Ask Dr. Z

Is an MD procedure description of "coronary angio performed", or "contrast injection was used to obtain coronary angiograms" really enough to code selective coronary angio? The hospital I work for says it is OK if the MD signs the department produced procedure log (which states "5 French catheter used for angio of left coronary artery" and "5 French catheter used for angio of right coronary artery") and the MD chooses "selective coronary angiogram" from the procedure quick pick list. The MD description of procedural results range from "normal coronaries" to describing far branches of each artery.

Patient had a post-op breast seroma. Does that code to 10160 or 19000? "Female presenting for ultrasound-guided seroma drainage of the right breast. The patient has a history of right breast cancer with skin sparing mastectomy with reconstruction Procedures: 1. Ultrasound-Guided seroma drainage - Right breast Site 1: The skin was prepped with alcohol and draped in sterile fashion.  Lidocaine 1 percent was administered for local anesthesia. The lesion of interest in the lower outer quadrant of the right breast was identified by ultrasound. Under direct sonographic guidance, 1 pass was made with an 18 gauge needle. Approximately 300 mL's of serous fluid was removed and sent for culture and cytology. Hemostasis was achieved and the skin was bandaged."

Why is an atrial clip not separately coded at the time of a CABG? Would modifier -22 be appropriate?

Is 75736 one of the visceral angiograms that 75605 and 75625 should not be billed with? Example, when 75625 is performed with 75736 before uterine artery embolization.

I have a question regarding when the doctor at Cardiology does remote interrogations of pacemakers and ICD units. For PPM we bill 93294 with 93296. With ICD we bill 93295, 93296, and 93297. Why is 93297 fine to bill with 95 and 96 while we get an edit when trying to bill 93294 with 93297? The only difference I see is what kind of device is being interrogated. Also if we want to bill 93294 with 93297, what modifier, if any, would work?

No idea how to code this. Patient with NICM stage C and moderate LV dysfunction presents for ICD generator exchange due to single chamber device at ERI. Physician removes old generator and tests the single existing lead. But, instead of installing a single chamber ICD, physician places a dual chamber ICD and wraps the extra lead around the generator before placing it in the pocket. The dual code 33263 does not seem right because there is only medical necessity for a single chamber device. The single chamber code 33262 has lower reimbursement than the device that was actually placed. Code 33249 does not seem right because the new lead is just left in the pocket. If the physician later decides to unwind and utilize that extra lead, how would that be coded? Finally, do you know why the device may have been installed this way?

I would appreciate some clarification regarding the use of modifier -50 in vessel catheterizations. My understanding of modifier -0 is that it is for “pairs” of left and right. Can I use modifier -50 with the CPT 3624X series when left and right are different vessels but are of the same order? Example: on the left, 3rd order catheterization of the obturator artery. On the right, 3rd order catheterization of the internal pudendal artery. We have left and right 3rd order catheterizations, but they are not the same vessels. Eligible for modifier -50?

"Study carried out via the right common femoral artery utilizing 6 French catheters. The Judkins technique was used for bilateral selective coronary angiography. Left ventriculography was deferred. I placed a second sheath in vessel due to instability and small hematoma, to document absence of residual leak. Sheath left in place to monitor BP on a continuous basis. Subclavian and peripheral angio: This vessel is heavily calcified. There is 70% short concentric stenosis in the vessel but does not involve the ostium. This lesion was engaged coaxially with a 6 French JR 4.0 Mach 1 catheter. There was dampening of pressures when coaxial engagement was carried out; nonetheless, I was unable to pass a 0.35 mm Rosen, Wholey, or Terumo angled guidewire across the lesion." He wanted 93454, 75710, 36215, but I don't see that he gets cath plament in subclavian because he never states where the cath is placed. How would you code this?

PICC placement is ordered, unable to advance catheter and tip left in midline position. Dictation reads as midline placement. With the new PICC codes are we still allowed to code as a PICC (36573) with 52/74 mod, or is this to be coded as a midline (36410)?

When using multiple PCI codes (92920-92944), is it necessary to add an -X modifier in addition to the vessel modifier (LC, LD, LM, RC, RI)? Procedure performed included angioplasty and stenting of the proximal and distal vein graft to the PDA with two drug-eluting stents as well as angioplasty and stenting of the proximal vein graft to the obtuse marginal artery using one drug-eluting stent. This was done in the setting of an AMI with the PDA being the culprit vessel. Would you code 92941-RC and 92937-LC? Or would you code 92941-RC and 92937-XS-LC? Would -XS ever be appropriate to use when coding the coronary arteries?

Are you allowed to report code 96365 for the albumin infusion done after a paracentesis (49083)? There is an edit that can be bypassed with an -XU/-59 modifier. We are not sure if the infusion would be considered part of the procedure.

We have a doctor who did a left SI joint injection for pain with ultrasound guidance. There was a saved US image for the guidance. This is an outpatient procedure. They want to know what should be billed for the physician and what should be billed for the facility. Am I correct that the physician would bill 20552-LT with 76942-26? What would the facility bill?

We struggle with understanding when code 93655 can be used and when it cannot be used. Our provider indicated that he did two ablations; the first was for “Atypical Narrow QRS AVNRT (slow-slow) located in the lower 1/3 of the triangle of Koch and terminated through cryothermal ablation”. After being observed for 30 minutes, repeat testing resulted in a second ablation of “Orthodromic Narrow QRS AVRT (induction CS pacing off isuprel [burst and LAESS]) located in the mitral annulus - left lateral that was terminated through radiofrequency ablation” and is referred to as an “accessory pathway”. The provider documented SVT as the diagnosis with indentations separately identifying AVRT and AVNRT. Do the two different locations and the designation of being an “accessory pathway” qualify this as a distinct arrhythmia (93655)?

In this scenario we’re coding for the interventional cardiologist. Patient presented for a transcatheter pulmonary valve placement. The interventionalist performed a complete right and retro left heart cath with angiograms in the LPA and aortic root along with compliant balloon testing and coronary compression testing. Balloon inflation demonstrated an inability to safely land the transcath pulmonary valve (the valve was never deployed). It was decided that the patient should undergo a surgical valve placement with cardiothoracic surgery, and this concluded the interventionalist's involvement. Should we code for the work performed (heart cath, angiography, unlisted for coronary compression)? Or attempt to bill 33477-52/53 even if the valve was never deployed and the patient went on to have surgical placement on the same day by another specialty?

Could you please tell me if code 37700-50 is correct for the following? "High ligation of the bilateral anterior accessory saphenous veins. We had two incompetent anterior accessory saphenous veins documented on the preop ultrasound. I made transverse incisions in the groins at the highest point of the anterior accessory saphenous bilaterally. In each case, lidocaine was injected in the skin. A roughly 2 cm skin incision was created and a small amount of cautery was used for hemostasis. We dissected down through the subcutaneous fat and identified a large incompetent anterior accessory vein bilaterally. On each side, the vein was clamped with right angle clamps and divided with 3-0 silk ties."

I bill for the professional side. Can we code the selective catheter placement when an intervention was performed (e.g., lower extremity angiogram)? Even if the access was on the same side? Or does it depend if it's diagnostic? Please help!

"Patient status post heart cath with Angioseal device now intraluminal in EIA causing occlusion. Exposure of EIA then endarterectomy extended into the EIA and removal of footplate and Angioseal plug. Secondary to >50% medial wall calcified plaque, performed extended endarterectomy of EIA and CFA. Then 3 Fogarty used to perform embolectomy of profunda and SFA with multiple passes down SFA and profunda with minimal thrombus removal. Arteriotomy extended to distal CFA with focal endarterectomy with good endpoint in profunda and proximal SFA. Endpoint tacked down and arteriotomy closed with bovine pericardial patch." Would we look to CPT code 35355 (iliofemoral endarterectomy) in this case (EIA, CFA, proximal SFA, and proximal profunda)? (Embolectomy would be inclusive to the more comprehensive endarterectomy code.) For the retrieval of the Angioseal device, would this be separately billable or inclusive to the endarterectomy given the retrieval was by means of the endarterectomy? Your thoughts are greatly appreciated.

We are wondering if it is allowed to bill for a completed diagnostic radiology exam on the technical side (hospital facility) without there being a finalized (signed by attending radiologist) interpretation of the diagnostic study. We see that the resources were consumed, the patient had medical necessity to order the test and have images taken, but perhaps there may not have been a finalized/signed by attending interpretation of these images. Images were retained, the order is in place, but no report. Please advise on the facility technical billing piece, whether or not a finalized signed interpretation is required to be able to bill for the technical piece of the diagnostic exam.

Patient came in for EPS ablation of atrial flutter. During entrainment, patient developed atrial fibrillation and was cardioverted to sinus rhythm. Can I report code 92960 with 93653 in the case?

Please review if our documentation is complete to submit code 33866. "Redo median sternotomy for ascending aortic aneurysm repair, with debranching of the great vessels using Hemashield platinum vascular graft under deep hypothermic circulatory arrest. Circulatory arrest was done using protocol. Head was circumferentially wrapped with ice. Hemashield graft with multiple branches was opened. The distal end of the graft was beveled to fit the hemiarch. The graft was oriented so that the side branches for the great vessels are laid on the superior vena cava side. The distal end of the ascending aorta was reinforced with a felt strip on the outside. Branch of the graft was then cut to appropriate length. It was then anastomosed to the left subclavian artery. Middle side branch of the graft was then cut to appropriate length. It was then anastomosed to the left common carotid artery. Proximal side branch of the graft was then cut to appropriate length. It was then anastomosed to the innominate artery." (CODES: 33860, 33530, 34714, 33866)

How would you code this since 93566 and 93567 are add-on codes? "Procedure: The patient was brought to the hybrid catheterization laboratory from the PCICU on ECMO support. The chest was sterilely prepped and draped, the silastic skin patch was removed, and the chest was explored. A 5 French sheath was directly inserted in the RV through a purse string. A 5 French Berman was advanced via the sheath to the RVOT and AAO, and angiograms were performed. The catheter and sheath were removed, then proceeded with repeat surgery to address the RVOT obstruction. Angiograms 1. AAO-the aortic arch is patent, there is no recurrent coarctation 2,3. RV-there is severe narrowing just below the aortic valve."

The open AVF placement (ex: 36821, 36830), and the peripheral angiogram/PTA/stent are bundled up together. However, the NCCI edits say that you can put a modifier on one if it is “appropriate.” In what situation is it appropriate?

When a patient presents for a follow-up echo, but a complete echo is performed, would it be appropriate to bill code 93306? In our institution a limited study is scheduled, but the documentation ends up supporting a complete study.

Do you have recommended documentation regarding code 76937? We want to make sure we're having our physicians be consistent with one another in their documentation and capture the proper elements for the code.

What documentation should I see to code 33877 versus 35091? In the lay descriptions for 33877 the descending thoracic aorta is described in the exposure, the resection of the aneurysm, and proximal anastomosis. If the exposure, aneurysm resection, and proximal anastomosis are at the level of the supraceliac aorta, can I code 33877?

If a report indicates that fluoro and/or ultrasound guidance were used during a PICC placement, but permanent images are not documented for either, should we use 36573-52 or 36569 without guidance?

We have an outside auditor who is stating that we should code for a LHC when only an attempt to cross the AV is made. I have multiple reference books - your CV coding ref, CSI, Medlearn, and CPT Assistant. I cannot locate any reference that states this. They all say that the AV has to be crossed. Can you clarify? If the MD attempts to cross an AV and cannot, can we still code that as a LHC?

CT imaging demonstrated medial aspect of the lesion and a subsequent small right basilar pneumothorax. A single 22 gauge aspiration sample and five 20 gauge core biopsy samples were obtained from the lesion. The needle was removed using routine technique and with aspiration of the pneumothorax with withdrawal of the needle. Per pathologist, sufficient tissue was obtained to establish a diagnosis. There are two separate path reports, core and FNA. What do you advise for the aspiration of pneumothorax here?

A physician's report states a CT chest and CT abdomen/pelvis were both performed. The findings and impression for both studies are combined into one report. Is this allowed? Or should the impressions be clearly separated for each study in the same report? Also would the answer vary between a physician's office and hospital?

When using an unlisted code, should the guidance also be coded, or would you consider that inclusive since the report needs to be sent in and reviewed?

We have some clients that use both ultrasound and fluoroscopic guidance when placing a peripherally inserted central catheter (PICC) in the arm. Many physicians do not document the US guidance with all elements required by CPT. In the instances where both US and fluoroscopy are used, but US documentation is not complete, can we still use the 36572/36573 CPT codes?

"Transjugular liver biopsy was done. First, with US guidance, right internal jugular vein was punctured. Then with fluoroscopic guidance, right hepatic vein was selected." Do we add 76942 on 75970 in this case?

Hello, this question was originally asked/answered in 2015. The recommendation at that time was the embolic protection device was not separately billable using unlisted 93799 during a TAVR because the device was inserted to prevent stroke during the procedure. For FY 2019 CMS has approved the Sentinel Cerebral Protection System for a New Technology Add-On Payment (NTAP) for IPPS using ICD-10-PCS X2A5312. Does this change your advice regarding billing unlisted 93799 for the physician's professional fee or would it still be considered preventive and a component of the TAVR? Thank you.

The facility I charge for has done a Basilica procedure at time of TAVR. Is the work of this included with CPT 33361?

The use of codes 61650/61651 require at least 10 minutes of drug administration. Would it be appropriate to code only the angiograms when the drug admiration is less than 10 minutes?

Which CPT code would you bill for a wedge biopsy of the left upper and lower lobe performed via VATS: 32607 or 32608? This procedure was performed due to undiagnosed pulmonary fibrosis - progressively declining lung function.

How would I code for ultrasound-guided intratumoral injection of a left inguinal mass with NKTR-262? It also says a "fan technique" was used to equally distribute the agent within the mass. Is this chemotherapy and therefore coded 96405 and 76942?

What would you recommend when an indwelling catheter is removed and a new drainage catheter is inserted via a new access in a different location, but still treating the same lymphocele? Would this still be an exchange, or would you code a new insertion?

Can you please clarify coding for bilateral renal stent placements? I see where 37236 x1 and 37237 x1 has been cited as the correct codes with rationale given that modifier -50 does not apply to renals. But if I look at the MPFS RVU file in the column labeled BILAT SURG (column T), there is a number 1 assigned, and I thought you could "report the code with a -50 modifier when performed on both sides of the body".

Would you be able to code angioplasty of the central vein and stent of peripheral vein with the creation of this new graft? 36903-59, 36907-59, 36830? "Indications: The patient was evaluated with arterial studies that revealed adequate circulation of the upper extremities and also, with a venogram that showed that the superior vena cava was patent and that the left brachiocephalic vein had areas of occlusion as well as the left subclavian vein, and a preoperative venogram also showed that the axillary vein was occluded in the lateral and medial aspect, but there was a collateral that communicated with the subclavian vein. I recommended reconstruction of the central veins, and if successful, this will allow a placement of a new graft."

"Patient has a previously placed right arm fistula that has not yet been used and no longer has a thrill. She also has a left arm fistula with a declining flow rate. Fistulogram was obtained of the LUE. The venous anastomosis and occluded native brachial vein were balloon angioplastied. The right arm was separately accessed, fistulogram was performed, and the segment of the brachiocephalic fistula toward the upper humerus was balloon angioplastied." We coded this procedure as 36902-RT and 36902-59LT, but it was denied by Medicare. I looked at changing this to 36902-50, but my resources are showing that modifier -50 is not allowed with this code. Are the dialysis circuit interventions billable as bilateral procedures?

"Venogram was done through existing intravenous catheter of right upper extremity prior to creation of AVF. Incision was made in right wrist with dissection of cephalic vein of adequate caliber. Through the same incision the radial artery was dissected and arteriotomy performed; however, poor arterial inflow was identified so the procedure was discontinued. Arteriotomy was repaired and skin incision closed. Skin incision was made in antecubital fossa after ultrasound was used to identify the basilic and brachial arteries. Dissection of both basilic vein and brachial artery was performed. Brachial arteriotomy was made and basilic vein clipped with an end-to-side anastamosis completed." Would the initial discontinued procedure be billable with a -53 modifier since it is a separate incision, or would only the completed AVF be billable with the venogram?

I need clarification for question #11729. The CPT description is for a “complete acute abdomen series, including supine, erect, and/or decubitus views, single view chest”. My understanding is there must be a minimum of 2 views of the abdomen with 1 view of the chest. In your answer, you state only “one” or more views of the abdomen are imaged. In doing further research, I have come across an article from the AAPC that states for a single view of the chest and a single view of the abdomen, report 71045 (chest; single view) and 74018 (abdomen; single view). My question is, when a patient has only 1 view of the abdomen with 1 view of the chest, are you in agreement that CPT 71045 and CPT 74018 are the two codes that should be billed? If the patient has 2 views of the abdomen with 1 view of the chest, then CPT 74022 would be billed?

A patient undergoes selective native coronary angiography and selective left subclavian artery angiography. Findings are also noted for the LIMA graft, which is imaged non-selectively (I'm assuming via the subclavian). How is the non-selective coronary bypass angiography coded in CPT?

I have a question about the changes to 36569 for 2019. I understand the PICC line placement does not need image guidance for placement, but doesn't it still require a permanent image (i.e., CXR) to confirm the catheter tip is in a proper central vein/right atrium? We have a note where the PICC nurse inserted the line and stated the CXR was not needed "as tip is confirmed in lower SVC per ECG technology - maximum P wave and absence of negative deflection". Is the ECG enough for 36569? If not, how would we code this: 36140 or 37799?

What if during a standard left heart cath the physician performs an abdominal aortic angiogram (75625) because he had an "initial difficulty ascending". The results of that study showed no evidence of any disease. Should I still bill code 75625 for the study, or would this be included in the heart cath at this point? If it is billable, what type of diagnosis would support this service if no disease was found?

What is the appropriate HCPCS code for device without a C-code (L8699 vs C1889)? For implants we assign revenue code 278 and L8699 for C-code. We get Medicaid denials that do not allow L8699, then a denial for submitting 278 without a C-code. We tried C1889 as well, but are getting same denials. If procedure is not device dependent with a specific implant device code, is it appropriate to use 272 REV code instead? These are not inpatient accounts.

"Patient has documented ruptured AAA. Physician embolizes each internal iliac artery from separate accesses and then places the modular bifurcated device with two docking limbs that land in the external iliacs covering each internal iliac." Would you bill 34706 with one 37242 since facilitating the AAA repair, or would you add 37242-59 since both internal iliacs were embolized from separate accesses?

I am having a disagreement with another coder about whether this is a true CTO or not. Physician documents that the "LAD demonstrates diffuse 80% disease from the ostium to the proximal mid vessel. It is totally occluded around a stent site in the proximal mid vessel." Then he continues to refer to the lesion as a CTO. Is this a true CTO?

My doc is performing a LLE agram with possible intervention for a patient with a wound on his left foot. He passes the catheter in the abdominal aorta (75625). The catheter is withdrawn to the iliac bifurcation where contralateral injection was performed, and multiple subtraction images were obtained of the pelvis. Catheter was advanced to the contralateral left common femoral, and LLE was performed. In the impression it says bilateral common iliacs, external iliacs, and Internal iliac arteries are widely patent without significant stenosis. Then describes the left SFA/popliteal and tibial artery. My doc always performs a bilateral angiogram/runoff, but does that warrant a bilateral study to be coded (75716)? Or should I only code a unilateral study (75710) since that's ultimately where he was looking?