Ask Dr. Z

Medtronic REVEAL LINQ. Battery is good. He had no symptom, tachy, pause, brady, AT/AF episodes. Today's current EGM shows sinus with good sensing. Tachy and/or brady settings were reviewed during interrogation today. I am having trouble understanding the difference between 93291 and 93285. Does the above report support 93285 because he reviewed the tachy and/or brady settings?

Our EP physicians saw a recent article from CHRF Coding Corner that says it may be appropriate to add modifier -22 when inserting His bundle pacemakers. Example: if we charge 33208 for the insertion they say it may be appropriate to assign a -22 modifier to the 33208 where it is extra work for the His bundle pacemaker. What are you thoughts? Do you feel it is appropriate to add the -22 modifier on these procedures?

Could you please clarify if this procedure is reported with 36825 or 36830? "Left upper extremity brachial to axillary AV graft creation with 4 x 7 AcuSeal graft. Transverse incision was made across the brachial artery pulsation just proximal to antecubital fossa. Longitudinal incision was then made over the axillary groove in the upper arm just before the armpit. The axillary vein was identified and was circumferentially dissected. Once proximal distal control was obtained a tunnel was anesthetized in the skin between the 2 incisions in the shape of a Nike symbol. Using a curved Gore tunneler the 2 incisions were tunnel between with and a graft of the AcuSeal 4 x 7 was brought through the tunnel. Potts scissors were used to make 4mm brachial artery arteriotomy. The vein anastomosis was then performed.Using 7-0 Prolene suture after the graft was spatulated and Cobra it a large anastomosis was performed with 7-0 Prolene in a running parachute fashion. The axillary fascia layer was closed over the graft using interrupted 2-0 Monocryl sutures."

Surgeon placed a Y graft for the treatment of atherosclerosis with gangrene of left leg and extensive thrombosis of the aorta. The left limb of the Y graft was anastomosed to the external iliac, and the right limb was anastomosed to the right common femoral artery. Prior to creating the anastomosis of the aorta, the MD also performed an extensive thrombectomy of the aorta. How would you code the Y graft, and is it appropriate to code the extensive thrombectomy?

A physician recently documented that as part of a pacemaker implantation he implanted one lead in the right ventricle and a second lead in the bundle of His. Should this be billed as a dual chamber pacemaker implantation or in some other manner?

Is it appropriate to bill 3D imaging codes 76376 and 76377 with the echo codes 93306, 93308, 93312, and 93355?

"Left radial artery graft was carefully anastomosed side-to-side to the ramus and then end-to-side to the OM1 in standard vascular anastomotic fashion. A separate vein graft was placed onto the acute marginal side-to-side and then end-to-side onto the PDA, which was then interpositioned anastomosed to the RIMA in standard running vascular anastomotic fashion. An SVG was placed end-to-side to the D1. LIMA was carefully anastomosed to the mid LAD in standard running vascular anastomotic fashion. The proximal SVG was carefully anastomosed to the ascending aorta in standard running vascular anastomotic technique. The hood of the radial artery graft was placed onto the hood of the SVG off the ascending aorta." I'm a bit lost... is this reported with 33535, 33519, 35600, and 33508? I'm very confused as to the meaning of the last sentence.

In 2019 with code 76001 deleted we are questioning charging for fluoroscopy greater than one hour. In the operating room, C-arm and tech are required to stay available for one OR surgery, so fluoroscopy is charged for the entire time in the operating room. Should fluoroscopy only be charged per time that the actual fluoroscopy is on? And if it's more than one hour of time can 76000 be charged with more than one unit of service?

Physician performs removal of a biliary drainage catheter without fluoroscopic guidance. Since code 47537 requires the use of fluoroscopic guidance, what code would you use for removal without fluoroscopy?

Is it appropriate to report code 93657 for a left atrial posterior wall isolation ablation after a PVI for continued/persistent atrial fibrillation?

Patient presents for a clotted/thrombosed catheter. Catheter is immediately exchanged with no confirmation of presence of thrombus (nor refute of presence either). ICD-10 guidelines are to code based on what the physician documented. Since he stated thrombosed CVC, is coding T82.868A the most appropriate? Or should we defer to T82.49XA since there is no confirmation of presence of thrombus (or overthinking here)?

I have been using code 36821 for both radiocephalic and brachiocephalic fistulae. My physician states code 36821 is okay for radiocephalic but not for brachiocephalic, and he states code 36818 is for both cephalic transposition and brachiocephalic fistula. I'm very confused now. Please clarify.

How would I code an embolization of vulvar/pelvic varicosities?

I have a physician asking. Patient here for a renal biopsy; target is the renal cortex. A core biopsy is done. They run it to pathology, and pathology states the cells are from the medulla, not the cortex. They then perform another core biopsy. Would we be able to report the biopsy twice? And would it matter if the pathology stated the sample was insufficient to test and then biopsy was done again for bigger sample?

"Patient with existing ICD on the left side is diagnosed with lung cancer. The tumor is on the left, so the existing system is in the way of radiation treatment field and it needs to be moved to the right side. The existing left-sided generator is removed; leads are connected to adapters, connectors, and extenders and tunneled across the chest to right side. New pocket is created in the right upper chest, and the existing lead system is connected to a new ICD generator." We have 33263 for the right-sided generator and 33223 for the pocket relocation. Is there anything to code for extending and relocating the existing leads?

First MCP joint space pain, evaluation for ulnar collateral ligament tear. They performed an arthrogram of the left thumb. "The dorsum of the first MCP joint was prepped and draped in usual sterile fashion and anesthetized with 1% lidocaine. Under fluoroscopic guidance, a 25 gauge needle was induced into the first MCP joint space. Approximately 3 cc of Omnipaque 300 was instilled into the joint space under fluoroscopic observation. Fluoroscopic time is 3 minutes 10 seconds. Ten images were obtained. Contrast extravastion is present at the distal ulnar collateral ligament attachment site. No fracture noted." Would this be coded as 20600 or 76499?

For UFE we do not code for diagnostic imaging because we know what we are treating. We bill catheter placement(s) and 37243. If we are doing a PAE (prostate artery embolization) for treatment of BPH, would you charge the same way or would you get any imaging codes? Do you know if there is any payment issues with this procedure?

How would you code this, and would we use C1883 for the lead extension supply? This patient has a biventricular ICD, to which we added the LV lead last month. The LV lead that we added had fallen out. The patient went to surgery and had an epicardial lead placed as the new functioning LV lead, but they did not extend it all the way to the device or hook it up. So here is what we did: "We made an incision at the device. We removed the LV lead that we had placed and had fallen out. We made an incision at the tip of the epicardial lead. We added an extension to the epicardial lead and TUNNELED it to the device pocket. We attached epicardial lead extension to the biventricular ICD and closed both pockets."

Occasionally our cardiologists (facility billing) will perform an intervention on a coronary CTO as a staged procedure. I am assuming this is done to minimize risk to the patient during a long and arduous procedure. Stage 1 they will cross the CTO and perform atherectomy. Stage 2 the patient returns weeks later for angioplasty and drug-eluting stent placement in the same lesion. I have been coding stage 1 as a CTO with 92943, and I've been coding stage 2 with 92928 (or C9600 for Medicare). Is this correct, or should I be using CTO codes for everything, or maybe modifier -58?

Sometimes Isoprel is given at the end of the procedure to induce an arrhythmia. When no arrhythmia is induced, what should be in the documentation to differentiate between drug given for induction rather than for efficacy of the ablation? Would the following be enough? "Isuprel was infused up to 5 mcg/min for arrhythmia induction."

"Patient in for mechanical thrombectomy for acute thromboembolic stroke. Left ICA - Cello balloon was inflated to cause occlusion and attached to under constant suction/aspriration for reversing flow, and a 4 mm x 2 cm aviator angioplasty balloon was advanced across eccentric plaque and dilated, again reversed flow condition. This was in addition to using the angio guard protection device. Angio guard device removed. Later a 7 mm x 3 cm precise stent was placed in left M1." Would code 37215 be appropriate?

Would you code both of these scenarios with code 19081, 19083, or 19085 (guidance dependent) with a modifier -52? Scenario 1: Pre-procedure images are done the day of the procedure and the lesion disappeared or cannot be found and there is nothing to biopsy; however, the order is for a breast biopsy procedure. Scenario 2: The radiologist preps the breast and attempts the biopsy, but for some reason the case is aborted and no tissue sample obtained for pathology.

My provider billed code G0278 for the following heart cath. Would this be billable for the following operative note? "Initially access was gained with ultrasound guidance in the right common femoral artery; however, we were unable to advance the wire, therefore a JR4 catheter was placed in the right common iliac artery and angiography was performed, which showed a 100% occlusion of the proximal right common iliac artery. Therefore we prepped the right wrist and gained access in the right radial artery. A 6 French Terumo slender sheath was placed in the right radial artery. Selective angiography of the right coronary artery was performed with a 5 French JR4 diagnostic catheter. Selective angiography of the left coronary arteries was performed with a 5 French JL3.5 diagnostic catheter. Left heart catheterization was performed with a 5 French pigtail catheter placed in the left ventricle."

A pediatric echo was done, and the results were normal except for "aberrant right subclavian artery". Do you consider this a cardiac congenital anomaly? Would you code it using 93306 or 93303?

A kyphoplasty of the L3 is performed under fluoroscopic guidance and not CT guidance and the patient then has a CT of the complete lumbar spine, but the indication for the exam is compression fracture of L3 and back pain. Status post kyphoplasty of the L3. Can code 72132 be billed in addition to 22514, or is the CT considered inclusive in the kyphoplasty procedure? There is an NCCI edit with 22514 and 72131. What exactly is the reasoning for the edit? Is it only when the kyphoplasty and CT are both done using CT guidance?

There is not a lot of information out on this Cobra nanocoated stent. Is it considered a bare metal stent? From what I was reading, I couldn't determine if it had a short-term antiplatelet on the stent or if dual antiplatelet therapy was given out as a prescription.

Can we report a therapeutic drainage with a biopsy of the same lesion? Would this be reported with 49180, 10160, and 77012? Or just 49180 and 77012? "Imaging guidance for biopsy: CT access location: Left lower quadrant. Needle gauge: 18 gauge. Technique: Image guidance was used to identify the biopsy site. A total of 10 cores were obtained. In addition, approximately 50 mL of foul-smelling dark red material was aspirated from the lesion during the procedure. Hemostasis was achieved before withdrawing the introducer needle. In addition to autologous blood clot, the needle tract was embolized with Gelfoam slurry. Intraprocedural or immediate post-procedural complications: None. Findings: Preprocedure CT imaging showed a large intra-abdominal mass appearing to arise from the sigmoid colon and containing a central hypodense component as well as gas, suggesting fistulous formation with the colon. No drain was placed at this time due to historically poor healing when drains traverse masses. Impression: CT-guided pericolonic mass biopsy and aspiration."

During laser lead extractions, my provider always prophylactically places a venous occlusion balloon in the SVC in case of a tear in the SVC. Can code 37244 be reported (in addition to the 33234) for that if there is no SVC tear?

Can you please tell me if a midline placed by an IV nurse or Vascular Access Team in an outpatient hospital setting should be charged? We are questioning if this should be charged with 36410 if a MD did not perform the procedure.

Provider performs percutaneous nephroureteral access into the bladder for PCNL to follow by urologist with no dilation. Is code 50437 reported with modifier -52 for the following? "PROCEDURE: Patient was placed in prone position and general anesthesia administered. The right flank was prepped with chlorhexidine, which was allowed to dry and drape in the usual sterile fashion. Under ultrasound/fluoroscopic guidance, an 18 gauge Hawkins needle was advanced into stone, and urologist placed ureteroscope bearing renal upper pole calyx. A wire was then advanced into the collecting system, snared by the urologist, and advanced/pulled into the ureter. Over wire, 4 French catheter was advanced down the ureter and into the bladder. No immediate complication. The radiologist performed the procedure with assistance from the urology team and actively participated in the entire procedure. FINDINGS: Right renal stone. Percutaneous access was via subcostal posterior upper pole calyceal access. IMPRESSION: Successful placement."

During a left heart cath: "After radial artery access was obtained we could not navigate the wire to the right subclavian. Right brachial artery angiography was performed through the diag cath. There was mod tortuosity and the vessel size was small, and decision was made to pursue with the right femoral artery access." Can we report the angiography with cath placement from this access in addition to the left heart cath performed via femoral access? Reason for cath NSTEMI.

For epinephrine, Isoprel, and procainamide challenges either during a stress test, EP procedure, or by itself, what CPT code(s) is/are used to report for physician billing? If we use unlisted code 93799, do we need to put in a code comparison or any comments? This is for testing performed in a hospital but reporting physician work/supervision.

When the procedure is ordered to treat ED, and from the femoral artery the catheter is selectively placed into the internal iliac to the pudendal and then finally into the penile artery where angioplasty is performed, should codes 37246 and 36247 be reported? Or should codes 37788 and 36247 be reported? Then how about atherosclerosis was the reason for the ED and it was treated with angioplasty... would the code then be 37220?

Would it be appropriate to also report 75625, or would this be considered incidental and not coded? Patient came in for lower extremity angiography and intervention. Report states: "We then advanced the catheter to the abdominal aorta and performed aortoiliac angiography with excellent resluts." Findings state: "Aorta: calcified patent."

I have searched your database and cannot find a case like this. "Patient underwent a right femoral-posterior tibial bypass with in situ vein a month and a half ago. Patient develops infection with fever and elevated glucose and white count. Patient was taken to the OR and placed on her back and given general endotracheal anesthetic. She was already on antibiotics. Her right leg was prepped and draped in a sterile fashion. The remaining few sutures overlying the incision at the knee were then taken out, and hematoma was then evacuated. The existing right femoral to posterior tibial bypass graft was already thrombosed and had pulled apart, separated at the previous anastomosis. Both ends of this graft were then ligated with 2-0 Vicryl. A 1 L of antibiotic-containing solution was used for pulse lavage after which the wound was then packed with a sterile dressing. The patient tolerated the procedure well. There was no additional blood loss." Is this reported with codes 37799 and 10180? Or 37618 and 10180? Or 37650 and 10180?

Most often in high impact accidents, our physicians will order a CT of the chest, abdomen, and pelvis with a request for 3D reconstructed images of the thoracic spine, lumber spine, and/or cervical spine, if needed. This generates both a T-spine, L-spine, and/or C-spine from the chest/abdomen/pelvis scan without having to rescan the patient. The facility is billing only one 3D reconstruction charge. Can the facility submit a technical charge for more than one 3D reconstruction in this scenario? Can technical charges be billed for the T-spine, L-spine, and/or C-spine? Can professional charges be billed for interpretations of the T-spine, L-spine, and/or C-spine?

Would codes 36005 and 75822 be the appropriate to report for this procedure? "A 20g peripheral IV was inserted in the patient's dorsal aspect of her hand. Tourniquets applied just distal to the antecubital fossa and axilla. Isoosmolar nonionic contrast and saline prepared in 20cc syringes and attached to bivalve stopcock and attached to peripheral IV. Fluoro utilized to obtain images of the venous anatomy of the left forearm and upper arm. 5 cc contrast injected first, followed by 10 cc of saline. Fluoroscopic images obtained during injection and then removal of tourniquets successfully, first distal then proximal. The process was repeated for the right upper extremity. Post procedure findings and diagnosis: Left side: Good size basilic vein in forearm and upper arm with no central stenosis. Small cephalic vein throughout forearm and upper arm. Right side: Basilic vein is good size in forearm and upper arm with no central stenosis. Cephalic vein is small in forearm but good size in upper arm."

When a physician does kissing stent in left and right common iliacs and then does a stent in the proximal left common iliac, do you code just 37221-50, or do you also get to add 37223?

Procedure note: "After obtaining the patient's consent I numbed the pharynx with hurricaine spray. The oropharynx was exposed with a tongue depressor, and a 18 gauge needle was inserted into the area of maximal swelling with the needle aimed medially. Approximately 1cc of pus was aspirated. The patient rinsed his mouth with water, and there was no significant bleeding noted. He said his throat felt less swollen immediately." Would we report code 42700 since it is peritonsillar abscess (however, no incision done), or should this be reported with an unlisted code? No 10022 since no FNA used and 10160 is subcutaneous.

Our surgeon did a left Iliac artery aneurysm repair. He documented as follows: "An IBE graft was deployed, placed through the 16 French sheath. This was a 23 x 10 x 10 Gore-ex. The graft was then deployed within the iliac artery. The wire placed from the right side was drawn back into the gate of the graft that had been deployed. A long 8 French sheath on the right side was utilized, and the guidewire was placed in the internal iliac artery. An 8 mm x 39 mm balloon-expandable Viabahn stent was deployed. Completion angiogram was obtained, and patient had good distal seal. Subsequently, a 23 cuff was placed just at the take off of the left common iliac artery. A Compliant balloon was utilized and dilations performed from the left femoral artery. Repeat angiography revealed good seal with exclusion of the aneurysm. Right-sided sheath was removed and perclose was utilized for closure. Sheath on the left side was removed and femoral artery repaired by means of running 6-0 prolene." Is code 0254T appropriate, or would it be an unlisted? External iliac is not documented.

In the specials room the AVF thrombus is laced with tPA and macerated with a balloon. Outflow improved but large clot burden remained. Patient was then brought to the OR for mechanical thrombectomy. A cutdown was done, and clot was manually removed with use of a Fogarty. There is an NCCI edit that says 36904 is not allowed with 36831, even with a modifier. Would the first PerQ thrombectomy (36904) be bundled into the OR open thrombectomy procedure 36831?

How would you code wire-free breast tumor localization? We have a doctor wanting to use SAVI SCOUT, which is a wire-free radar localization system that detects a reflector, smaller than a grain of rice, that can be placed into the target tissue at any time during the continuum of care.

"Surgeon mapped the bundle of His, located a satisfactory signal and fixated the lead onto the HIS and checked thresholds. The sheath was slit, removed, and lead fixed to the cephalic vein and pectoral muscle. Surgeon then advanced 7 French pacing lead into the RA. Lead tip was placed into the lateral RA wall and screw deployed. The sheath was removed and lead secured to pre-pectoral fascia. Pocket formed, dual pacer inserted, RA lead placed in RA port, HIS lead placed in RV port." Summary is: "Uncomplicated implant of a dual chamber pacemaker with non-selective His bundle pacing achieved with the RV lead via a left cephalic vein cutdown and axillary vein puncture." What is the correct CPT code to report? MD wants to charge 33208 because the His lead was placed in RV port. Medtronic vendor coding information states to code 33206 and 33999. Based upon my experience, I think code 33206 is appropriate. Please provide rationale that I can present to the surgeon.

Radiologist placed NU catheter at 9:00 AM. At 1:00 PM same day, NU catheter removed, renal track dilated to 30 French, then stone extraction performed by the urologist. Following stone removal, an NU catheter was positioned into the distal ureter, and a 10 French JJ stent of similar length was then placed with its tip in the urinary bladder and proximal aspect in the right renal pelvis (by radiologist). What is the correct coding (including modifiers) for the procedures performed at different sessions on the same DOS?

Please advise if code 36569 would be appropriate when replacing a PICC without image guidance age 5 or greater, or would unlisted code 37799 be more appropriate?

I'm having a disagreement with our central billing office regarding the appropriate "primary code" to bill with 37252. "Transverse incisions made in both groins. Dissected out the left groin, Dr. X, the right. Incisions made transversely just cephalad to inguinal creases. Dissection carried down. Common femoral artery, profundal and SFA was dissected out circumferentially. Dissection performed in the right groin. Size 8 sheaths were placed in both groins; wires were passed from the groins into the abdominal aorta. IVUS interrogation of abdominal aorta and common iliac arteries bilaterally was performed revealing the distal aorta filling defect thromboembolus and an area in the prox aspect of left CIA. Initially thought I may cover this with a covered stent, but elected not to do this and rather simply used the Reliant balloon in the thromboembolectomy fashion and this was passed through bil CFA withh resol of source." We billed 37252 with 34201 and 34203 since IVUS was diagnostic. What do you think?

Do leadless pacemakers require a modifier (-Q0) for codes 33274/33275, and are there specific diagnoses (Z00.6)?

What would be the proper coding for performing an unsuccessful LAD PCI (physician made multiple unsuccessful attempts but could not place stent and ultimately patient was brought to the OR for urgent CABG). The physician describes: "An aortogram showed a mildly dilated arch but no stenotic disease of the innominate or left subclavian arteries. There was no obstructive disease in the visualized portions of the carotid arteries bilaterally." Does the documentation support billing 93567 and/or 36222?

We are having a problem when billing 93355 with the following codes due to NCCI edits: TMVI - 0483T / TMVR - 33418, 33419 / TAVR - 33361, 33362, 33364 / LAA - 33340. CPT states that this would be the appropriate code. My MD is not also performing the main procedure but is performing the entire TEE. What is your guidance for the proper coding?

Please explain the "overdrive and pacing" done for the AVNRT and what can be coded for that. I have 33216 for the new RA lead in the dual chamber pacemaker. "Generator was extracted and leads disconnected. Access to subclavian vein with US guidance. Fluoro was used to position lead. New atrial lead was placed in the right atrial appendage. The old atrial lead was capped. During atrial lead placement, SVT spontaneously emerged with a rate of 120 bpm and a short V-A interval consistent with typical slow-fast AV nodal reentrant tachycardia. Ventricular entrainment pacing was performed, demonstrating a post pacing interval minus tachy cycle of 150ms - consistent with AVNRT. Ventricular overdrive pacing repeatedly terminated the SVT. A total of 10 mg of Metoprolol was administered for SVT. Generator was secured to leads and placed in pocket with closure." What would you code for this besides the 33216?