Ask Dr. Z

Would this still be coded 37236? It sounds more involved. "Given the extensive aortic disease we elected to perform a CERAB using an EVAR Ovation device. The ipsilateral device was placed from the LCFA (preclosed with two percloses) over a Lunderquist wire, then deployed at the level of the renal arteries noted stents. This was a 20 mm main body device. The ovation rings were then filled and allowed to dwell for 14 minutes. At this time the contralateral limb was engaged with an angled glide wire and Berenstein catheter. The catheter was confirmed in the lumen of the Ovation graft. Then a Lunderquist wire advanced there to the graft and a 10 x 10 limb were deployed to the level above the iia. At this time the remainder of the Ovation main body was deployed and the resin port removed. Then the ipsilateral limb received a 10 x 10 limb stent graft without complication. The main body was dilated with a Coda balloon to the main transition, and the limbs were treated with two 10 x 4 Dorado balloons at the gate and distally." 

I have a question regarding endarterectomies. An endarterectomy is performed in common femoral down to superficial femoral. Incision and arteriotomy performed in common femoral. Do you code to where endartectomy ended (35302), or do you code to where incision and arteriotomy made (35371)?

Our hospital-based IR doctor is going to be doing everlinQ vascular procedures. I found HCPCS code C9755, but I think this is for the facility or ASC only. Do you have any coding guidance for the physician (pro) side of billing for this new technology? I'm thinking unlisted code 37799 for the creation of the percutaneous fistula. Are we to bill everything else separately, like US guidance, angioplasty, etc.?

What code should be reported for antitachycardia pacing or ATP delivery for an ICD? Is there an ICD equivalent to 93724?

What supports the MI stent? Does the dictation have to say they were taken emergently? Does emergently mean it's an MI? Doesn't the hospital coding have to match the physicians? For example, 92941, C9606 in same setting, is it possible to code 92928, C9606 in same setting? I'm very confused now after an audit. Where can I get the rules in black and white hard copy paper?

I placed two separate 6 x 50 Viabahn stent grafts in kissing fashion with the proximal most end in the tibial/peroneal trunk and the distal ends in the PT and peroneal respectively. These were deployed simultaneously. What codes should be reported?

Is the catheter placed very close to the site of stent placement or can the device be advanced? Example: can the cath remain in the common iliac while a stent is placed in the SFA?

I went to your seminar last fall in Nashville and learned that we can report code 93623 after an ablation with specific documentation. Will the following work? I think it does, but need to ask the experts to be sure. "Medication administration with adenosine was then performed with and without pacing maneuvers with further attempts at arrhythmia induction and to confirm isolation of the pulmonary veins."

"Per order, postoperative CSF leak scheduled for epidural blood patch. Initially a 22 gauge needle was inserted into the fluid collection in the subcutaneous tissues overlying the L3-L4 segment. Approximately 40 cc of slightly xanthochromic CSF was obtained. Subsequently, a 20 gauge touchy needle was advanced into the posterior epidural space at L4-L5 utilizing the sublaminar approach and the loss-of-resistance technique. Approximately 12 ml of autologous blood were injected into the epidural space." Since blood patch performed and fluid collection performed at two different segments both can be coded. What would you advise for subcutaneous fluid collection?

Our electrophysiologist inserted an HB lead into the left ventricle and plugged it into the ICD LV port. This is a single chamber ICD upgrade to a biventricular implant. Would an unlisted code be used (an unlisted code for the HB lead and use the 33225 as a comparable)? Or, would we code 33241 (generator removal), 33249 (generator implant/ new generator placed), 33225 (for the LV add-on)?

My question is in reference to dx coding and medical necessity on an aorto-femoral bypass graft that has a stenosis in part of it and has thrombosis and also an occlusion. I have been using T codes - T82.868A etc. I have been having issues with denials for medical necessity for stent placement; the only codes that are allowable are the I codes I70.203 etc., even the I70.409 is not covered. Any advice is appreciated.

Do you think CPT 33866 applies? "Cardiopulmonary bypass instituted. The left common carotid artery had been dissected and encircled at its base with a vessel loop as was the innominate artery. Antegrade cardioplegia spike inserted. The crossclamp was applied to the distal aorta and cardioplegia delivered in the aortic root. Prompt left mechanical arrest. Ascending aorta was then excised. It was taken to the sinotubular junction. Aorta was then sized to a 36 Terumo graft selected from stock. End-to-end anastomosis completed with running 4-0 Prolene suture over a felt strip. This graft was then trimmed. applied at the base of the innominate and carotid arteries, low flow to the cerebral circulation carried out. No change in pulse oximetry. Aortic cross clamp removed. Ascending aorta was then trimmed in a hemiarch configuration to allow end-to-end anastomosis to the 36 mm graft, which was then completed with running 4-0 Prolene suture, again over a felt strip. Full flow was established."

There is no NCCI edit for 93463/36140; however, I don't feel it would be appropriate to report 36140 when 93463 is performed. Can you provide any insight? I am unable to find anything that clearly states whether this is appropriate coding or not. Note a left cath (93458) is also being performed.

Based on this documentation, is the His bundle lead in the right atrium or the right ventricle? "Dual chamber permanent pacemaker. A peel-away sheath was inserted over one guidewire, and a C315 His sheath was advanced to the RA. A 3830 lead was then advanced to the tricuspid annulus, and electrical His bundle mapping/pacing as well as electrical mapping pacing of the right atrial and right ventricular tissue in the region of the His bundle were performed. His potential was recorded, and the lead was screwed into place with a current of injury being visible.”

I have a question about embolic protection when placing a carotid stent. This is a cutdown and percutaneous approach. The physician used flow reversal technique for distal embolic protection. States predialation PTA using 5 x 20 mm balloon under flow reversal. Then stent to right ICA using 10 x 40 mm enroute stent under flow reversal. Is this technique and acceptable means of distal embolic protection to get code 37215? That is if he states this is the technique used for DEP? I am working on getting him to say just that. Right now he says that's the technique I used but does not state it is "disal embolic protection" and is assuming coders would know this. He will be changing his dictations to mention this in the future. Or does it have to be a filter? What are you thoughts if he states he used flow reversal technique when placing a carotid stent as a means for distal embolic protection?

Can a nurse practitioner or physician assistant supervise an RN or Tech for a cardiac stress test and bill 93016 under their own name or number? CMS rules seem to indicate that they cannot supervise, but can perform the procedure.

Can codes 52353 and 50433 be reported in addition to 50080/50081?

For 2019, are providers given full credit if they state within their office note they reviewed and verified prior data and updated as necessary? Particularly for the HPI section? We are wondering how this new documentation update impacts billing and coding. Please help!

I was at the AMA CPT Symposium for 2019 CPT changes last November. During that meeting, they mentioned that with the new PICC codes, if a different physician reads the CXR and confirms tip placement, that physician can report the CXR. Does that only apply to the radiologist professional component? Or does it apply to both technical and professional components of the follow-up CXR?

If an US-guided radial access is being performed (for a LHC procedure), and the doctor notices the vessel is tortuous and performs an upper extremity angiogram with radial/ulnar findings, can this be reported with code 75710? We are having a hard time determining if this would be a guiding shot or if the fact the vessel is tortuous upon access would establish medical necessity for the angiogram. 

We have a discrepancy in opinion and need guidance please. Is it correct that we no longer need to append the -Q0 or -Q1 modifier to the defibrillator codes for payment now that the NCD does not require a registry? What about condition code 78 and the -KZ modifier as documented in transmittal 497 from 2005; are these discontinued with the NCD revision as well? 

Can I report code 93657 for the box lesion? "Ablation of AF (secondary mechanism): A posterior box lesion was performed by ablation; lesions placed point by point from the LSPV to the RSPV and a second line from the RIPV to the LIPV. Pacing from the posterior LA confirmed exit block from within the posterior LA."

We have a vascular surgeon who performed an open exposure of the left cephalic vein for pacemaker insertion by the EP surgeon due to the depth of the vein. I was thinking of billing either an unlisted code or co-surgery for the 33208. Here's the vascular procedure note: "The patient was taken to the hybrid room and placed on the table in supine position. After induction of general anesthesia, the left upper arm cephalic vein was interrogated and marked along the deltopectoral groove to the subclavian vein. The left shoulder and the chest were prepped and draped in sterile surgical fashion. Ioban covered the exposed skin surface. A longitudinal skin incision was made just below the clavicle directly on top of the marked course of the cephalic vein within the deltopectoral groove. The incision was deepened through the subcutaneous tissues. The fascia was next incised. The cephalic vein was identified. This was dissected of about 4 cm segment. At this point, the operation was turned over to the EP surgeon."

Can the bilateral modifier -50 be used with CPT code 37223?

Would we report 33273 for the repositioning of an S-ICD? "The S-ICD was placed the day before and now there was appearance of migration of the subcutaneous generator. Following infiltration with 2% lidocaine, an incision was made in the left chest region at the site of the prior surgery. The generator was removed and the pocket cleaned with antibiotic solution. After irrigation with an antibiotic solution, the pocket was inspected and no bleeding was seen. The S-ICD generator was inserted into the pocket and anchored with silk sutures."

We did a right 6, 7, and 8 intercostal block for relief of pain. Should we report codes 64420/64421? Then in a week we will be doing a neurolysis or nerve ablation (however you call it) for palliative purposes with alcohol. Would this be 64420/64421 or unlisted 64999?

Your 2019 IR coding reference states: “While the AMA has instructed that a nerve block performed after a surgical procedure for post-operative pain management can be reported separately, CMS has implemented edits preventing this billing. Nerve block procedure codes are “0” edits for physicians with surgical procedures and “1” edits for hospitals. The nerve block should NOT be reported separately when performed by the same physician who performed the surgical procedure on the same date of service.” We have been asked if this would be billable if the SHNB were performed by a second IR physician on site. It seems this would still deny because first, the IR physician on site belongs to the same group, and second, the "0" edit is for physician billing... is that correct? Regardless of how a physician bills, the SHNB will be denied because of the bundling NCCI edits, correct?

A provider does a complete diagnostic US of the thyroid gland and the lymph nodes of the neck. He then performs, during the same session, an US-guided FNA of the thyroid gland. The US of the neck would be 76536. Would you code the US-guided FNA as 10021 (FNA without imaging-since we billed for the diagnostic US), or would you still bill 10005 (FNA with US guidance)?

"Left nephrostogram and removal of the left external drainage catheter. Right nephrostogram noting the proximal end of the double pigtail is located in the proximal ureter, requiring adjustment. Removal of the right external drainage catheter. Adjustment of the right internal stent with an ensnare wire. The end of the pigtail was snared, the internal stent was pulled up into the right renal pelvis. Snaring wire was released. All catheters and guidewires removed. Final image demonstrates the proximal end of the internal stent is coiled again in the right renal pelvis." Would you code anything for the adjustment of the internal ureteral stent?

"The patient was found to be in atrial fibrillation with a ventricular rate of 110 bpm. The ICD was programmed to VVI at 30 bpm. The QRS width measured at 200 milliseconds, and the QT interval was measured at 510 milliseconds. The HV interval was measured at 59 milliseconds. Electrical recordings of the high right atrium, His bundle, and right ventricle were then obtained. Radiofrequency ablation was then performed at the head of the compact AV node with a maximum temperature of 54 degrees and maximum wattage of 40 watts. Accelerated junctional rhythm, followed by complete heart block with a ventricular escape of approximately 30 beats per minute, was present. Additional radiofrequency ablation was then performed to consolidate the first ablation. Chronic atrial fibrillation noted on the atrial lead. The ICD was reprogrammed. No PR interval was done due staying in Afib." The physician wants to bill code 93620. Is this allowed since a full study wasn't done?

You posted a question regarding whole body MRI back in 2017. You stated the ACR recommends using the unlisted code of 76498. This is regarding pediatric patients and osteomyelitis. Is there any additional information on this subject? There is no code for a "whole body MRI".

Our cardiologists read (outside hospital) ECG. Should I use the date the ECG got done or the date the interpretation got done?

CPT 33993, Repositioning of percutaneous ventricular assist device with imaging guidance at separate and distinct session from insertion, indicates that this procedure is performed “with imaging guidance”. If a percutaneous LVAD is repositioned without fluoro guidance, how would you recommend coding this?

Procedure performed: open AV graft thrombectomy with angioplasty of the AV graft (peripheral dialysis segment). Would this be coded with 36831 (open thrombectomy) or 36833 (revision/thrombectomy)? Would angioplasty and/or stenting be considered a "revision"?

"Dual chamber permanent pacemaker. A peel-away sheath was inserted over one guidewire, and a C315 His sheath was advanced to the RA. A 3830 lead was then advanced to the tricuspid annulus, and electrical His bundle mapping/pacing as well as electrical mapping pacing of the right atrial and right ventricular tissue in the region of the His bundle were performed. His potential was recorded, and the lead was screwed into place with a current of injury being visible. There was selective His bundle capture at this site. Satisfactory R waves and pacing thresholds were obtained. The sheath was split with the lead secured in place at its entry to the vein. Then, the atrial lead was advanced through a similarly placed peel-away sheath in the same fashion and positioned in the right atrial appendage and screwed in place under fluoroscopic guidance." How would you code this His lead placement? Is the tricuspid annulus part of the right atrium or right ventricle? 33206 (atrium) vs. 33208 (atrium and right ventricle). He is also stating right ventricle tissue, which makes me think it would be 33208.

Partial note with cut out parts: "The plantar arch did not connect on the tip due to low flow. Subsequently, it was decided to proceed with a posterior tibial retrograde pedal access. The posterior tibial artery was accessed. There was a very small area to access the artery, as the artery quickly was 100% occluded thereafter. (Several wires were attempted)...using the Confianza Pro and the Quick-Cross the distal cap was finally crossed. Advanced to mid level PTA. The wire was withdrawn, and an angiogram revealed that the position was intraluminal. Next, a long Runthrough wire was advanced through the retrograde access and was snared antegradely and brought back out through the sheath in the left groin. A hemostat was applied to the wire at the right foot so as to secure it. A 2.0 mm x 40 mm balloon was advanced into the posterior tibial artery using the access in the left groin. Successful angioplasty was then performed." Can we bill the catheter access and angiography on plantar arch beyond the post tibial? Is there a code for snaring a wire to do the procedure?

The staff in my cath lab department insist on charging 76937 when completing heart catheterizations and pacemaker insertion. I know that according to Chapter V-17, #21, it should not be billed with pacemaker insertions. And also in the chapter regarding heart catheterization it should not be reported. I am not getting edits; does this not apply to hospitals?

The doctor does an RF ablation of the GSV, then through a separate access ablates a large perforator vein with a laser catheter. How would you bill this? Codes 36475 and 36478 bundle with no modifier allowed, and code 36479 cannot be used with 36475. Is it okay to bill as 36475, 36476?

How would you code for insertion of an Angel Catheter? It is a multi-lumen CVC inserted into the IVC, which combines a CVC and IVC filter.

"Cervical stations of the right subclavian performed to rule out any abnormal cervical AVMs or any abnormal vessels from right subclavian to intracranial circulation. Findings: No abnormal vessels from the supreme intercostal or deep cervical to the intracranial circulation. The origin of vertebral is normal. The other branches of subclavian are normal. Then the cath was placed into the vertebral and angio done." Do we code subclavian angio as upper extremity angiogram, or is it a part of vertebral angio?

Our doctors commonly access the right femoral vein and artery and a jugular vein when performing congenital heart catheterizations on patients who are s/p bidirectional Glenn. Based on my understanding of the Glenn procedure the SVC is essentially disconnected from the heart because it terminates at the pulmonary arteries. As such it would stand to reason that for a patient who is undergoing pulmonary artery imaging (93568) that the catheter from the jugular would not be separately reported as a 36010 because the angiography code includes catheter placement into the pulmonary arteries. Do you agree with this, or is there a better approach?

I have a VT ablation case where mapping and pacing did not clearly identify the morphologies, so the femoral artery was accessed and then closed at the end of the procedure with a Perclose device. I am not receiving any NCCI edits (facility) with 93654 and G0269, but I would like your input please.

If a TAVR is performed by percutaneous axillary approach, what is the appropriate CPT code? Should we use an unlisted code (33999), or should we use 33363-52?

What is the appropriate way to code takedown of AV fistula that includes excision of aneurysmal portion in addition to ligation? The description of code 37607 only describes ligation with sutures or banding. Is it still appropriate to use 37607 for this case? We considered 36832 as well, but this is a complete takedown due to hemorrhage, skin thinning, and ulceration. Or should we use unlisted code 37799? "Course of the fistula as well as the two aneurysmal portions were marked and excised through the skin using a 15 blade. The proximal portion of the fistula was encircled with a right angle and clamped with a Cooley clamp. Fistula was divided and then oversewn at the proximal portion in a horizontal mattress followed by overhand fashion. The fistula was then excised, the diseased portion to the more distal outflow cephalic vein, and clamped at the distal aspect. The tourniquet was deflated for total tourniquet time of approximately 15 minutes. The distal most aspect of the outflow cephalic vein was similarly oversewn with 5-0 Prolene in a horizontal mattress fashion followed by overhand fashion."

Is there a limited TEE? What is needed for documentation for a "complete" TEE? Are there no separate testings for complete or limited TEE? Or whether a Doppler or a color flow study is done would dictate what set of codes may be billed for a TEE study? 93312, 93320, and 93325 for a "complete TEE", but replacing 93320 with 93321 could indicate a "limited" TEE?

Patient basically had an open lower extremity angiogram. I'm looking at codes 35741 and 75710. Is this correct? "Patient came in for a bypass. An infrapopliteal incision was made; greater saphenous vein identified; branches ligated and transected, saphenous vein mobilized; dissection extended; semiteninosus tendon exposed and transected; popliteal vein exposed and encirecled; traction app0lied; micro sheath introduced in a retrograde direction; exchanged for a 5 French sheath; advanced to the proximal aorta, aortogram obtained; patent common iliac, external, and hypogasric vessels; femoral and profunda vessels patent; oriice of superficial femoral artery contains non-occlusive plaque; stenosis at level of abductor canal; second angiogram with pedal runoff; disease of infrapopliteal artery; anterior tibial arteries appeared to be patent to foot; there is stenosis; posterior tibial artery occluded at origin; occlusion could not be crossed; procedure terminated."

Radiologist performed the following: "25 gauge spinal needle was advanced into the right hepatic lobe mass under US guidance. A 1mL syringe of RP1 provided by the research coordinator was then injected into the tumor mass." This was done for clinical trial. Is there a code for this, or it is unlisted?

What is the CPT code for thoracoscopy with radical reconstruction of mitral valve with ring? Since 33247 does not state the surgical approach in the code title, should we presume it is an open approach?

Is repair code 35226 supported instead of Impella removal 33992? "High risk regular manual pull of Impella due to suspicion for HITT and dual antiplatelet therapy for cardiac stent, which was recently placed. Incision right groin. Dissection of common femoral artery. The inguinal ligament around the sheath was dissected, and the external iliac artery above the sheath was dissected in standard surgical fashion. The right superficial femoral artery and profunda femoris artery were then dissected in a standard surgical fashion. The patient was then bolused with argatroban as per pharmacy dosing, and then the external iliac artery, superficial femoral artery, and the PFA were controlled using clamps. The sheath was then removed. The hole in the external iliac artery was found to be less than 50% of the diameter. There was satisfactory back-bleeding from the SFA and PFA with no clots inside the arterial lumen. The artery edges were refreshed, and the arteriotomy was closed using interrupted 6-0 Prolene sutures. The incision was closed in multiple layers."

I have a question on sternal debridements post-op CABG. To use code 21627 does bone have to be removed? I have a case where he removed the fibrinous proteinaceous material on the edges of the wound and the sternum. He also removed two wires and placed a wound vac. I am not sure what code/s to bill for this procedure.