Ask Dr. Z

Do you have any official sources that direct hospitals about who ought to be adding department charges? My gut says the staff closest to the actual procedures are the best people for that job, while HIM's forte is reading and coding from physician documentation. What do you say? What do your professional organizations recommend?

Patient presented for implant of a biventricular ICD. Prior to implant the physician performed atrial and ventricular pacing. Would we be able to bill codes 93610 and 93612 with the 33249-Q0?

Coil embolization is done for a known MCA aneurysm (61624, 75894, 75898). Is the catheter placement also coded (36217)?

A guidewire and a cath were introduced to the IVC and RA to SVC and eventaully LUE. The cath and wire were guided under fluoro through the AV fistula into the brachial artery. Cath was removed. The area of stenosis within the fistula was dilated with dorado balloon. The area of stenosis in the left subclavian vein and brachiocephalic vein was then treated and angioplasted with 12 mm balloon with good results. Can we code the 36140 (brachial artery access), 36902 (angioplasty of fistula), 37246 (subclavian vein through femoral access), and 36012 (cath placement from femoral to subcalvian access)?

If the provider starts surgery on Sunday but finishes on Monday, which date would we report as the date of surgery? I've tried looking in the CPT book for some clarification but have had no luck. CMS mentions using the date of service as the date service was furnished, which to me would mean use the date the service was completed... is that correct? Any guidance to references would be much appreciated.

Would this disqualify a 33866 since a cross-clamp was used with a 33860? "The arch of the aorta was then explored. A tape was placed around the innominate artery. The origins of the left carotid and subclavian were identified, and they were not involved with the intramural hematoma. The intramural hematoma did extend proximally to the level of the aortic root, but could not be well visualized while the patient was still being perfused in a normal antegrade fashion. Once this had all been completed, a #30 Hemashield graft was obtained, and a beveled cut made. This was then sewn endtoend to the aortic arch utilizing running 40 Prolene suture. Once this had been completed, the graft was allowed to fill with blood, and the aortic crossclamp placed on the graft after first measuring the graft for length to the proximal anastomotic site. Once the aortic clamp was in place, the clamp on the innominate artery was removed, and rewarming commenced as well as standard antegrade cardiopulmonary bypass. The graft was cut to length then sewn endtoend to the proximal aorta."

We have a patient who had a procedure done that I've never seen before. I'm getting the following codes: 36481 for the portal vein catheterization, 36000 for the femoral vein catheterization, and I am wondering if I can code 36430 as well? "The right upper quadrant and right groin were prepped and draped using sterile technique. Under ultrasound guidance, the right portal vein was accessed with AccuStick set, and microwire was advanced into the main portal vein. The inner stylet and microwire were removed with immediate return of pressurized venous blood. Portal venous catheterization was confirmed with injection of approximately 10 cc of contrast and portable spot radiography. A 035 guidewire was advanced into the portal vein, the percutaneous tract was serially dilated, and a 9 French sheath was placed into the main portal vein. Positioning was confirmed with portable spot radiography."

Patient has malfunctioning spinal epidural lead. Existing IPG 63685 and T9 lead 63663 are removed and new ones placed. Also an additional T10 lead is placed, which would be coded with 63650, but I have NCCI edit it is component of percutaneous 63663. What is the correct codes to use?

Patient presented for biventricular ICD relocation for radiation therapy. The existing generator was used, but three new leads were inserted. What would be the correct code for the pocket relocation (33223?), or will this end up being bundled into 33217 and 33224?

Left common iliac was selected and angio of left leg from knee to ankle. Ultrasound used to identify varicose veins at the medial ankle, lateral calf, and medial leg below knee. Butterfly needles were used at the three sites to perform a venogram prior to infusion. Doctor coded 36247 x 2, 36471, 76998, 36005 x 3, 76942, and 75710.

Question reference #11166: the response was to use code 0440T-0442T for cryoanesthesia or cryoablation. However Medicare does not recognize these codes. Can CPT code 64640 or 64450 be utilized in place of the suggested codes, or would the charges have to be removed?

Should we use code 93618 for this procedure? "Patient has NICM and has a biventricular ICD for primary prevention. Although adequately biventricular paced, his QRS duration remains long and his intrinsic QRS seems shorter. Patient was brought to the lab in the post-absorptive state. IV antibiotics were administered prior to the procedure. After the left pectoral site was prepped and draped in the usual sterile fashion. The skin was infiltrated with 1% lidocaine and 1% bupivacaine for local anesthesia. Right axillary vein access was obtained using ultrasound guidance and seldinger technique. However, the wire could not be passed beyond the superior vena cava in spite of using multiple wires and multiple attempts. Then left axillary vein was accessed using ultrasound guidance. Although we tried using Biotronik and then Medtronik systems we could not identify the His location. Then right femoral groin access was obtained and then His mapping was attempted using RV and HIS catheters. But in spite of repeated attempts His could not be consistently mapped. Hence the procedure was aborted."

Patient with dual chamber pacemaker upgrade to a biventricular pacemaker. Generator change and His Bundle lead implanted in RA (Basal Septum). Retained RV and RA leads; patient with two RA and one RV lead. Would this be charged as 33229 with unlisted code or just 33229? 

The patient arrived with already placed IABP. The IABP was removed and MD did R&L 93453 before placing a 33990 Impella and then proceeded with planned PCI. Is it okay to charge again for the R&L heart cath? Different scenario: patient arrives for Impella 33990 and the doctor does 93453 prior to Impella insert. Is that okay to charge?

"Procedures performed are: 1) Ultrasound-guided right femoral access. 2) Aortoiliac arteriogram. 3) Left lower extremity arteriograms with runoff. 4) Second order cannulation of the left popliteal and superficial femoral arteries. 5) Drug-coated balloon angioplasty of the left superficial femoral artery. Provider documentation: An Omniflush catheter was placed into the visceral segment of the aorta. Aortic and bilateral iliac arteriogram was performed. This revealed a widely patent infrarenal aorta. Patent common iliac arteries on both sides. Patent external iliac arteries and patent bilateral proximal internal iliac arteries. Internal iliac arteries after bifurcation into the anterior and posterior divisions had segmental mild to moderate stenosis. The catheter was then advanced into the left distal external iliac and left lower extremity arteriograms performed. Cath advanced to superficial femoral artery, angio performed and drug coated balloon angio was performed." Can we code 36246-LT for left external iliac angio, 37224, 75625, and 75710? 

Would this be 35663 or 35281 or 35286? "The tumor was identified and was circumferentially freed. The right external iliac artery was completely encased in the tumor and appeared to be invading the anterior wall of the external iliac vein. We attempted to develop a plane between the artery and the vein; however, the tumor was clearly invading the vein wall. A piece of cryopreserved superficial femoral artery was thawed. After 5 minutes of heparinization, the external iliac vein and artery were clamped proximal and distal to the tumor. The artery was transected 1 cm proximal and distal to the tumor. The anterior wall of the vein was then resected using a #15 blade. The specimen was passed off the table. The cryopreserved artery was inspected and flushed. A segment was cut to size to be used as an interposition graft for the right external iliac artery. End-to-end proximal and distal anastomoses were then created using a running 5-0 Prolene suture. Prior to tying the last suture the artery was backbled and forward flushed. Flow was restored to the RLE."

I code for an office based lab and bill global - place of service 11. Why is the reimbursement higher for 36245 than 36246? The RVUs for 36245 are 4.65 while the RVUs for 36246 are even higher 5.02, yet global reimbursement is close to $500.00 less for the more complex procedure?

Since there is a new code for 2019 for placement of a CardioMems device (33289) in the pulmonary artery, what code will we now use when the device is placed inside an aneurysm sac for monitoring? Would it be unlisted code 93799?

Is there a code for Endoloop, or is it included? "A 5 mm incision was made in left upper quadrant, and under direct camera vision a 5 mm trocar was placed in the abdomen. Belly was insufflated. There was no trocar site injury. There was ascites present, which was drained around 1 liter with clear yellow ascites. After this, a 5 mm incision was made above the belly button, and under direct vision 62 mm dual cuff pigtail peritoneal dialysis catheter was pushed into the pelvis. A separate stab incision was made in the pelvis in the midline, and under direct vision an Endoloop device was used to tack the catheter to the belly wall. Hemostasis was confirmed. Belly was desufflated. A tunneler was used to tunnel the catheter from the incision site to the trocar site and brought out. Attachments were applied to the catheter. Incisions were closed. A liter was instilled into the belly without any difficulty in 3 min and drained in 3 minutes."

Denial received for use of 36246, 75710. Please clarify is this is allowable. This is diagnostic, no recent studies billed with 35876 for primary procedure, notes states graft was punctured. The aortofemoral bypass graft could be seen coming down into the femoral level here. Next, the origin of the fem-pop bypass graft could be seen with a patch on this. A micropuncture was then placed above into the graft here, and a wire was placed. Then, an angiogram was performed of the left leg, which showed that the profunda had a significant stenosis where the patched area was, but that there was a patent fem-pop bypass graft with very slow flow due to distal occlusive disease in the graft.

Procedure: Access of Codman Holter Rickham reservoir, 9.5mm Burr hole; Site: R frontal parietal reservoir; Medication Administration: Brineuria infusion; Brineura administration of 4 hour infusion. Can you please advise the correct CPT to report for this administration; would CPT 96542 be appropriate? This is high risk; however, the drug itself is not chemo.

Can we ever bill both endomyocardial biopsy and right heart cath together? For example: patient here for possible rejection, renal failure, edema, and shortness of breath. Would this be a patient that you could bill both together?

How would you code the following? "Through the sheaths in the left femoral vein, an ICE catheter and a CS catheter were placed. Diaphragmatic pacing was performed in the RA and the SVC and was unable to capture the phrenic nerve. Anesthesia was also unsuccessful with stimulating twitches. The thought was the patient had a pseudocholiesterase deficiency. As diaphragmatic capture does need to be performed during both CRYO and RF, the remainder of the ablation procedure was aborted. At the completion of the case the sheaths were removed and sutured with 0-silk in a figure-8 pattern. ICE evaluation showed no evidence of pericardial effusion at the end of the case." Being that 93662 is an add-on code, and 93610 (for the RA pacing) isn't one of the reportable base codes for 93662, should unlisted code 93799 be reported?

The facility charged 36246 and 37224. Does this seem accurate? I was thinking about billing only for the lower extremity angiography. The only vascular catherization documented is “Access – Right fermoral artery”, followed by documentation of fluoroscopy time for and the reported findings of the angiography of both lower extremities, and the following documentation: "Additional Peripheral Intervention Comments: Unsuccessful intervention to left distal SFA. 6 French sheath for up and over, heparin for anticoagulation. Attempted to cross the lesion with Winn and Confianza wire. we went subintimal and then tried to re-enter with a Enteer device but were unsuccessful after several attempts. RECOMMENDATIONS: 1. Will reschedule for CTO intervention with possible pedal/popliteal access."

Would you code this as revision or what? "The 7 French sheath catheter pigtail was exchanged for an Xtra Sport wire over which a 7 mm x 16 mm Formula stent was placed and advanced to the mid TIPS. The pigtail through the 10 French sheath was exchanged for an Amplatz, and the sheath was advanced through the existing TIPS. A new 10 x 7 x 2 TIPS was deployed in line with the existing TIPS and postdilated with a 10 mm x 4 cm Dorado balloon. The 7 mm x 16 mm Formula stent was then deployed at the midportion of the TIPS and inflated to maximal pressure (12 atm; 7.27 mm). Post-constraint portal venogram demonstrated expected decreased flow through the TIPS with increased flow through intrahepatic portal vein branches. Post constraint portosystemic pressure gradient was 12 mmHg.  The catheters and sheath were removed and hemostasis was obtained with manual compression. TIPS device: Gore Viatorr TIPS type: Covered."

What guidance code is most appropriate to assign? Is code 76940 reported due to the documentation of US guidance used for probe placement and subsequent ultrasound monitoring of the ablation? Or is code 77013 reported, as CT was used to validate the trajectory of the probes and CT imaging was performed to complete the procedure? "PROCEDURE: Percutaneous microwave ablation of a right hepatic lobe lesion. The patient was prepped and draped in sterile fashion. Under real-time ultrasound guidance, microwave probes were inserted bracketing the lesion. Unenhanced CT confirmed parallel trajectory of the probes and approximate positioning by landmarks. Ablation was performed with real-time ultrasound monitoring. Then, the probes were retracted 2 cm each and additional ablation performed. Tract ablation was performed as the probes were removed. Finally, contrast enhanced CT of the abdomen targeted at the liver was performed in the arterial and portal venous phases. IMPRESSION: Successful CT and ultrasound-guided microwave ablation of the right hepatic lobe lesion."

A patient has a VDD pacemaker. It is my understanding that a VDD pacemaker has a single lead, which paces and senses in the RV but only senses in the RA. Although there is technically only one lead, a dual chamber generator is used for the VDD system. The patient is having his VDD lead extracted. Would this be coded with 33234 or 33235?

I just finished listening to your webcast of 2019 CPT code changes and wanted to ask you if you believe that the rules about 76937 being not reportable with heart catheterization and EP procedures extends to CPT 33340 as well?

Is it okay to bill wound vacs that are placed after an amputation is performed? For example, 28810 and 97605? NCCI states they are bundled, but I'm getting conflicting information that they are billable together.

What CPT code would you bill for a PICC removal under fluoroscopic guidance?

"Under direct ultrasound guidance, we gained access into the right internal jugular vein via the modified Seldinger approach. A 7 French short sheath was placed in that area. Through that sheath, a screw-in pacing lead was delivered into the right ventricular apical septum where the screw was deployed under radiographic visualization... The pacing wire was sutured in place at the surface of the skin. The wire was attached to an externalized generator and programmed... Consider placement of permanent pacing system pending response to therapy." Would this be billed with unlisted code 93799 or with code 33216 since it is temporarily permanent?

"Our physician performed a balloon angioplasty of a right-sided axillary-femoral artery bypass at both the proximal axillary and the distal profunda femoral ends of the bypass. Using an abdominal incision, we maneuvered to the proximal axillary end, performed angiogram and angioplasty, and then repeated the process at the distal profunda end." Is the selective catheter movement to the proximal axillary end of the bypass billable? We used two balloons to treat the stenosis at both ends of the graft; are both angioplasties billable?

I'm looking for clarification on the catheter placement for CNS embolization of right ICA. I understand a true diagnostic angio is separately billable, but somewhere along the line I thought that when there is no diagnostic angio that the catheter placement is separately billable with 32617 for the artery being embolized, so in this case 61624, 36217, 75894, 75898. Is that correct, or is the catheter placement inclusive?

I have seen several posts regarding the use of code 36833 when an open thrombectomy is performed along with a PTA of the peripheral segment. In one answer the CPT book was referenced. The only thing I can find is that they are saying the percutaneous interventions are bundled with the open interventions. Where can I find the instruction to use 36833 when an open thrombectomy is performed, along with a PTA or stent placement?

A patient was scheduled for an open aortic valve replacement, but once surgeon did sternotomy, opening the sternum and pericardium, it was decided not to proceed after evaluation of the ascending aorta. The physician made the decision the patient would need to return at a later date for a percutaneous procedure and the patient was closed up. I am wondering if the physician evaluating the aorta would be considered "exploratory" in order to code the 39010? If not, would the better option be code 21750, even though it only states closure of sternum? One coder suggested to code the planned procedure (33405) with modifier -53, but I don't feel the physician attempted enough to code that, but of course please let me know what you think.

"After the left SFA access we performed a left leg angiography from sheath access site. We advanced catheter to abdominal aorta and performed aortoillac angiography with excellent result. We then crossed the aorto-illiac bifurcation and positioned a catheter in the right superficial femoral artery and performed right leg angiography." Should I be using code 75630 or codes 75625 and 76716?

I need clarification regarding when we can charge code 76937 with AV fistula intervention. In question is the term "failing". Would any intervention on the fistula imply that it is failing, or do we need documentation that states the fistula is "failing"?

Not sure what CPT to use for the following procedure. "Cryoablation of periaortic nodal mass for metastatic adenopathy. Procedure: 14 gauge cryoablation needles were advanced into the left periaortic mass. The mass now measures 4 cm AP by 4.1 cm transverse by approximately 5 cm cephalocaudal. The needles were placed within the same oblique plane with T1 needle approximately 17 mm below the other. This provides adequate coverage from the top of the lesion to the caudal margin. Following confirmation of good needle position, 2 cycles of cryoablation were carried out for 10 minutes. CT imaging was used to confirm good location of ablation zone."

An injection of Amphotericin B is performed with a Yueh cath/needle into right upper lobe aspergilloma with CT guidance. I'm considering 32999 vs. 32561 vs. 20500. I'm leaning towards 32999, but I would appreciate your expert opinion.

Patient has atherectomy performed of mid SFA to distal popliteal artery, then drug-coated balloon angioplasty of same vessels. Do you report two codes for atherectomy (one for each vessel), and do you also add the angioplasty with drug-coated balloon as additional code(s) (one per each vessel)?

We have neuro IR doctors who are treating pseudotumor cerebri by placing a stent in the venous sinus. The question is regarding coding the venous and IVUS portion of the exam. We would appreciate your input. For cerebral venous imaging: RT/LT jugular, RT/LT sigmoid sinuses, RT/LT transverse sinuses (from a femoral access): 36012 x 2, 75860 x 2 for jugular veins. When the catheter is advanced, is additional cath/imaging billable for the sigmoid or transverse sinuses? Is there a different access code when a transtorcular approach is used? (Ex. LT IJV via right-side transtorcular approach) IVUS: RT/LT jugular, RT/LT sigmoid, transverse/sigmoid junction, RT/LT transverse sinuses 37252, 37253? Code additional 37253?

Is it appropriate for hospitals to report code C8937 with codes 77046/77047 when breast MRI is done with CAD? Are codes 77048/77049 meant for professional use only? 

This patient had a PVI ablation for A-fib. After the ablation, the physician documented, "Despite multiple DCCV, AF persisted during ablation. Ibutilide infusion was given and rhythm converted to sinus." Can we report code 93623 for this?

I wanted your opinion on diagnosis coding for rule out when a diagnostic study is ordered to rule out a-fib or cardioembolic source for a stroke. Would you suggest screening for cardiovascular disease Z13.6 or use the stroke as the primary diagnosis along with any findings?

Provider takes patient into IR for diagnostic angiogram and per the results decides in the same session to do embolization for occlusion in the left posterior artery. What would be the accurate codes? My train of thought is that angiogram codes would be bilateral CCA 36223, bilateral VA 36226-50, and left posterior 36228-LT. The embolization would supersede the 36228-LT and 36226-LT, so codes would be embolization left posterior 61626; catheter placement 36217, 36223-50, and 36226-RT; and 75898-26, 75894-26. I was informed not to bill out 36217 and to bill 36228. Please advise.

Is it appropriate to bill for a pharmacological cardioversion? "Patient has a history of PAF with episode of SVT. Performed as outpatient in hospital setting. The patient had pads placed in the anterior and posterior positions. Patient had a good 18-gauge IV placed in the left antecubital. He was given 6 mg of adenosine IV. His baseline rhythm was junctional tachycardia with rate of approximately 106 bpm. He responded appropriately to the dose of adenosine but went right back into junctional tachycardia. He was given a 12 mg dose in the usual fashion but again went back into junctional tachycardia. I then gave him 5 mg of intravenous Lopressor, and he slowed down and then converted back in sinus rhythm with frequent PACs after that. He tolerated the procedure well." The physician planned for the patient to receive the "chemical" cardioversion. 

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 (HCPCS C1884). 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.

Our physician used a stent to cover a pseudoaneurysm in the common femoral artery. From a previous publication, I see that without the use of coils, a stent should be coded as a stent, which is now 37236. However, per our LCD in the Dallas, TX, area, Medicare will not pay 37236 + I72.4. However they will cover the 37226 with I72.4. Therefore, should I go ahead and code the stent placement with the 37226 code?

"INDICATION FOR THE PROCEDURE: History of coronary artery disease. Status post coronary artery bypass graft. Severe prosthetic aortic valve stenosis. The patient being evaluated for valve-in-valve TAVR. DESCRIPTION OF PROCEDURE: Patient was consented. Right groin was locally anesthetized. The patient was prepped and draped in the usual sterile fashion. A 6 French sheath was introduced into RFA. Thereafter, left internal mammary selective angiogram was undertaken using a LIMA 6 French diagnostic catheter. Left internal mammary artery graft to the LAD is patent. Distal LAD is patent with competitive flow. Right groin was closed with an Angio-Seal closure device." Question: How would you code this IMA angio alone without heart cath?

The physician did not do a cath but performed angiogram of ascending aorta, selective angiogram of central shunt, and selective angiogram of LPA. Then physician performed angioplasty of the central shunt and angioplasty of the RPA. What CPT codes would I use here? I know the 92997 for RPA, but unsure about the rest.