Ask Dr. Z

Our physicians do a ton of these procedures, and it can get confusing when reading through all the guidelines. If the physician is using an aorto-bi-iliac endograft for just a documented para-renal AAA (34705), but both common iliacs have occlusive disease vs. aneurysm, dissection, penetrating ulcer, etc., do you recommend using codes 34705 and 37221-50 for the occlusive portion of the case in the bilateral common iliacs? Or codes 34701 and 37221-50 (but that's not the device they are implanting)? You can see a person could code this many different ways depending how they interpret the coding guidelines. Any advice would be appreciated.

What is the CPT code for intervertebral disc space biopsy?

My physician is coding 93458, but there is no documentation of the aortic valve being crossed. The only documentation of pressures is "AO 141/81 (106)". What does that result mean, and what results should I look for to indicate a left heart cath was done?

Facility wants to charge 49422 for removal of a breast drainage catheter. It is not a tunneled catheter. There is no documentation of radiograph, contrast injection, etc. being done. From report: “The skin and the catheter tract were infiltrated with 1% lidocaine. The catheter was cut and removed. Hemostasis of the site was obtained with manual pressure. Successful removal of right breast drainage catheter." I am having trouble finding a procedure code. What would you recommend?

When an interventional radiologist performs a new access with dilation into the kidney (50437) and then a urologist or surgeon performs a percutaneous nephrostolithotomy (50080), your IR book (pages 408-410, coding instructon #10) advises to separately report these codes, but #12 advises for hospitals NOT to report 50436/50437 on same date of service as 50080/50081. Which of these are correct? CPT convention advises not to report 50437 with 50080 also. Can we report 50437-XP wtih 50080 on same date of service, given physicians have different specialties? Please clarify how we should report each part of this procedure, which was performed on the same operative episode.

We have seen what seems to be some mixed guidance on routine pre-op and post-op EKGs charged with EP ablations and cardioversions. Is it ever appropriate to charge EKGs performed routinely before and after either of these procedures? Our facility wants to charge these before and after every ablation and cardioversion.

Can 10035 be used for lung radiotracer localization nuclear med placement? "Once the needle was advanced through location adjacent to the targeted lesion, the needle stylette was removed, and 0.3 mCi of Technetium-99m MAA with 0.15 ml omni 180 was then injected into the lung parenchyma, followed by a small saline flush. The needle was then removed under breath-hold and deposited in the radioactive waste. A sterile dressing was then applied. Postinjection CT scan was then performed."

What CPT code would be appropriate when performing an ascending aorta without any type of prosthetic and/or graft? This is a new procedure similar to anastomosis, preventing the patient from incurring any future infections or complications because the body fights any foreign implanted materials. The closest CPT code is 33860. The description does state "when performed'; however, is that only directed to the valve suspension or can it refer to the graft as well?

I received a denial for codes 35860-RT and 35860-LT. Bilateral surgery indicator 0. I see this now, but how would I code the following procedure? "Patient had undergone coronary intervention and was noted to have enlarging hematomas in the LT and RT groin. Incision made in LT groin and dissection carried down to enter large hematoma. Active bleeding was encountered at this point in time, and dissection was carried down further to expose common femoral artery. This was corrected by interrupted prolene suture. Hematoma was also drained. RT groin incision was performed and dissection carried down to enter large hematoma. There was once more active bleeding encountered. Dissection was carried down to expose the common femoral artery. It was noted the patient had active ongoing bleeding from a puncture site. This was also corrected with a 6-0 Prolene and wound irrigated. Hematoma was also drained. Bilateral drains placed in thighs and connected to bulb suction by means of silk suture. Wounds irrigated and closed in double layered fashion." Am I coding this incorrectly?

If, during one operative episode, one physician performs a diagnostic heart catheterization and coronary angiogram (i.e., 93458), and then calls in an interventionist to perform an intervention (i.e., drug-eluting stent), what would be most appropriate modifier on the diagnostic? Modifier -XU appears to be most appropriate to identify a true diagnostic study. But would modifier -XP be more descriptive?

Can the radiologist bill code 49465 if the nurse injects the G-tube and he is just doing the interpretation?

Patient has Klippel-Trenaunay Weber syndrome with numerous varicosities that are painful. Doctor embolized (using Glue) the lateral thigh, deep posterior thigh, and mid-calf varicosities. I know we can’t code 37241 for varicose veins in the extremity veins, and 36470-36471 doesn’t fit since he didn’t inject a sclerosant. Would I resort to 37799 (unlisted)? If he embolizes and injects a sclerosant, would I code 36470-36471 only? Also, if the doctor embolizes vulvar/pelvic varicosities, would I use 36468 or 37241? The pelvic isn’t considered lower extremity but the trunk, but 36468 is for spider veins which these are not. These codes are confusing me.

Can code 35045 be billed with 36901 for an aneurysm repair in the radiocephalic fistula? The fistulogram was done first.

A VT ablation was done by one of our providers, and the following sentence was documented in the note: "Epicardial access was then obtained using an epicardial needle from the subxiphoid approach." I have not seen this documented before. How would that be coded?

Fluoroscopically-guided lumbar puncture and intrathecal administration of baclofen for spastic gait – 96450 or 62323?

Physician states he is doing a voiding cystogram (VCUG). In the dictation he states that contrast is injected into the bladder, and during a cyclic exam the urethra is unremarkable. Would you consider this a voiding exam? Is cyclic the same as voiding, or do they have to actually say the "voided, voiding" to get the 77455?

When billing for a right heart cath (93460-26), is just having the pressures sufficient documentation? Or must the provider actually state the catheter was placed into both the arterial and venous systems? Please help to clarify so I can properly educate the provider on appropriate documentation.

Can you please clarify if IVUS can be reported in the peripheral circuit and the central circuit, or is the circuit considered one vessel?

A physician's documentation indicates that procainamide was infused for 20 minutes with serial ECGs performed every 10 minutes over a one-hour period to test for the presence of an arrhythmia. Since no CPT code accurately describes this procedure, would it be appropriate to bill a code for the infusion (96365) and a code for one or more ECGs, if the documentation supports them?

This is the only documentation for mapping during Cryoballoon PV isolation, "3D electroanatomical mapping by NavX was used to help position the Achieve mapping catheter into each of the four pulmonary veins." Is this sufficient to bill 93613?

When a patient gets bilateral nerve ablation of the genicular nerves (superior-medial, superolateral, inferomedial, and suprapatellar), can you code this as a bilateral procedure: 64640-50, 64640-XS-50, 64640-XS-50, 64640-XS-50? There is an MUE of 5 if listed individually, but I do not get an edit if I code them as bilateral.

Would this just be 34203? "Clamps were placed on the legs to make a transverse arteriotomy in the common femoral, and we first identified the profunda femoral, passed a #3 Fogarty balloon to 15 cm, and then brought it back with a small amount of clot and excellent backbleeding. A second pass revealed no further clot, and so we placed a bulldog on that and turned our attention to the SFA. A 5 mm Foley balloon was advanced down the SFA and into the anterior tibial to 60 cm. The balloon was inflated and brought back with return of clot. A second inflation did as well and the third revealed nothing further. Clot was removed There was some spasm and the anterior tibial had some spasm in it The peroneal was essentially occluded as was the posterior tibial. We used a TrailBlazer catheter and an angled Glidewire to get into the posterior tibial and we were able to get down to the level of the foot and placed a catheter, embolectomy balloon into the posterior tibial artery brought the clot back into the artery with no futher debris."

How is a whole body CT scan reported? We perform a whole body low-dose CT for patients with multiple myeloma. These cases are done for patients with a known process, not for “screening” purposes. The scan is from head-to-proximal femurs or, if indicated, head to toe. We are hesitant to use unlisted code 76497, as we typically get denials or pends from insurers looking for documentation. Is there another CPT code that could be used?

1. Bilateral iliac artery angioplasty 2. Abdominal aortography with bilateral iliac artery angiography 3. Failed attempt to place Endurant stent graft on either side (i.e, right CFA or left CFA). Procedure terminated. Is the aborted stent graft coded with a -53 modifier, or can you only code the successful iliac PTA?

Typically our cardiothoracic surgeons perform a bronchoscopy prior to a VATS procedure. From what I have read, this is customary and would not be billed separately, unless the bronchoscopy becomes diagnostic (if an abnormality is identified). In that case we would bill the bronchoscopy and append modifier -59. Can you please confirm if this is accurate?

In 2015 it was recommended that we use unlisted code 37799 for angioplasty to dilate a fistula when no stenosis is present. Is this still the recommendation, or are we able to use CPT code 36902 for the dilation of a small vessel?

Coding for pro-fee AND facility here. My instructor said for facility we can only code for what is successful, but is the same true for pro-fee? Patient has a thrombosed AV fistula, but after performing an open thrombectomy and angioplasty they could not salvage the existing AV fistula. They "aborted plan to salvage the dorsal vein" (which had been transpositioned months back when the original radiocephalic AV fistula was not able to be salvaged due to thrombosis) and created a new one by anastomosing the basilic vein to the radial artery in an end-to-side fashion. Am I looking at coding only 36821 for facility and for pro-fee for this procedure?

Would this be enough documentation to report code 93621? "Deflectable decapolar catheters were advanced to the coronary sinus for left-sided recordings as well as a decaNav to the lateral right atrium to allow for activation mapping for arrhythmia." 

In our facility, we frequently encounter patients who receive more than one echocardiogram on the same date of service. For example, patient presented for echo at 10:07 AM (CPT codes 93303, 93320, 93325 were documented and billed). Patient returns later that day (2:52 PM) and has a second echocardiogram performed (documentation supports 93304-XE, 93321, 93325). Knowing that 93325 has an MUE of 1, would you suggest that we append a modifier -76/-77, bypass the MUE, and submit documentation to support the second color flow charge? Assuming documentation would support separate encounters and/or medical necessity that is (i.e., change in patient clinical status). Or would you suggest reporting 93325 only once? We encounter the same issue when reporting fetal echocardiography on twins (76825 x 2, 76827 x 2, 93325 x 2). In twin fetal echo scenarios, color flow is being performed on two different fetal hearts; however, it’s all done during the same session. Does that warrant only one unit of 93325?

I have a physician who did an innominate to subclavian arterial bypass. I have not been able to find a code for this procedure. Can I use code 35612 for subclavian to subclavian, or do I have to use unlisted code 37799?

Doctor is billing 37238, 37239, 37248, and 37249 for the following: Angioplasty of LLPV, stent of distal LUPV, angioplasty of RUPV, stent in right middle pulmonary vein. The note states the stent spans the RUPV/RMPV ostium. Are the above listed codes correct?

We are coding for a vascular surgeon who placed an aorto-bi-iliac endograft to repair a non-ruptured abdominal aortic aneurysm. We are reporting CPT code 34705. The code is, as you know, a combination code that includes "all radiological supervision and interpretation." Since the 2019 CPT manual specifically states that all codes with radiological supervision and interpretation in their code descriptions (whether in the radiology or surgery sections of the manual) require image documentation in the record, we have been clarifying with all of our physicians that images are being stored and are retrievable in the event of a payer audit. In this particular case, though, the physician responded that his radiology S&I images were not stored. This is pretty unusual to my understanding. Would we need to report code 34705 with a reduced service modifier -52 since he cannot produce the radiology S&I imaging in the event of an audit and the rad S&I is included in the code description?

Baylis has a new wire (PowerWire® RF Guidewire) to cross a CTO in peripheral vessels with the use of radiofrequency energy. Can the ablation of the CTO be coded as an atherectomy?

"The left brachial vein is punctured, and a midline catheter is placed with its tip in the left brachial vein. Ultrasound guidance was used, and images were saved in the PACS system." Would I report this with codes 36410 and 76937?

I'm fairly new at coding. How would I code a CRT placement with capped atrial port? An RV single-coil ICD lead was delivered and deployed, as well as CS lead, both leads anchored to the floor of the pocket. Pulse generator was brought to the field and the atrial port was plugged. Code 33249 is correct for dual leads. How do we account for CS lead, 33225?

Hospital outpatient coding. Is it correct to append a -59 modifier to conscious sedation code 99152 while it is performed during a colonoscopy or EGD? There are quite a few differing opinions on this.

We will be performing CEVUS for vesicoureteral reflux. We will be using Lumason, and we're wondering if it is appropriate to charge 76978 [US targeted dynamic microbubble sonographic contrast characterization (non cardiac); initial lesion]. Our concern is that vesicoureteral reflux isn't a lesion. Would 76770 be more appropriate and then charge for the units of Lumason (Q9950) injected. Or charge 76770, 76978, and Q9950? Lumason has been approved for use in the urinary tract for vesicoureteral reflux.

We found conflicting guidance on when to use modifier -74. See procedure below: "GA initiated. Initial limited CT scan of the abdomen was initially performed without intravenous contrast. The known left renal lesion was identified given internal linear low-attenuation. However, the complete extent of the lesion was not confidently visualized. Therefore, the patient was given 80 mL of Isovue-300 intravenous contrast and a repeat acquisition of the abdomen was obtained. This better delineated the small 1-1.2 cm enhancing lesion arising from the posterior aspect of the superior left renal pole. The left flank was prepped and draped in the usual sterile fashion. At this time, an open window to access in the lesion was identified. However, the patient began to experience hypotension, which became difficult to control for the anesthesiology service. Given the nonemergent/nonurgent nature of the procedure, the procedure was aborted prior to introducing the ablation probe or biopsy device." Is this considered an elective cancellation? If yes, we've coded 76380.

Patient came in for sclerotherapy for a post-operative lumbar spine seroma. The code I am coming up with is 17999, which is an unlisted skin tissue procedure. Can you provide some clarity if the unlisted is appropriate? "INDICATION: Patient with postoperative lumbar spine seroma. PROCEDURE: Risks and benefits of procedure were discussed with patient and signed consent obtained after answering patient's questions. Patient identity and procedure were confirmed. Sonographic interrogation of the lumbar spine reveals a large fluid collection in the surgical bed. Overlying skin was prepped and draped in a sterile fashion with 2% Chlorhexidine and a sterile sheet. Collection was accessed with 5 French Yueh system under ultrasound guidance. Track was dilated for placement of an 8 French pigtail catheter. Collection was evacuated. Contrast was instilled into the collection. Contrast was evacuated. Dehydrated alcohol was instilled into collection. Alcohol was allowed to well for approximately 2 hours. Alcohol was then evacuated and pigtail catheter removed."

Our radiology department has been asked to perform a Gastrograffin Challenge study to evaluate the small bowel, but without any fluoro imaging. Contrast is injected on the floor by the ordering provider and timed portable kub’s are obtained on the floor. The increments are: 4, 8, 12, and 24 hours post injection. How do you advise we bill for this? Would it be appropriate to bill CPT 74250 (even though fluoro imaging was not performed and water soluable contrast was injected by ordering physician), or would each subsequent kub billed separate? 

Can you please provide clarification on the following guidance regarding billing for post-biopsy mammograms? According to the ACR’s Committee on Coding and Nomenclature it is appropriate to code for a unilateral diagnostic mammogram (77065) for verification of clip placement after biopsy when it is performed on separate pieces of equipment, if it is a different modality from the primary procedure, or if separate physicians are involved. Is the ACR directive intended to be interpreted as three separate qualifying circumstances? (1) On a separate piece of equipment, OR (2) it’s a different modality, OR (3) separate physicians are involved. If any of the qualifying conditions exists, then the post-biopsy mammogram can be separately billed?

What is the correct CPT code for fluoroscopically-guided intrathecal stem cells infusion? "DX: ALS here for brainstorm trial. This is a new procedure to our facility. so far i understand the technology is NurOwn a type of cell derived from an individual’s own bone marrow. Thank you. PROCEDURE: The patient was placed in the prone position on the fluoroscopy table. The L5-S1 level access The area was prepped and draped in the usual sterile fashion. The overlying soft tissues were anesthetized using 1% lidocaine. A 20 gauge spinal needle was advanced into the thecal sac under fluoroscopic guidance. CSF was returned. 5 mL CSF fluid was removed, 4 mL of stem cells was infused. At the conclusion of the procedure, the needle was entirely removed and site dressed. SPECIMEN TO LAB: Fluid sent to laboratory for evaluation."

We are hoping to get clarification on when it would be appropriate to report code 47554, if the gallstones were fragmented with Yag Laser advanced through the endoscope. The fragments were flushed through the ampulla into the bowel or flushed out the tract. Since the stones were only broken up and not removed, can I report code 47544?

If angiograms are done and vessels are selected in the extremities (in this case the arms and the legs) to evaluate for possible large bore access, would we code/charge for them? I'm thinking not, but in the case involved, they don't place the large bore; they are just evaluating for them. They also did a RHC and coronary angiograms. 

In 2016 (question ID #7569), you suggested utilizing 75716 for the angio of the external iliacs that supply the legs. My question is, if the portion of the external iliac that supplies the pelvic region is selected and imaged, and the impression has no extremity findings (only inferior epigastric artery impressions), would I code as a pelvic angio?

It appears that CPT guidelines for 2019 are allowing FNA and core biopsies for the same lesion, same session, same day, and same imaging guidance. So if the radiologist performs a fine needle aspiration with US guidance of the thyroid, followed by a core needle biopsy with US guidance of the same lesion, can we report code 10005 with 60100 (but no imaging)? I just want to make sure this is correct since this hits an NCCI edit.

Can you explain what is meant by the CPT instruction on the hemiarch graft that states "extension of the ascending aortic under the aortic arch by construction of a beveled anastomosis to the distal ascending aorta and aortic arch without a cross-clamp (an open anastomosis)"? Does this mean that if a cross-clamp is used at all then you cannot use the add-on code 33866?

Could you please help me with this scenario? "Patient came in for a fistulogram. Fistulogram performed. Reflux arteriogram was performed to rule out inflow lesion. 10 cm of the brachial artery were described in the findings, along with 80% stenosis in the AVG. The stenosis was treated. Following angioplasty, in order to avoid reflux imaging and extravasation while imaging the post angioplasty area, catheter was manipulated into the upstream artery and contrast was injected to visualize the arterial supply, the AA, and the JA segment." I do not believe this meets the criteria for a selective catheter, but this is a very grey area for me. Could you please give me direction on if 36215 should be coded in this scenario?

Our surgeon performed this cone procedure for Ebstein's anomaly for the first time. What CPT code would you use to code this new technique?

Is an external cardioversion billable if done prior to starting an ablation procedure? The patient has a-fib, and they cardioverted after they placed a sensing and recording catheter. The ablation was then performed. I thought if the ablation catheter was in place, then the rhythm started and cardioverted, it wouldn't be billable. Isn't it the timing that affects when it's billable? I'm confused. Please advise.