ray) during the same encounter? The chest x-ray is done after the thoracentesis. I'm getting an NCCI edit that states, "A modifier is allowed on the chest x-ray if appropriate."

In regards to Ask Dr. Z question ID 1#1065 (36833/36831), when a percutaneous balloon angioplasty and open thrombectomy are performed in the peripheral segment of an AV fistula this is reported as 36833, correct? CPT Assistant has stated "patch" angioplasties are considered revisions, but I was not aware that balloon angioplasties were. In my case the physician performs an incision into the graft and does a thrombectomy of the graft, closes the graft, and obtains percutaneous access of the graft. Through the percutaneous access, a balloon angioplasty of a 50% stenosis of the venous outflow was performed and procedure was ended. I don't believe 36902 can be reported, but I am not sure if this is 36831 or 36833.

My provider described doing an intervention in a manner that I can't really put a code to. Is there a code for the following? "I then used an 8 x 80 mm balloon and performed bilateral common iliac artery angioplasty with the balloon straddling over both common iliac arteries."

When a patient is being seen for a graft surveillance study, but also has other disease, is it appropriate to still use Z09 as primary on these studies? Example: Patient is scheduled for graft surveillance for a fem-pop bypass, but the patient also has known tibial disease that is being treated medically. Is it most appropriate to report the Z09 with an additional code for the tibial disease or only report the tibial dx with a history code for the graft?

"Patient was transferred to our hospital for massive pulmonary embolism. Due to patient's hemodynamic instability and non-existing Doppler signals, the physician performed four compartment fasciotomy at bedside in ICU. After a few hours the patient had not regained signals, so physician suspected the antegrade cannula for ECMO had been placed into the venous system rather than arterial. Patient was taken to OR and exploration and injection through antegrade sheath. This revealed placement into the venous system not the arterial system. An antegrade sheath was placed, and the fasciotomies were further extended by incising the medial and lateral incisions in the calf. Exploration and reexamination with Bovie cautery showed the muscle still being pale and not contractible in the posterior deep and superficial compartment. The anterior and lateral were contractible." Is there any coding for the extension of the fasciotomy wounds and exploration? I'm not sure if it would be possible to code for fasciotomy again or not.

What diagnosis code would we use for buttock pain?

"Patient status post Whipple with occluded portal vein and multiple bleeding varices around the hepatico-jejunostomy bowel loop. Diagnostic IVUS and hepatic venogram with pressures performed from right IJV access. Then, from a right CFA access, SMA angiography was performed through the venous phase, imaging the SMV filling of the varices. A Chiba needle was then placed under US/fluoroscopic guidance into the IVC, and from there the superior mesenteric vein was able to be cannulated. After angioplasty of the SMV, two Gore Viabahn VBX covered stents were placed from the SMV through to the IVC. Mechanical thrombectomy was performed in the SMV for thrombi that developed post-stent. Following this, the patient demonstrated good flow through the SMV to the IVC and decreased flow to the varices." Is this procedure a mesocaval shunt with thrombectomy reported with codes 37182 and 37187? Or is this SMV stenting with thrombectomy and coded with placements and angiography? This patient was treated as an outpatient.

The patient had a pacemaker inserted on the same date of service. For the AV node ablation, can we report codes 93650, 93600, 93602, and 93603? "Using the modified Seldinger technique under ultrasound guidance, a 7 French steerable, F-J, 4 mm irrigated tip catheter was inserted through an 8.5 French SR-0 right femoral vein sheath (later exchanged for a steerable long sheath) and advanced to the right ventricle, atrium, and His for mapping and ablation. The patient arrived in AF with RVR. The ablation catheter was placed in the RA, RV, and His for mapping. The compact AVN was mapped and ablation at this site and resulted in complete AV block. Of note, a steerable sheath was required to provide enough reach and adequate contact for successful ablation. Following a greater than 15-minute waiting period, AV block persisted. The patient's pacemaker (SJM SC PM) was set to VVIR 80 and normal function was confirmed."

The lumbar arteries are often selected in AAA endoleak embolizations as well as in traumatic or spontaneous retroperitoneal hemorrhage. Which S&I code should be reported? Spinal structures are not imaged, so code 75705 is not applicable. They are not visceral arteries or really pelvic arteries.

We have been getting multiple denials from Anthem Medicare stating that an anatomical modifier is needed with our heart cath/angiography codes. I am not able to locate any kind of policy with Anthem that states that. The modifiers they are asking us to use are the -LD, -RI, -LC, -RC, and -LM modifiers, which we use on our stent/angioplasty codes. My question is, do you know if there has been some kind of change that has to do with these denied codes that only pertains to Anthem? Or would this just be another insurance shenanigan?

Can you clarify the instruction in Dr. Z's coding reference that states that 37252 should not be coded for IVUS performed with the Pioneer catheter? Is this based on a particular coding guideline? We were recently cited in an audit for not coding 37252 in an atherectomy case: "I was able to pass the wire into the subintimal space to the level of the patent pop above the knee. I was not able to reenter the artery using just the wire. A Pioneer reentry device with IVUS was passed over the wire into the SFA. Using IVUS the location of the wire was confirmed to be within the previously stented segment of the SFA. There was no color flow within this segment. The eye of the catheter was then advanced over the wire into the mid pop just above the knee where a patent segment was seen with positive color flow. The IVUS catheter was turned to the patent pop and the reentry device was then used to reenter the true lumen. A wire was advanced into the true lumen and into the distal pop and finally into the TBT. The IVUS catheter and wire were removed."

When performing sclerotherapy of lymphatic malformation (37241) preceded by aspiration of the macrocyst(s), can the aspiration be reported as well (i.e., 10160, 10022)? “Under direct ultrasound guidance, a 21 gauge EchoTip needle was introduced into the right submandibular macrocystic lymphatic malformation. Gentle pressure was applied on cystic area to aspirate the lymphatic fluid, and approximately 4 mL of fluid was aspirated. The cyst was injected with contrast under fluoroscopic roadmap technique. There was good dispersion of contrast throughout the lesion. The contrast and more lymph were aspirated by applying mild pressure on the the LM. Sclerotherapy was performed with sodium tetradecyl sulfate foam under fluoroscopic roadmap guidance and intermittent ultrasound.”

In Ask Dr. Z question #9274 dated 2017, you advised coding Impella RP with 33999 without a -GZ modifier. Has there been an update since then regarding coding of Impella RP?

I have a patient who had a "medically aborted inferior STEMI". The H&P states, "She was found to have ST elevation in the inferior leads with reciprocal ST depression. She was pain-free upon arrival to the ER without ST segment elevation. Therefore, she does not meet criteria for STEMI." The impression states, "The patient is having intermittent chest pain, has a positive troponin, and had an initial ST elevation, which has now resolved; therefore, she does not meet criteria for an ST segment elevation MI for coding purposes." The code assigned to this patient by the provider is an NSTEMI. My question is, is the cardiologist correct in coding an NSTEMI if the STEMI has been medically aborted? I have looked online but am not finding anything related to this.

We have a breast surgeon who is doing the wire placement intraoperatively and then doing a lumpectomy right after placing that wire. We don't feel that a -59 modifier is appropriate. There is an NCCI edit for this; however, the surgeon wants to know why we aren't billing for this. Procedure codes are 19285 and 19301. I just can't find any other scenarios where someone has billed like this. Your thoughts please!

When a radiologist performs a lymphoscintography and a SPECT CT at the same time, is it appropriate to code both 78195 and the 78199? The hospital bills for the injection of the tracer (38792). Example: "TECHNIQUE: Planar gamma camera images and merged SPECT CT images of the neck and chest were obtained after the peritumoral or intratumoral injection of 1 mCi Tc-99m filtered sulfur colloid radioactive tracer."

Cardiologist performs C9602 and CPT 92978. Can we report code 92978 for a non-Medicare patient? Is C9602 considered a primary code for CPT 92978? There is conflicting information on this topic due to CPT only listing BM stent codes and NOT C-codes. We understand CMS released updated edits to allow C-codes with CPT 92978 in April 2014; however, we are being instructed by the coding department that it is incorrect to report CPT code 92978 with C-codes.

"Using ultrasound guidance, an 18 gauge BioPince spring-loaded core biopsy gun was used to the 2.6 cm circumscribed subcutaneous mass in the left lower abdominal wall subcutaneous tissues to obtain two core specimens. From path: Hyalinized stroma with histiocytic infiltration. Negative for malignancy." Not sure if this is 49180 since only subcutaneous mass. Please advise. 

For the hospital, how would you code a staged liver embolization? Documentation states: "Continuation of planned, staged, bland hepatic embolization with metastatic neuroendocrine tumor, having previously undergone right hepatic embolization on two separate dates. He is brought back for the third treatment today, targeting segment IV hepatic artery for the middle hepatic. Gastrohepatic trunk catheterization. Segment III/III catheterization and bland embolization to near stasis." Should I report code 37243 with catheter placement, or would you append modifier -58 to 37243? This was done by a different MD than the first two.

A question came up about whether branches should be considered separate vessels that go in separate directions—and can be coded separately—OR whether they should be considered branches of branches that follow one another linearly ending in a terminal vessel and therefore coded as one vessel. Example: “From the proximal superior mesenteric artery the microcatheter was advanced into two proximal mesenteric branch arteries and angiography was performed.”

A provider and I are coming to a disagreement on what is necessary when documenting a left heart catheterization, or any type of catheter procedure for that matter. Does the provider need to document where the catheter ends up, or does simply having the measurements of the LHC support the use of the code?

Physician states Mediport revision. Would unlisted code 37799 be appropriate? "The patient's neck and chest were prepped and draped in the usual sterile fashion. 15 cc of 1% lidocaine local anesthetic was infused. A small incision was made over the prior Mediport site, and the Mediport was dissected free. It was deep with a lot of fat overlying the Mediport, and it was non-functional, not sutured in place, and slightly kinked/facing inwards. The incision was extending 1 cm medially, and a new subcutaneous skin pocket was dissected free. The Mediport was secured in this new pocket with 3-0 prolene. Hemostasis was achieved and wound irrigated with antibiotic solution. The wound was closed in layers with 2-0 vicryl and 4-0 monocryl. Final x-ray confirmed that the catheter was in good position. The huber needle was used multiple times, and it flushed and aspirated well in the new position."

This is a side-by-side G-tube conversion. "The existing G-tube was removed. A 6 French CorFlo feeding tube was advanced through the stoma and negotiated through the gastric outlet. Using a Glidewire, the catheter was manipulated into the proximal jejunum. Contrast injection confirmed satisfactory position. A 12 French MIC G-tube was advanced through the stoma in tandem with the CorFlo feeding tube. Contrast was instilled via the gastric port and showed intragastric balloon position without gastric outlet obstruction. Contrast was injected via the jejunal post to confirm proper positioning in proximal jejunum. The tubes were then flushed with water and secured to each other using high tape. Successful conversion from a G-tube to a side-by-side system consisting of a 6 French CorFlo GJ feeding tube in tandem with a 12 French MIC G-tube." Can we report code 49446 for this conversion, or do we have to report codes 49446 and 49440 here? I am confused with these kinds of side-by-side GJ tube exchanges and insertions.

Report states: "Stereotactic-guided vacuum-assisted core biopsy of the left breast. Using tomographic guidance, a 12 gauge Suros EVIVA vacuum-assisted core needle was advanced to the lesion in the medial direction. Assessment: Successful stereotactic-guided core needle biopsy of the left breast." Looks like stereotactic and tomographic guidance was done. Should this be reported with code 19081 since we can only report one guidance and tomography may be used just to help localize the mass?

"Patient was brought emergently to cath lab for NSTEMI. Coronary angiography was performed, and then aspiration thrombectomy and PCI with drug-eluting stent to RCA was performed, which was considered to be the culprit vessel. The RCA had 99% stenosis." The physician also documented, "Patient did not undergo primary PCI." Should we still report code 92941-RC?

Physician performed a right SFA percutaneous atherectomy and stent placement (37227). Post procedure, patient had a single vessel runoff that now shows the anterior tibial artery occluded. Note specifically says, "Clot was farther down. I felt it was probably embolic from the atherectomy even though filter was placed." Surgeon proceeded to make incision above malleolus and arteriotomy made, 2 Fogarty balloon was passed proximally and distally with return of calcified plaque. Arteriotomy closed, subcutaneous tissue reapproximated, etc. Would you bill it as 34203? I am not sure since it sounds like the device/procedure "caused" the occlusion. Is this just a risk of procedure or one of those incidents in which, if you caused it, you shouldn't bill the repair? Your thoughts?

Is it necessary to apply the -Q0 modifier to a line item charge on a hospital account when the procedure performed is a part of the inpatient-only list? For example, CPT code 33340 is inpatient-only, and the facility is a part of the TVT registry along with a trial for a portion of these patients. I am under the impression that there is no place (i.e., an FL spot) for the -Q0 modifier to be placed on an inpatient claim, as these claims are rolled up into the revenue codes and their respective total gross charges. The only necessary piece to pass along to those who validate claim data is the NCT number. Is this correct?

If a patient presents to a small, rural facility with an NSTEMI/STEMI, and then the patient is given tPA or other thrombolytic therapy and then emergently transferred to a larger facility for an emergent coronary angiography/interventional procedure, can the larger facility still charge code 92941? Also, would there be a time limit from the diagnosis of NSTEMI/STEMI at the rural facility to transfer/treatment at the larger facility?

Would you append a -74 modifier if they get into part of the lesion? "Unsuccessful attempt at PCI of a 95% severe stenosis of the proximal-to-mid RCA. The main issue was lack of back-up support via left radial artery approach despite 6 French XBRCA guide and 6 French guideliner. I was only able to get a Fielder XT wire through the lesion into mid-RCA (no further due to lack of support). A 1.2 mm Threader and a 1.2 mm Emerge balloon were advanced into proximal portion of lesion and PTCA performed, but not all the way into lesion."

Patient is day 2 tPA. Infusion catheter injected, pelvic and IVC venography performed, infusion catheter removed, additional pelvic and IVC venography performed, AngioJet performed (final catheter placement in IVC), and infusion catheter replaced. Would the additional pelvic venography, IVC, and catheter placement be separately reportable or included in 37213?

Would this vaccine be reported with code 38999, 11900, or 90749? "The left flank was prepped and draped in the usual sterile fashion. A 11.8 cm, 17 gauge coaxial needle was inserted towards and then into a left para-aortic lymph node in incremental steps, as guided by limited axial CT images. Through the 17 gauge needle, a 15 cm, 18 gauge BioPince biopsy needle was inserted, and a core biopsy was performed. A total of one core biopsy was obtained, which was sent for pathology. Subsequently, a 2 mL solution containing the PSV2 vaccine was obtained from pharmacy. A 20 gauge Chiba needle was inserted through the 17 gauge guide needle. The tip of the Chiba needle was in the center of the lymph node, as documented by CT fluoroscopy. The vaccine containing solution was slowly infused into the lymph node."

Is this considered an open or percutaneous procedure? "Left upper extremity prepped and draped. 3000 units heparin given IV. Small transverse incision was made over the graft 3 cm distal to the arterial anastomosis. Graft was exposed. Opened transversely with 11 scalpel blade. #4 Fogarty thromboembolectomy balloon catheter was utilized proximally with recovery of thrombus twice, but not the third time, and recovery of the arterial. With torrential inflow obtained. The graft was clamped on that side. 4 Fogarty was then used through the venous end and went through the venous anastomosis without any resistance. Pulled back twice without any resistance through the venous anastomosis and thrombus removed. Not the third time. Distal end of the graft flushed easily with heparin saline and clamped. Graft was closed with a running double layer closure Blalock style 6 0 Surgipro. Air vented prior to tying the knots. Clamps were removed. Wound was irrigated with some Betadine and closed in layers."

My surgeon performed a vertebral artery angioplasty and a basilar mechanical thrombectomy on the right side. Can these both be coded as 37246 and 61645-59?