Ask Dr. Z

What is the correct CPT code to utilize for a case where tPA was administered through an existing drain in the peritoneum in order to dilute the fluid prior to withdrawal?

In the surgeon's indications he lists that he felt it was best to treat the patient's extensive aortoiliac occlusive disease as well as his AAA with this procedure. 18 French could not be placed due to extensive iliac disease on the right. A 12 x 10 iliac limb was placed across the external iliac as an endoconduit. Main body (Gore C3) was then delivered via the endoconduit. Ipsilateral and contralateral limbs were deployed (right contralateral limb specifically states for treatment of the common iliac artery aneurysm) as well as an extension limb on the left. I don't believe this would be CPT 34833, as it was not an open conduit placement. I believe he is using it to treat the occlusive disease as well as as a conduit for device delivery. My question is this: could we bill for possible stent placement (37226) since it covers the right external iliac artery? Or is this something that should be considered inclusive/integral to the AAA repair?

My question is in regards to the nuclear medicine examination during the pre work-up for Y90 radioembolization. Is this imaging considered a lung perfusion scan or a liver scan? Our radiologist is injecting MAA into the right hepatic artery for lung shunt fraction calculation.

Is 39220 appropriate for this case? Are there additional codes needed? "Procedure-median sternotomy w/resection or anterior mediastinal mass. Median sternotomy incision performed, disection carried down into the mediastinum.Pt had a large mediastinal mass w/extension into both pleural cavities. Careful dissection achieved and it was noted the mass was invading the pericardium. Pericardium opened anteriorly. Dissection was carried around the mass. Both pleural cavities opened. Adhesions were taken down from the RT & LT lung paranchyma. Dissection was carried down w/combination or electrocautery and sharp dissection. The area of the innominate and SVC was visualized. PT had direct extension into the junction of the innominate and mass was resected as best as possible off the vessels. The area of the AP window superiorly also had infiltration directly into the mediastinal tissues. It could not be safely removed therefore mass was subsequently transected. Most of the mass was excised." How should I be coding this? Any help is greatly appreciated.

Patient with bilateral 70% common iliac stenosis and 80% bilateral external stenosis treated with combination of bilateral orbital atherectomy and bilateral drug-coated balloon angioplasty. Would this be coded as 37220-50, 37222-50, 0238T x 4? Or 37220-50, 0238T-50 x 2? Thank you!

I am aware of 0505T for femoral popliteal revascularization, but this case is for anterior tibial artery to vein intervention. Should I use an unlisted code and reference 0505T for RVU value? "Deep venous arterialization was performed creating a fistula between the mid right AT artery to the mid right AT vein. The vein was lined with a Viabahn stent graft to exclude valves and side branches. The AT was lined with drug-eluting coronary stents due to extensive disease. The fistula has TIMI3 flow. Description: Antegrade access of right common femoral artery, retrograde access right anterior tibial vein. A V-18 was advanced retrograde to the popliteal, and a 4 mm balloon was advanced over this to the proximal AT region. A Pioneer catheter was advanced antegrade to the level of the ATV inflated balloon. The wire was advanced into the balloon and pushed down while the balloon was pulled back down the vein. Multiple overlapping coronary drug-eluting stents were placed in the AT vein, and overlap from the ATA to the ATV was lined to the ankle with a propaten-coated Viabahnn."

A division of a myocardial bridge was performed as a stand-alone procedure. Code 33507 seems close, but the procedure did not involve repositioning of the LAD. What are your thoughts? "SUMMARY OF PROCEDURE: LAD was visible distally and followed in its intramuscular course, and thick muscle bridge was carefully divided. Hemostasis was obtained."

Is 96374 reportable with resting echo? Per CPT Assistant: "A contrast agent may be administered with a stress echocardiogram to improve the delineation of the left ventricular endocardial borders in a patient whose non-contrast echocardiography study is inadequate or suboptimal, and for whom the LV function information is essential to the management of the patient. Neither the CPT code 93350 nor 93351 includes the administration of a contrast agent. If the physician performs intravenous administration of an echocardiographic contrast agent in conjunction with a stress echocardiogram (code 93350 or 93351), report the add-on code 93352, which is reportable only on a global basis. To further clarify, contrast material may be used during performance of resting echocardiography (codes 93306, 93307, and 93308). In this circumstance, the injection of contrast media for imaging code 96374, Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug, may be reported." CPT Asst Jan. 2010, Vol 20 pg 8

The physician is documenting slow pathway signature was mapped and ablated. The early areas of crista terminalis, base of the appendage, and SVC/RA junction were ablated... is this sufficient to support 93655 x 2 because there are ablating three separate areas? If I understand this report correctly it looks like all ablations were in the right atrium; does this matter when using 93655? I thought they needed to retest between ablations to bill the each additional code. They document cath placements, 3D mapping, infusion isoprel, and a tachycardia cycle length and VA time. Baseline measurements they reference the procedure log for details. Post RF testing performed for ten minutes after ablation. No arrhythmias were induced.

Our radiologists are documenting "3D advance post processing on an independent DynaCAD workstation with active physician supervision and interpretation". Is this equivalent to 76377?

Coils were placed into the left atrial appendage in order to occlude a Peri-Watchman device leak. There was a transseptal puncture and catheterization, and coils were delivered. Is this reported with an unlisted code? if so, what is the comp code? 33340?

"The patient was placed in the prone position upon the CT fluoroscopy table. The skin overlying the mid thoracic spine was prepped and draped in the usual sterile fashion. The overlying skin was anesthetized with 10 cc 1 percent lidocaine. After obtaining IV access and during continuous vital sign monitoring by a registered nurse under my direct supervision, monitored conscious sedation was performed using 4 mg of Versed and 250 mcg of Fentanyl. 13 minutes of face-to-face sedation time was spent with the patient (99152). Under CT fluoroscopic guidance a 13 gauge bone cutting needle was advanced into the T6-7 disc via a costovertebral approach on the left. Needle was advanced into the affected disc. Through the trocar, a 22 gauge needle was advanced into the disc. Three fine needle aspirates were obtained. Aspirate was then obtained with the trocar. There are no complications." Is there enough documentation to report codes 62267 and 77012? Or would code 10009 be more appropriate?

We have orders for bilateral hips AP only with the patient standing. Code 73521 is for two views, and our facility is only taking one view. Should this be coded as a hip unilateral 1-view with modifier -LT/-RT, or should we report code 73521 with a -52 modifier since only one view is done?

I believe this is reported with unlisted code 37799. For this procedure they do arterial revascularization and vein stent. Is it correct to code 37229, 37233, and 37238? Or is it just 37799 to include all? "Impression: Successful lower extremity anterior tibial artery to anterior tibial vein arteriovenous fistula creation and deep vein arterialization."

I'm trying to understand the NCCI edit between 93561 and the heart catheterization code set. If a patient presents for a left and right heart cath, and subsequently thermodilution study data is obtained during exam, should 93453 be coded or 93561? The NCCI indicates that the heart catheterization codes are the primary procedure when checked against 93561 with indicator of zero for mod. Perhaps I am misunderstanding... isn't it inherent that a heart catheterization would take place if a thermodilution study is performed?

This is what is stated in the MD report: "Left brachial artery access. Cath DX Expo Pig 5 French was selectively advanced to abdominal aorta for abdominal angiography. Glidecath angled taper 5 French was selectively advanced to common femoral, left use for left side extremity angiography. Angiographic Findings: Abdominal Aorta: Selectively engaged. Diagnostic study performed. Common Iliac, Right: Diagnostic study was performed, previous stent. External Iliac, Right and Left: No significant disease. Common Femoral, Left: Selectively engaged. Diagnostic study was performed." He mentions profunda, superficial femoral, popliteal, anterior tibial, and tibia/peroneal trunk, left mostly as patent or no significant disease. On films cannot see cath movement from abdominal aorta lower/bifurication. So do we report code 75630 since he did not dictate that the catheter moved? Others are suggesting 75625 with 75710 for shots below the CFA, left. Of course, we charged code 36246 for selective catheter placement.

Percutaneous tricuspid valve repair with the MitraClip device. Should I use unlisted code 33999, or should I report code 33418 with modifier -22 appended?

We inserted a permanent peripheral nerve stimulator utilizing two leads to the bilateral sacroiliac joint. The Stim Wave representative said I can charge for 64555, 64555, 64590, and 95972. The only charge I am concerned with is 64590 due to the receiver being attached outside the body even though this is a permanent receiver. Can you give any assistance with this charge?

What are the documentation requirements to support reporting G0288 surgical planning for vascular surgery of aorta? It is understood to be a technical only procedure but I'm unclear as to what specifically needs to be stated. Are measurements derived off of the CTA images along with mention of surgical planning enough to report G0288?

We are receiving denials on the entire claim when billing 0238T with 37220. Can you give me some guidance on what information or reference material we may be able to use to support it is medically necessary to perform and bill the codes and get reimbursement on at least one of the codes?

Can more than one specialty bill the ECMO daily management codes 33949 and 33948? Both our cardio interventionists and our CT surgeons want to bill daily management codes, but as a coder I don't see what each physician would do different to require billing twice.

"Acute RLE ischemia after percutaneous neuro-intervention via RT CFA access closure with Star device. RT CFA incision and dissection of the CFA, SFA and PFA. CFA arteriotomy revealed fresh thrombus that was removed and demonstrated a large posterior wall dissection flap. Arteriotomy extended distally and found the Star device had been deployed intra-arterially and had tacked down the origin of the RT SFA over the origin of PFA completely occluding both origins. The majority of the origin of the SFA was excised off the CFA in order to explant the Star device. Primary repair of the SFA with a patch and CFA and Star device associated dissection flaps with tacking sutures and bovine pericardial patch angioplasty. Thrombectomy of RT EIA, CFA and PFA. SFA was then end-to-side anastomosed to CFA patch using sutures. Below-knee RT popliteal artery cutdown and arteriotomy with thrombectomy of RT SFA, popliteal, tibial, and peroneal arteries. 4 compartment fasciotomy of calf." I reported codes 35226-22, 34203, and 27602. Is this correct?

Is there a code that can be utilized to report a pocket revision for an ICD? Patient was having pain, so the physician enlarged the pocket and anchored the generator lower in the pocket. This is the only procedure done.

"The patient was given isoproterenol EP study was again done to look for re-entrant arrhythmias. None were found." Hospital wants to charge 93623. Does this documentation support charging 93623? 

Would you think this is enough documentation to capture 33508 for billing? "Left greater saphenous vein was harvested from the left lower extremity using endoscopic vein harvest." I would think that the doctor would have to at least "describe" this procedure: how he did it, what he saw, at least a little... otherwise, it's no different than coding from a "title of a procedure". Correct?

How would I code this case? Left external iliac vein stent, right common iliac and external iliac vein stent. Venogram of pelvis performed with cath in bilateral common femoral veins (access site retrograde left SFV). IVUS performed with images of bilateral illiacs and IVC. I am working with my physician to better his documentation. I gave him samples of your examples from modules I used of yours for when I was studying for my CIRCC. He does a lot of venography with vnacavography and IVUS. Sometimes he does not do interventions when he does selective and non-selective venography with IVUS. In this case he did both with the iliac stenting.

Patient with GSW injury had a right iliac artery injury repaired. On day two the patient had a bleed and was taken back emergently to the OR. The physician documents: "Catheterization of the right SFA with an angiogram of the right iliac that showed what appeared to be a filling aneurysm. A balloon-expanded stent was placed from the iliac origin down across the pseudoaneurysm with successful ceiling of any hemorrhage and the pseudoaneurysm." I am looking at 36140, 75710 and 35131 or 37236. Can you help with code suggestions and rationale? I'm struggling with the correct code for the iliac stent graft.

I was wondering if you could please assist with a guidance question regarding TIPS procedures. Can you tell me if ultrasound guidance is included with the TIPS or DIPs procedure code 37182 or 37183?

Our coding staff was involved in a discussion with the cardiologist's office staff. My question is, if a left ventriculogram was done without documentation of pressures, is that still a left heart cath? Do you need to document the pressures or is the ventriculogram enough? The office staff said the cardiologist does a left ventriculogram without pressures "all the time".

Would code 33881 cover any device placed in the thoracic aorta, or is it only for a tube device? The physicians are placing a modular bifurcated device in the THORACIC aorta and placing the contralateral limb, allowing the bilateral limbs to dangle in the lower thoracic aorta. It is a staged procedure where they then come back and place stents from the limbs into the visceral arteries to provide blood flow. I have been coding as an unlisted procedure for the initial modular device with the limb, then coding stent placements with visceral catheterization (36245) codes for the second encounter for the staged procedure. Do you agree? I am now thinking I should be coding 33881, as that code does not stipulate a specific device.

What would be the appropriate CPT for a transcarotid TAVR? And is the common carotid angioplasty bundled?

My provider wrote "VATS with evacuation of hemothorax, 700 cc of bloody fluid drain". I'm leaning towards 32601, but my MD is suggesting 32653. What do you think?

Physician is billing 37246 for angioplasty of Impra tube graft/native LPA anastomosis (wouldn't this be 92997?), which was unsuccessful, and they were not sure they were even in the Impra tube graft. Same day patientt was transferred to OR for LPA stent. Since angioplasty is bundled into stent placement, can I only bill the 37236 for the LPA stent, or am I able to bill the angioplasty since this was done at different settings?

The patient presented to cath lab for planned TAVR. A coronary stent was placed to protect the non-stenotic LM that was behind the valve. Should we bill for the placement of the coronary artery stent with the TAVR, 33361 and 92928?

We are getting denials on 96450/77003. We bill this code when our radiologist does the puncture and the oncoligist admins the chemo. Insurance is saying per AMA manual chemotherapy administration should have an accompanying chemo drug. This is performed at the hospital. Wouldn't the hospital bill for the drug? Please advise.

If Spiranza is administered under CT guidance, can we code 96450 and 77012? 3M shows only 76942/77003 with 96450. Or what will be the codes for Spiranza administration under CT?

Doctor did a PTCA of the first obtuse marginal branch for in-stent occlusion. What code would I use?

What ICD-10 code would procedure code 93590 fall under for inpatient? They keep billing 93590 as an inpatient mitral procedure.

Patient has an intra-aortic balloon pump inserted through the axillary artery; however, incision is made to expose axillary and dissect for creation of anastomosis. Greater saphenous vein is harvested and anastomosed to the axillary in order to use a conduit for insertion of IABP. Would this procedure be considered an open insert of IABP with unlisted 33999 or percutaneous insert of IABP with 33967? The procedure to create the conduit is stumping me. Same question but with Impella insert creating a conduit on the axillary artery: 33990 or 33999?

Fogarty thrombectomy of the external iliac, superficial femoral, profunda femoris, and the distal popliteal artery. If an anterior arteriotomy occurred on the femoral, but the distal popliteal also received an intervention. Would you code 34203 to reflect the popliteal? Or, would 34201 be required because the arteriotomy occurred on the femoral? Also, 34201 is bundled into 34203, correct?

Physician did ablation (93653) for atrial flutter and did RHC (93451), stating "given his chronic lymphedema and dyspnea RHC was performed". He took a right atrial pressure with results and a right ventricular pressure with results. Unable to get into pulmonary artery. Indications are Aflutter, but he does state under summary/conclusions that patient had elevated right heart pressures. Is this sufficient enough to charge for 93451?

What CPT code would I use for the closure of a valsalva aneurysm performed with a right and left congenital heart cath?

This is in regards to Ask Dr. Z #12465 regarding ablation of a left lateral accessory pathway with sustained oAVRT SVT with RBBB induced, replicating arrhythmia. Accessory pathway confirmed by mapping, with pacing and sensing from CS cath. Post ablation no further AP function seen and no SVT. This was performed transseptal. Are we to assume from the "transseptal" that the pacing from the coronary sinus is being done of the left atrium? And that it supports 93621? Please explain, as Ask Dr. Z #9503 specifically pointed out documentation should specifically state left atrial pacing and recording was performed from the CS to report 93621.

Our providers are performing ethanol injections with the purpose of attacking a tumor. I have one example where the endometrium was injected and another one where the shoulder was injected. They are injecting ethanol. What code should I assign?

In researching your Q&A regarding 47554 and your comment that more radiologists are now performing this procedure, question #11374 is exactly what I am coming across with my radiologists. You only have 47554 listed, I'm assuming the catheter exchange is also included with this procedure as that question has this same scenario as what my radiologist is performing.

Patient had a breast biopsy, and the path report came back as lymphoma. No mention of lymph node tissue. But based on the diagnosis, would we report code 38505 instead of 1908x? Or would we still code as biopsy of breast tissue with the lymphoma diagnosis?

Need clarification for the "includes injection(s) thrombolytics" during procedure for 37184. Would Heparin and tPA both need to included in this procedure? Or only the documentation stating that a thrombolytic was injected? And is tPA considered a thrombolytic?

What is the CPT code for thoracoscopy with radical reconstruction of mitral valve with ring? Since 33427 does not state the surgical approach in the code title, should we presume it is an open approach?

For lower extremity AV fistula peripheral segments, what is adjacent segment of native artery, peri-anastomotic region/arterial anastomosis? Does this mean only common femoral artery or iliac arteries also?

What is the difference between both 36821 vs. 36825 that makes a note pop out at me? I'm not sure if the direct anastomosis means that it's just a side-by-side and that 36825 is considered the loop fistula. Am I correct?