Ask Dr. Z

Physician dictates, "Ultrasound -uided percutaneous biopsy of bilateral thyroid nodules." Patient had a 3 cm nodule in right lobe and a 3 cm nodule in left lobe. Do I code this 60100-50? Or 60100, 60100-XS?

In the hospital setting when an NP/PA within the cardiology group assists with the performance of a stress test/stress echo, can he/she report the supervision of that for pro fee billing purposes? For example, can the NP/PA report 93016 under his/her provider number since he/she was the one that supervised that test, even though the cardiologist is the one providing the interpretation and report and available when/if needed?

I'm not sure if this entire case should be coded with only 35091 or 35091 and 35654. I know the other bypass (hepatorenal) is included in 35091, but I'm not sure if the axillo-bi-fem should be too. The operative note described a right axillo-bi-fem bypass, hepatic to right renal bypass, ligation of right renal, resection, and ligation of infrarenal aortic aneurysm. Diagnosis is mycotic aneurysm and penetrating ulcers of juxta-renal abdominal aorta. I'm leaning towards only 35091 and diagnosis codes I71.4 and I72.2. Would you agree? 

"Patient with tetralogy of Fallot presents to the cath lab for placement of a stent in the right ventricular outflow tract. Angiography revealed multilevel obstruction of the RVOT with the infundibular area measuring 1.8 mm, and the MPA measuring 3.1 mm. The decision was made to proceed with placement of a 4 mm x 12 mm Rebel coronary stent. The valve was crossed using an angle glide catheter over a 0.014" BMW wire. The wire was stabilized in the LPA, and the catheter was removed. The stent was advanced over the BMW wire under fluoroscopy to the RVOT. Multiple check angiograms were performed to ensure appropriate positioning. The stent was deployed with inflation of the balloon to 18 atm. The balloon was removed, and repeat angiography was performed. The stent was widely patent with no evidence of injury. The final stent measured 4.5 mm. Patient returned a week later for balloon angioplasty and second stent placement of the RVOT." How are these two procedure reported? 1. Stent placement in the RVOT. 2. Balloon angioplasty with stent placement.

Patient had a dual chamber pacemaker generator change with placement of new right atrial lead. They capped the old RA lead. What codes would you use? The old generator was removed, a new one was inserted, and a new right atrial lead was placed.

Patient had placement of bilateral catheters into the bilateral segmental pulmonary arteries on day 1 for a large PE with acute right heart strain. Day 2 the provider documents, "Pulmonary lytic catheters removed at the bedside today - termination of lytic therapy. Will remove left JP drain today. Will restart Heparin drip now. Will need long-term anticoagulation. Out of ICU when off vent - heparin drip -> long term oral after cardiology closes PFO." The provider is asking to capture the bedside removal with 99214. We have not come across this before, and I'm not certain if this is appropriate to bill given the available documentation. Would this be part of the inpatient subsequent visit for this day?

We did a left subclavian cutdown TAVR, and I'm not sure what code to use. Would the closest code be 33363 (TAVR open axillary approach), or would I use unlisted code 33999 since there is not a specific code? Also, what would I code for the repair of the cutdown? Procedures performed: 1) Left subclavian TAVR. 2) Complex repair via cutdown. 3) Angiography left common femoral – PAD – would not allow transfemoral TAVR.

Patient had 60% in-stent restenosis distal aorta, 80% in-stent restenosis LT external iliac, 65% lesion LT common iliac, 60% RT common iliac, 80% RT external iliac, and kissing balloon PTA was performed with 7x200x135 balloons for all of these sites, and a stent was placed in the RT external iliac. I know we can code for the righjt external iliac stent (37221-RT) and the left external PTA (37220-LT), but can we also give him the additional common iliac PTAs (37222-50) since only one balloon was used for the PTAs, but there is documented stenosis in these areas? 

Would the following be reported with CPT code 49185? "Status post colectomy complicated by pancreatic leak. Patient here for Dornase injection due to decreased outputs with CT scan demonstrated continued fluid collection. Through the existing drainage catheter, 5 mg of dornase in 20 mL of sterile water and instilled 18 mL. Let dwell for 1 hours. And then reopened. Will bring patient back in tomorrow for repeat dornase instillation and will irrigate drain. Mild leakage at the skin site was noted when dornase was instilled. The patient tolerated procedure well. No immediate complications. Pt reports - 40-45 cc output/day of output (was 10 cc last night). Repeat CT scan 6/21 shows slightly increased collection size."

"The patient was placed on the angiographic table in prone position. A standard time-out procedure was performed. Utilizing sterile technique and fluoroscopic guidance, the puncture site was marked for a right L2-L3 level translaminar lumbar puncture. 6 cc of 1% Xylocaine was infiltrated under the skin, and a 22 gauge Whitaker needle was advanced under intermittent fluoroscopic surveillance into the thecal sac. The opening CSF pressure was 22 cmH20. Samples were sent for laboratory analysis. Afterwards, 0.5 mCi DTPA was injected intrathecally. The patient tolerated the procedure well with no complications. The patient will be transferred to nuclear medicine department for CSF leak study." Do we bill codes 62270, 62323 for this procedure as well as 78650 additionally for NUC?

Under what circumstances is 37221 (stenting of iliac) acceptable to bill with AAA repair? What would have to be included in the documentation/op note in order to bill this successfully and have it paid (and not denied as bundled)?

Regarding the coding of "type 2 NSTEMI," this advice was given in February 2018: "Answer: Currently there is no AHA Coding Clinic advice provided for this particular scenario. However, 4th Quarter 2017 does address reporting a type 2 NSTEMI. In that instance only code I21.A1 is reported." In looking at 4Q2017 Coding Clinic, it actually states, "Assign code I21.4 NSTEMI for type 2 MI. Typically type 2 MI is marked by non-ST elevation and occurs secondary to cardiac stress from other causes...." The CC actually does not mention the code I21.A1 at all. Can you please clarify the correct coding of "type 2 NSTEMI"? 

I have a report for a patient with a tumor on the kidney; they have requested a preoperative left renal mass embolization for hemorrhage control. I'm not sure what to use. The patient is not actively bleeding. Is it still okay to use "hemorrhage embolization"?

Would codes 36010 and 37197 be supported for this, or would a UPC be more appropriate? "Fluoroscopic evaluation of the right IJ Swan-Ganz catheter demonstrated a knot to be tied in the distal catheter. A 025 wire was advanced through the catheter, without changing the orientation of the catheter. Therefore, the right common femoral vein was accessed using the Seldinger technique and micropuncture set. A 45 cm 10-French sheath was advanced into the distal IVC, and through it a 4 French Omni Sos catheter and 20 mm Gooseneck snare were advanced. These were used in an attempt to untie the knot and pull it open. The catheter was pulled partially into the sheath and the knot untied. The catheter was then removed through the IJ, and the sheath was removed in the process. Hemostasis was obtained with manual compression of both the femoral and IJ sites."

I have a physician who states in his report: "An intracardiac ultrasound catheter was used to create a 3D anatomical map of the right and left atrium. A Pentaray catheter was then used to finish the 3D anatomical and voltage map of the right atrium." I think code 93613 (3D mapping) should be used, but I'm getting conflicting comments from the EP staff. They feel that the Biosense CARTO 3D mapping system is the only equipment that can create a true 3D map. The code does not list specific equipment, it just states intracardiac electrophysiologic 3D mapping. Would this be the appropriate code to use?

I have seen in the Q&AS about unsuccessful lumbar puncture that you can still bill even though no CSF fluid was obtained. I have a myelogram that says "unsuccessful". However they still were able to get the needle in and inject contrast. The only thing is that the contrast they are saying de-accessed into the epidural space, but I think I can still bill it. They also did the post CT. 

Would it be more appropriate to charge limited CT 76380 or attempted drain placement CPT with a modifier -74 appended for this scenario for a hospital outpatient case? "Patient presents for abscess drain placement. Patient received a combination of Versed and fentanyl for conscious sedation purposes. Real-time CT scanning through this area demonstrates a deep pelvic abscess. No safe window into this abscess is identified. Therefore, the patient was straight catheterized to remove the urine from the bladder. Repeat real-time CT scanning demonstrates that there still is no safe window into this fluid collection. Therefore, no procedure was done."

Is it appropriate to use modifier -74 when a procedure is terminated after moderate sedation begins, but before any local anesthetic is given or incision is made? Preliminary imaging indicates the procedure cannot be safely performed or is unnecessary.

Our radiology group has started using the BioSentry tract sealant system after lung biopsies to reduce the risk of pneumothorax. Is there a CPT code/charge for this?

Patient came in for a stereotactic-guided breast biopsy; however, on the preliminary stereotactic images, they found that the location of the lesion was not amendable for biopsy. The biopsy was never begun. What CPT code would you recommend for reporting for this?

The physician orders both chest and abdomen on infant to be on one "film". This is NOT for foreign body. This is also hospital billing (not radiologist). If order, medical necessity, interpretation all covered, does it make a difference this was on one "film"? I understand the radiologist may be able to bill for both the abdomen and chest. This question keeps coming up.

If an inpatient is scheduled for a heart cath but goes into an acute MI while being taken to the cath lab and/or goes into an acute Mi during intervention, can I bill code 92941? When reading the code it seems to indicate that intervention during an acute AMI would be appropriate if supported by the documentation. Our physician's argument is that the MI during the intervention has greatly increased the complications of the case. Any guidance you can share with us would be greatly appreciated.

Can we bill both codes 62323 and 27096-59 for this? They are treating one condition with both injections. "Access to the posterior lumbar epidural space at L4-L5 was obtained by using a 22 gauge spinal needle, which was advanced from an interlaminar under fluoroscopic guidance and using sterile technique. The needle tip was directed toward the right para midline. A small amount of contrast was injected through the needle to confirm satisfactory needle tip positioning. Subsequently, a mixture of 4 cc of Kenalog (40 mg) with 2 cc of 1% lidocaine was injected through the needle into the epidural space without incident. The needle was removed. Access to the posterior, right SI joint at its midportion was obtained by advancing a 22 gauge spinal needle under sterile technique and fluoroscopic guidance. Following fluoroscopic confirmation of needle tip positioning, a mixture of 2 cc of Kenalog (20 mg) with 2 cc of 1% Xylocaine was injected without incident. The needle was withdrawn and the procedure was complete."

Our provider placed a drug-eluting stent in the large bifurcating posterolateral marginal vessel and the proximal portion of the posterior descending coronary artery. I have never heard of the "posterolateral marginal vessel" in the right coronary artery. The diagram that I have shows an acute marginal branch off the RCA, and then it shows the PDA with posterolateral branches. Where is the posterolateral marginal branch? Would this intervention be considered two separate branches and therefore coded with C9600 and C9601? Or is the posterolateral marginal vessel a branch off the PDA (and consequently only one branch for coding purposes) and therefore only C9600 would be coded?

For the following example, are codes 36246, 36246-59 x 5, 75726, and 75774 x 6 correct? "PROCEDURE: SMA angiography, individual SMA branch angiography including the ileocolic, middle colic, 4 separate intestinal branches, & gastroduodenal/small bowel sidebranches from a replaced hepatic artery. Patient placed in supine position and right groin prepped. The right groin was punctured and a right lower extremity angiography performed. RLE ANGIOGRAPHY: Study demonstrates a widely patent external iliac and common femoral artery. Puncture site should be good for a Minx Grip. SMA ANGIOGRAPHY: Injection of the SMA demonstrates a normal branching pattern. Initially it was thought to be some blush by the replaced RHA.A microcatheter was directed into the duodenal/small bowel branches from the replaced hepatic artery and injection performed in 2 planes demonstrating no definite contrast extravasation. Subsequently the ileocolic, middle colic, 4 intestinal branches of the SMA were individually selectively cannulated and injected and no definite bleeding site was seen. Successful SMA angiography."

Would this be reported with codes 93458-26, 92978-53, and 77001-26? "The patient was brought to the cath lab after informed consent was obtained. The patient was prepped and draped in a sterile fashion. Access site was marked under fluoroscopic guidance. 2% lidocaine was infiltrated into the left groin for anesthesia. Left femoral arterial access was obtained using a modified Seldinger technique, and a 6 French sheath was introduced into the left femoral artery. Selective coronary angiography was performed using a 6 French JL4 and 3 DRC preformed catheter. Left heart catheterization was performed using a 5 French angled pigtail catheter. All catheters were removed over the wire."

How would you code "reduction aortoplasty" to address an ascending aortic aneurysm? This was performed after a two-vessel bypass and aortic valve replacement. Coronary bypass grafting x2 with reverse saphenous vein graft to the high obtuse marginal (OM) and reverse aortosaphenous vein graft to the right posterior descending artery (PDA) using cardiopulmonary bypass support. Aortic valve replacement with 25 mm St. Jude Trifecta GT pericardial bioprosthesis using cardiopulmonary bypass support. Repair of ascending aortic aneurysm with reduction aortoplasty and primary closure using cardiopulmonary bypass support. "Attention was turned to the ascending aorta. Longitudinal aortotomy was performed anteriorly so that we can perform reduction aortoplasty at the end to address the ascending aortic aneurysm. Aortic valve was replaced and then reduction aortoplasty was performed. The elliptical portion of the ascending aorta was excised to downsize the ascending aorta to about 3.5 cm in diameter."

We are getting numerous Anthem denials for 93458-26 (Denial code - 4-PX INCONS W/ MODIF/REQD MODIF MISSNG). The anatomic-specific coronary artery modifiers designate the area or part of the body on which the procedure is performed. These modifiers are required to allow automated payment without having to request additional documentation to rule out duplicate or other inappropriate billing. How would any of these modifiers be appropriate for coronary angios?

What CPT code would be assigned for this procedure? A holmium laser (a laser fiber) is used/delivered through a percutaneous (existing tract from biliary drain) endoscope working channel into the biliary tree/gallbladder. The laser fragments the large stones, so for that it would be considered 'destruction' or lithotripsy. Once the stones are fragmented, they must be removed from the biliary tree/gallbladder, which is also performed with the scope using other tools (graspers, baskets, balloon-sweeping) and is the 'removal' or 'extraction' process - for this part, the laser is not needed.

I am unsure how to code this procedure. The IR report documents the following: "A transgluteal drain is noted within an air-fluid collection in the deep pelvis measuring 4.1 x 4.5 cm. Subsequently, it was decided to perform aggressive lavage with normal saline. Approximately 100 mL was instilled via 10 mL aliquots, followed by aspiration and removal into the existing UreSil drainage bag. Follow-up CT showed complete resolution of the fluid collection and collapse of the existing cavity. The procedure was then terminated. The patient tolerated the procedure well. There were no immediate complications." I am unable to find a direct answer if code 49084 can be used for lavage through a drainage catheter. Any directive would be appreciated.

Are codes 10022 and 10160 charged per fluid collection/cyst or per organ? For example, patient had aspiration of seven liver cysts.

My provider performed a femoral to popliteal vein (not artery) bypass with a cryovein. All the bypass codes found are artery to artery with a vein or other than vein. Should we use an unlisted code? "Procedure: I dissected the proximal and distal femoral vein. A prepared cryopreserved femoral vein was used for the bypass (7-10 mm diameter). The femoral vein was clamped, transected, and spatulated. The cryovein anastomosis was performed using two running 6-0 prolene sutures. Significant redundancy was created in the length of the graft to accommodate the prosthesis. The proximal vein was clamped proximally and ligated distally. The proximal anastomosis was then performed end-to-end with two running prolene sutures."

Would the correct code for this procedure be 36833 or unlisted CPT 37799 since we cannot find a CPT code for a venovenostomy anastomosis? "Procedure performed: Revision of left upper extremity cephalic AV fistula with translocated basilic vein AV fistula and a venovenostomy anastomosis. Operative technique: The distal aspect of the cephalic vein was ligated just below the area of occlusion and the vein divided. There was thrombus at this level, which was easily removed, and the remaining portion of the cephalic vein appeared to be patent. The basilic vein was ligated distally. The vein was then mobilized and tunneled to the open incision over the cephalic vein. An end-to-end anastomosis venovenostomy was performed using 6-0 Prolene sutures. Upon completing the anastomosis, flow was instituted through the vein and the AV fistula, and excellent thrill was palpable."

Would thrombectomy of an AV fistula and angioplasty in the peripheral zone of the graft be considered thrombectomy with revision (36833) or thrombectomy without revision (36831)?

Can we utilize the entire/all available records to code the diagnoses for an encounter? If the provider documented obesity for the patient on a procedure report, but no mention of BMI, can the BMI from H&P can be added to the procedure claim? Are the diagnoses limited to what is documented on the service being coded? Should we go with unspecified carotid stenosis if the provider does not specify the side, when the side is documented on other notes (H&P, progress notes, etc.)?

I need some clarification on the appropriateness of billing G0278 for iliac angio at the time of a heart cath. Much info out there suggests that this is a code only used for Medicare. CMS has released an LCD for the use of this code with a heart cath stating it be treated the same as the other angios at the time of a heart cath, requiring an indication before the cath was done be documented or else it is not medically necessary. If the physician documents that he did the iliac angio due to difficult access or using for guidance then this does not meet the medical necessity and shouldn't be billed anyways, correct? If there was medical necessity, and the patient does not have Medicare, should we be using another code to capture this iliac angio at the time of a cath?

The cardiologist attempted to cross a pedal artery that’s 100% occluded using four different wires/support catheters for two hours, eventually giving up because the wires would not cross the occlusion. Could we charge a procedure for this case?

"Patient had an extra long nephrostomy tube extending from the ileal conduit into the intrarenal collecting system. A wire was inserted through the existing catheter and advanced into the right renal pelvis. The exisiting catheter was removed. A new nephrostomy catheter was placed, with a pigtail in the right renal pelvis and exiting the ileal conduit ostomy site. In a similiar fashion, the left-sided nephrostomy tube was placed through the ileal conduit and left ureter, and the renal pelvis was injected with contrast to demonstrate partially decompressed collecting system. A glidewire was then placed through this catheter, and the catheter was exchanged for a 12 French extra long nephrostomy. Change of bilateral nephrostomy catheters placed in the ureters from the ileal conduit." We reported codes 50688-50, 75984, 75894-XS, but it came back stating we could not use a bilateral code. Can you please assist us with the coding?

If during a TEVAR a physician accesses the femoral percutaneously and uses an 11 French sheath and deploys the device and then later changes to a 20 French sheath and then closes the access can the 34713 still be charged? I was under the impression that the larger sheath was to aid device delivery and should not be billed if the device is already deployed. "5 French sheath had initially been placed. We then placed two ProGlide devices at perpendicular angles in the preclosure technique and advanced an 11 French sheath. A long Glidewire Advantage and JR4 catheter were used to cross the aortic valve, and a double-J Lunderquist wire was extended. We then advanced a 44 tapered to 40 Cook stent graft. We had placed a small O marker at the distal end of the branch graft for guidance, and the TEVAR was deployed just past this marker. We exchanged for a 20 French sheath in the right groin. Next, we returned to the open portion of the procedure."

Can we report code 36227 if we catheterize the external carotid artery but do not inject for angiography until we inject the IMA? We do inject the CCA and document findings of the external carotid branching, but we do not inject in the ECA. Patient with Moyamoya disease.

"Patient had a thrombosed brachial-axillary AVG. We did an open thrombectomy (36831?) and closed. We then performed a fistulogram and a retrograde brachial arteriogram. It showed kinking and narrowing at the origin of venous end, subclavian, and SVC. Balloon angioplasty was done on both (36907 for the central segment?). As we were closing we could feel the flow turn very sluggish, and over the next 10 minutes had lost her flow completely. We felt we needed to re-evaluate. Therefore, we reopened and found the AVG was thrombosed again. Based on the previous fistulogram retrograde brachial arteriogram I felt we needed a larger arterial inflow and decided to revise and make this an axillary-axillary AVG. This was done utilizing a new graft (36832?). Flow was restored. Another fistulogram was performed and showed everything to be widely patent." Since the open thrombectomy was completed and closed up, would we be able to bill the open thrombectomy, angioplasty of the central segment, and then the new open revision? Or would we just bill the open revision with declot (36832)?

Do all radiology images need to be saved in order to bill out the CPT codes for diagnostic and invasive procedures (needle guided biopsies, etc.)? I am unable to find documentation to support this on the Medicare website or in the CPT Codebook. Am I overlooking this somewhere?

This question is in regards to code 35355. It is described as both extremity and abdominal access. If the operative note does not describe any abdominal access, would it be coded the same? Or is there another code to be utilized?

We recently have to account for our staff with productivity. We have perfusion staff that are on stand by for certain procedures whether they are used or not. I am looking for a possible CPT code that would account for their standby services when they are not needed.

An asymptomatic patient with a history of breast cancer who is currently disease-free was referred by her primary care physician for a screening mammography. The radiologist performed a diagnostic test due to patient's history of breast cancer. Interpretation showed no findings. What is the correct code assignment for this encounter? Are there different guidelines for Medicare patients vs. non-Medicare patients?

"Patient underwent lower extremity endovascular revascularization for arterial occlusive disease (angioplasty and atherectomy) of the SFA. A Spider FX embolic protection filter was advanced through catheter and deployed in the popliteal artery via right common femoral artery approach. Filter was retrieved after SFA intervention." I could not find an appropriate CPT code or CPT coding guidelines. Is there a CPT code?

In the Case of the Month for May 2018 an acute MI was not documented. The EKG showed ST elevations, and patient was taken to the cath lab emergently, but neither of these proves an acute MI. Under “3.) LAD” it states that lesions of the LAD “seem to be the culprit for current presentation” (substernal chest discomfort and dyspnea only). Also, there was no thrombus in the LAD, which is often present in an acute MI. Although the case does meet the three criteria for use of 92941 as described in CPT Assistant Jan 2014, that article warns that conditions such as non-cardiac chest pain or unstable angina “do not fulfill the designation requirement of ‘during acute myocardial infarction,’ even if there is emergent activation of the catheterization laboratory.” Under these circumstances I question whether code I21.02 or the acute MI procedure code 92941/C9606 are appropriate. Is it okay to code an acute MI in the absence of physician documentation of an acute MI when the three criteria are met?

How would you code a pouchogram?

During a CABG right after bypass, the surgeon "inspected the heart on bypass and found an area of coronary perforation over the lateral wall in the distribution of the OM off the circumflex atrioventricular groove." After she finished the CABG, she stated, "A Tachosil patch was applied over the epicardium in of coronary rupture to seal the area." I am relatively new to CT, so I am unsure how this would be coded. 33507? TIA.

Would this be reported with code 33533 or an unlisted code? "LEFT ANTERIOR THORACOTOMY INCISION; MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS X1; LEFT INTERNAL MAMMARY ARTERY BYPASS TO LEFT ANTERIOR DESCENDING ARTERY. The patient was sterilely prepped and draped, and a small incision was made just over the left nipple. The muscle was divided, and I entered the thoracic cavity. The double-lumen tube was used to selectively ventilate the right lung in the left lung collapsed nicely. I then dissected out the left internal mammary artery in a skeletonized fashion using the LIMA left device. I dissected this up to the 1st rib. Heparin was given, and this was clipped distally and transected. I then placed the off pump retractor and opened up a pericardium placed stay sutures. The LAD was dissected and opened in its midportion with a proximal silastic snare and a 2 millimeter shunt placed. The snare was removed. The left mammary was anastomosed using running 7-0 Prolene, removing the the shunt just prior to completing the anastomosis."