Ask Dr. Z

"During the TIPS procedure, a Blakemore tube was positioned in the stomach, and the gastric balloon of the Blakemore tube was inflated. The esophageal balloon of the Blakemore tube was left deflated for the procedure." If the patient has evidence of repeat or ongoing variceal hemorrhage, the esophageal balloon may be inflated. How is the Blakemore tube placement coded for a TIPS procedure?

I would appreciate your help with this case. "Patient came in for staged PCI of RCA CTO. After the CTO was fixed, he decided to close the SVG to the RCA to prevent closure of thrombosis of the native coronary artery. They attempted to use coils but that was unsuccessful. Then they switched it out for an Amplatz 8 French Occluder device, which was successfully deployed in the SVG with 100% occlusion, as confirmed on angiography." Would you code this part of the procedure as an embolization (37242), or would you use the unlisted code (93799)? I have never seen an Amplatz occluder device used this way.

The procedure performed was a CABG x 4: left internal mammary artery to left anterior descending, saphenous vein graft sequentially to diagonal and obtuse marginal, and saphenous vein graft to right carotid artery. The physician wants to bill codes 33533, 33518, and 35526 because he anastomosed one graft to the carotid. I don't believe this is correct. Please advise.

If IVUS (not in pullback) done in the tibial/peroneal trunk and the posterior tibial artery, how many IVUS would you consider?

"Aneurysmal dilatation was observed in the lower arm basilic vein" for an AV fistula/graft patient. Would I99.8 or I86.8 be a more appropriate diagnosis for this when a specific venous vessel is mentioned?

Is it a requirement for codes 93922 and 93923 to be resulted/interpreted by a physician? Currently, our organization utilizes a certified hyperbaric technologist to perform and document the results.

The patient is brought to the cath lab for possible SMA ischemia, and the MD performed angioplasty at the access site prior to the diagnostic study. He documented, "Severe right external iliac stenosis (90%) requiring POBA with a 7 x 2 balloon to access the aorta." Would you bill for the angioplasty?

Recently our vascular surgeons have been using the endoscopic vein harvest technique for the vein harvests for vascular procedures. They have requested to bill for this. We have pushed back and stated that per CPT this is bundled for professional billing. Can you please shed some light as to why this is bundled currently when it's not for CABGs? Or should we be billing for this technique?

I am hoping you can clear up the appropriate code for TAVRs when there is percutaneous femoral and left subclavian arterial access. "We advanced a catheter through femoral arterial sheath into ascending aorta. We advanced a wire through the catheter into the aorta and removed the catheter. We advanced a balloon into left axillary artery, then inflated the balloon and punctured peripheral balloon to access left subclavian artery. Micropuncture wire was advanced into left subclavian artery and sheath advanced into vessel. We advanced new balloon into proximal left subclavian artery over wire and inflated the balloon during exchange as needed to maintain internal tamponade. Two perclose suture devices were deployed to left subclavian arteriotomy. We dilated arteriotomy site and advanced sheath over wire into left subclavian artery. Through the subclavian arterial sheath, catheter crossed aortic valve. We advanced valve to aortic arch across annulus and deployed Medtronic Evolut R valve." My providers are reporting code 33363, but I am hearing unlisted might be more appropriate. Please help.

What code may I use for LVOT reconstruction and repair of aortic root abscess? I was thinking of the unlisted code 39533.

I was wondering how this should be coded since there is no active bleeding. Technically successful mesenteric angiography with demonstration of hyperemic flow to the antrum and duodenum without identifiable active bleeding. Technically successful particle and Gelfoam embolization of the gastroduodenal artery.    

Should we report 47531 or 47537 for the following? "Verbal informed consent was obtained from the patient. The patient was placed supine on the fluoroscopy table. Following completion of the proper patient verification and timeout protocols, contrast was injected into existing external biliary drain. Radiographs were obtained. Antegrade cholecystogram showed proper position of tube. There is prompt, free passage of contrast into the jejunum. No evidence of anastomotic stricture, and there was free passage of contrast through the Viabil stent. There was a branch of the left bile duct that was opacified. The main left bile duct was opacified, but the branch of the left bile duct was not dilated. Given patient remained asymptomatic and free passage of contrast, the decision was then made to remove the drain. The retention suture and drain were cut, and the drain was pulled without immediate complications. A sterile dressing was applied."

We are having a conversation in my office about the term "coated/covered". To qualify for C1874 does the stent have to be coated AND covered, or can it be a non-coated stent but covered? Then, where would "Wall Stents" fall? I guess the terminology is what's confusing.

Patient with CardioMEMS implanted 15 months prior with inaccurate CardioMEMS transmissions (negative pulmonary pressures) being transmitted. "CardioMEMS was successfully calibrated under right heart cath guidance. At the end of the case CardioMEMS and right heart cath hemodynamics did correlate." Would this be 93451 with unlisted 93799 for recalibration?

Can you please advise how you would code this case? "Patient has existing dual pacemaker who comes in for CRT pacemaker upgrade. Physician does venogram and attempts to place LV lead but is unsuccessful. He then opts to place His bundle pacing lead. His pacing lead was fixed to the LV port of the pacemaker, and LV pacing was programmed at 80 ms ahead of the RV pacing to allow His conduction and pacing."

What is the most accurate way to report placement of a percutaneous transfemoral catheter within a hepatic segmental or lobar artery, with immediate acquisition of CT images while the catheter is injected? This form of CTA differs from conventional DSA, or standard CT angiography involving intravenous contrast injection. Catheter-directed CTA has multiple applications, but it is most often associated with Y-90 therapy (in our experience). For more information see "The Effect of Catheter-Directed CT Angiography on Yttrium-90 Radioembolization Treatment of Hepatocellular Carcinoma", Journal of Vascular and Interventional Radiology, Volume 16, Issue 8, 2005 Tags - 75726 75774 74175 75635.

Is diagnosis code T82.898A (other complication of vascular prosthetic device, implant of graft) or I25.810 (atherosclerosis of coronary artery bypass graft) correct for occluded SVBG or SVT to RCA - atretic, severely diseased?

"Examination: Ultrasound-guided placement of pericardial drain. PROCEDURE: The patient was placed in the semiupright position on the fluoroscopic table. Transthoracic abdominal ultrasound just below the xiphoid was performed to identify a moderate to large pericardial effusion. The skin was prepped and draped in a sterile fashion. 1% local lidocaine was used. A 19 gauge needle was placed into the pericardial space with ultrasound visualization. Yellow fluid was aspirated. A guidewire was then placed through the needle and the tract dilated. A 10 French pigtail catheter was placed in the right lateral pericardial space under fluoroscopy. 800 cc of serosanguineous fluid was removed. The tube was sutured in place and attached to a suction bulb." As previously stated in a 2017 response, code 33015 is only assigned when done by incision. Is this the current direction? In my example is 33010 the correct code?

Your help with correct coding is greatly appreciated: "Indication: Stroke. Access: Right CFA. Initially right CCA was selected. Angiogram demonstrates no significant stenosis of bifurcation. Contrast advanced gently into proximal right ICA. Angiogram demonstrates patent right ICA. Angiogram over the head demonstrates occlusion of very distal small posterior division right MCA branch. The right ACA is patent. Right subclavian artery was selected demonstrating stenosis at the origin of the right vertebral artery." - 36225/RT "Catheter repositioned into brachiocephalic artery. Patient noted to have an bovine arch. Simmons 2 catheter was used to select the left CCA. Angiogram demonstrates no significant stenosis at left carotid bifurcation. Left ICA imaging demonstrates patent vessel, without significant stenosis at cervical level. Angiogram over the head demonstrates chronic occlusion of the MCA with multiple collaterals to distal MCA branches." 36223/LT (CCA) (Left ICA selective cath not documented.) Please advise if I am missing anything. 

I received two reports today that were submitted because the surgeon requested IR to come to the OR and perform a cerebral angiogram post aneurysm clipping. Our IR docs have submitted reports and want to bill for their work. I’m hesitating since there is no indication that there was a complication or new clinical symptoms. The only reason I can see is the surgeon wants to validate the aneurysm clipping was successful. Is this billable??

I do charge review for IR and CCL. We have confusion surrounding when anesthesia end time occurs for a procedure. The cath lab is insisting that they are not responsible for inputting the time after the patient leaves the room. I believe that we should go by anesthesia start and end time. This starts when the anesthesia service begins to prepare the patient for anesthesia (this can be in holding or procedure room). It ends when the patient is released to PACU after the procedure. The cath lab states that there would be a problem with the patient being charged in two departments (the last few minutes of anesthesia time for CCL and the start of PACU time). I have always coded by "when the patient can safely be turned over to a non-anesthesia provider", which usually occurs in PACU, not in the OR or procedure room. Please tell me if I am off base because I only want to be correct.

Should CFAE ablation post PVI be coded as 93657 in all circumstances? Or do you agree that the physician needs to delineate in the note whether CFAE ablation was performed empirically vs. as an attempt to terminate continued AF post PVI?

We are seeking coding clarification of LAA ligation during a CABG. In the ZHealth CTS reference book, it states, “Do not code for simple ligation or resection of left atrial appendage during CABG procedure.” In addition, your answer to a question in 2017 states, “Appendage exclusion during valve and CABG procedures is included.” The STS states if an atrial appendage procedure (ligation, plication, or clip) is performed with a cardiac procedure other than MAZE or mitral valve, then it may be reported separately. For anything other than thrombus removal, append the -22 modifier to the main procedure or use the unlisted code, 33999, to report the atrial appendage procedure. https://www.sts.org/resources/coding-and-reimbursement The above information is contradictory. Do you mind providing your rationale?

Patient had dual chamber pacemaker replacement for ERI in the morning. While in recovery one of the leads lost capture, and the patient was taken back to the cath lab. They performed venogram on the left side and found that the patient’s subclavian vein was occluded. The physician elected to move this newly placed pacemaker generator to the right side, cap the old leads, and place two new leads. So basically in one day this patient had two separate procedures done in the cath lab. One dual chamber generator placed on the left side and then later moved to the right side where two chronic leads were capped and two new leads were placed. What codes would you recommend for these two procedures? We are running into problems with edits and are not sure how to proceed.

My provider is looking to do a lateral antebrachial neurectomy on a patient for forearm pain likely secondary to inflamed sensory nerve that runs across the fistula. I am having trouble finding what code would be most appropriate. Any help would be greatly appreciated.

One of our providers performed insertion of wireless cardiac stimulator transmitter and battery (0517T) and the electrode as well (0516T). The transmitter and battery were put in first, and the electrode was done the next day. He also did a transseptal puncture (93462) and an intracardiac echo (93662) at the time of electrode insertion. These are both add-on codes, and I am not able to find any info stating that these can be billed with code 0516T. Can you please provide some additional info on this?

"The St. Jude Lasso catheter and a TactiCath contact force ablation catheter were inserted into the left atrium. Left atrial mapping was done to generate the geometry of the 4 PVAs. PV ostia voltages were recorded. EGMs along all 4 PVs and the LA posterior wall. Pulmonary vein antral ablation was performed as guided by viewing the ICE, mapping with the lasso catheter and the ENSITE Precision mapping system. All 4 veins were mapped and ablated. The left-sided PVs were isolated as a unit, isolation achieved after additional ablation on the anterior carina. The RV PVs were very difficult to isolate. The posterior wall had fractionated electrograms and was arrhythmogenic; it was also targeted for ablation. Linear ablation was done along the roof and posterior wall connecting the superior and inferior PVs. Bidirectional block was confirmed on the posterior LA wall (pacing while contact force > 10 gm). The PVs were rechecked and all were confirmed to be isolated with bidirectional block was again verified." Do you agree with codes 93656, 93613, and 93662?

Our patient had a leadless single pacemaker and came in for an upgrade to a biventricular pacemaker. A new biventricular device with RA, RV, and LV leads was placed. Would the correct codes be 33208 and 33225?

Two scenarios: First, if a physician orders a complete transthoracic echocardiogram (93306), but the ultrasound tech is unable to complete a full study due to patient body habitus, dressings, condition, cooperation, etc., do we report code 93308 with the appropriate add-ons, or do we report code 93306-52? Second, if a physician orders a complete transthoracic echo (93306), but tech determines that only a limited echo is needed (for example, mitral valve check, pericardial effusion check, etc.), do we report code 93308 with the appropriate add-ons, or do we report code 93306-52?

Is flow reversal included in code 37215, or should flow reversal be reported with an unlisted code along with 37215? "The common carotid artery was then accessed with a microsheath, and a stiff wire was introduced followed by introduction of the flow reversal sheath. The flow reversal circuit was established, and the common carotid artery was clamped. The patient was neurologically asymptomatic. An angiogram was obtained, which clearly delineated the severe stenosis at the common carotid. This was traversed with a Spartacore wire under flow reversal. Predilatation was then performed using a 4 mm balloon. Stenting of the lesion was then performed using a tapered 7-9 self-expanding Xact stent. Post-stenting angioplasty was then performed using a 5 mm balloon. Follow-up angiogram showed a good response and no residual stenoses. I did then leave the flow reversal for about 2 minutes after this was done, and the wire was removed."

In the 2019 Cardiothoracic Surgery Coding Reference book on pages 446-447, #11, you state not to report 93287 and 92960 together. Can you please explain why and if there is a better code to report when the dual chamber ICD interrogation/reprogramming is done after the cardioversion during the same encounter?

A patient underwent TIPS revision. The last lines of the procedure report are: "Follow-up portogram demonstrated brisk flow through the TIPS shunt. The portal pressure was measured at 22 mmHG. The right atrial pressure was measured at 10 mmHG. An 8 French sheath was exchanged for a triple lumen catheter under fluoroscopic control. The tip was positioned in the right atrium. The catheter was sutured in place. The patient tolerated the procedure and left the department." I'm not sure I understand why a catheter was left in the atrium. Is this a normal part of a TIPS/TIPS revision? If not, how would this be coded?

In 2012 there was a question answered about "stand-alone" coronary aspiration thrombectomy with a heart cath. The recommendation was to bill unlisted code 93799. Does this still apply?

I am aware that codes 33210 and 33208 bundle when performed in the same encounter. However, do they still bundle if the procedures were performed on the same date of service, but at different times? In this case the patient presented to the ER with bradycardia, 20-25 bpm, and a temporary pacemaker was placed urgently to stabilize the patient. Once the physician was able to review all of the test results and rule out a suspected MI, he then placed a permanent pacemaker. Given the timing of both implants, the date of service will be the same, but will these CPT codes still bundle?

"Bilateral femoral arteries were cannulated via ultrasound guidance. Lunderquist wires were placed with the tips in the descending thoracic aorta. An Endurant stent graft was advanced via the right femoral artery. It landed distal to the renal arteries, then the contralateral gate was released. A thoracic stent graft was then advanced through the left side. The bifurcated device was fully deployed and the carrying system removed, plugging the hole with an 18 French sheath. The thoracic stent graft was released. Left docking limb was deployed without incident. The bifurcated stent graft limbs were ironed out with a Reliant balloon. IVUS passed on iliac showed the end of the limb was crimped. The sheath was advanced into the iliac stent graft. Balloon-expandable stent graft was loaded onto a Reliant balloon and fed into the 16 French sheath. Final IVUS showed much improvement." Do we report codes 34705-62 and 34709-62 for the thoracic stent graft? Can we report code 37252-62? And do we need the documentation to say image was stored? 34713 x 1

When utilizing an IR suite with a cone beam CT on a C-arm, would it be appropriate to use code 76380 to report the cone beam CT after placement of Yttrium-90 in the liver, as a confirmatory shot, to make sure the tumor has been sufficiently implanted/surrounded with the Y-90? Code 76380 by definition is considered diagnostic in nature, therefore the need to confirm it is being used in an appropriate manner.

If a patient’s echo report shows the patient has cardiac hypertrophy (I51.7) and diastolic dysfunction (I51.9) along with mitral, aortic, and tricuspid regurgitation (I08.3), how would this be coded? There is an “excludes 1” note in the ICD-10 book under I51 for heart disease specified as rheumatic (I00-I09); however, the appropriate way to code all three valve disorders is with the combo code. Do we leave the hypertrophy and diastolic dysfunction off or code the three valves as non-rheumatic individually? And which code when "excludes 1" is involved is more appropriate to code?

"Congenital heart disease status post extracardiac Fontan procedure now with chronic hyperbilirubinemia and lesion seen on CT. Concern for hepatic cirrhosis. Anatomy is not favorable for a transjugular liver biopsy. IR consulted for hepatic venogram with pressures. Left femoral vein access. Catheter used to select second order branch of right hepatic vein with subsequent venography that demonstrated a normal patent hepatic vein without stenosis. Catheter was exchanged for occlusion balloon catheter that was utilized to obtain free (14 mmHg) and wedged (16 mmHg) hepatic venous pressures. The catheter was then withdrawn and advanced into the right atrial Fontan conduit. Angiography showed antegrade flow, and pressure (15 mmHg) was also obtained. Finally, the catheter was withdrawn into the intrahepatic inferior vena cava, and venography showed antegrade flow with pressure measurement (15 mmHg) performed. Catheter was removed and hemostasis obtained." Is this procedure reported with codes 36012, 75889, 75825, 36013, and 76496? Or should I report codes 36012, 75889, 75825, and 93530?

Excision of vascular malformation is reported with unlisted code 37799. The comparable code our practice currently uses is 26116 with an wRVU of 6.96242 (local), but the physician mentions it is more work than comparable code 26116. Is there another comparable code we could use, or how can we determine what wRVU should be used for an excision of a vascular malformation?

Code 93264 is a new code for 2019. What is the difference between 93264 and 93299 from a hospital outpatient clinic perspective?

Patient has swelling in the leg and has a leg bypass. Found to have three fistulae in the fem distal bypass. Fistulae were not thrombosed. The procedure: "Incision was made in the proximal thigh, and the fistula was dissected out and ligated with a clip. This was done in the same fashion to the two other fistulae." I'm not sure how to code this. It seems they are revising the bypass graft and not an AV fistula. Should I reported unlisted code 37799? Code 35903 doesn't seem correct because there is no infection. I'm undecided if 37607 would be correct. 35883 but there is no aneurysm. Do you have any suggestions?

Department charged 49423 for left thigh abscess catheter exchange. HIM states code 10030 should be charged. They advised that 49423 is strictly for the digestive system. If this is the case, why do you suggest 49423 for chest tube exchange?

My physician stented a popliteal aneurysm and subsequently performed a balloon angioplasty of a lesion in the SFA of the same leg. Would both 37236 and 37224 be appropriate in this instance?

When a provider documents heart pauses up to 10 seconds with associated syncope, is it okay to assume this is sinoatrial and code to I49.5, or should the provider be documenting sinoatrial pause?

I would like to ask a follow-up question to previous Ask Dr. Z question ID #10661. Can you bill for a limited echo (93304 or 93308) along with a limited Doppler (93321) and color flow (93325) when performed in addition to billing for 94621 when a patient has cardiopulmonary exercise testing (94621) along with a stress echo (93351) since the pre and post echoes are performed but are not part of a CPET procedure (94621)? Or can you bill the stress echo (93351) and an oxygen uptake, expired gas analysis: rest & exercise, direct, simple (94680) since that is not part of a stress echo?

Our physician was unable to retrieve the IVC filter on a patient, so he placed a stent in the IVC to push the IVC filter into the wall of the IVC to keep it open. Can we report this as 37238, or should we bill as unlisted?

When an ascending aortic aneurysm is repaired and the total arch is also replaced, do you report codes 33860 and 33866? Or do you report code 33870 only? Or perhaps 33860 only? Since the new add-on code is available you can no longer report codes 33860 and 33870 together. But code 33866 doesn't really represent the 33870. Do we need to go unlisted in these scenarios?

I have a provider that just did a sheath shot from an axillo-femoral bypass to check to see if there is a blockage in a patient who has a non-healing ulcer. Would you treat this as a non-selective catheter placement?

"A wire was advanced through the catheter into the brachial artery to secure access. A balloon was advanced over the wire and positioned in the juxta anastomotic outflow vein, and two small skin incisions were made medial and lateral to the outflow vein. A 2-0 prolene suture was tunneled deep to the outflow vein from lateral to medial incisions, then tunneled from lateral to medial incision superficial to the outflow vein. With the suture encircling the vein the balloon was inflated and the suture tightly knotted over the inflated balloon. The balloon was deflated and exchanged for a catheter, which was advanced to the inflow artery. Repeat angiography showed excellent restored antegrade flow into the forearm arteries. Impression: MILLER band was created over a 3 mm balloon but angioplastied to 4 mm to optimize flow through fistula and forearm. AV fistulogram, left arm arteriography and banding procedure." 36901, 36215, 75710, 37799. Would this be a unlisted procedure or 37607 ligation "or" banding? Appreciate your thoughts.

Duplex scans of the right upper extremity and the left lower extremity were done. Do these need to be billed separately with 93971 for each extremity, or could 93970 be used?