Ask Dr. Z

Sx background: Patient had mediatinoscopy with bx done and three days after developed bleeding from mediatinoscopy done three days before. The MD placed the patient on cardiopulmonary bypass through the left femoral artery and vein as well as venous catheter in the right atrium, median sternotomy, and mediastinal exploration. All of these were done to control of bleeding. On the same sx session he did 33025. Is 32110 the correct code for the control of bleeding? The provider is choosing the add-on code 33369 (no TAVR was done). The provider wants to bill the cardiopulmonary bypass as well with the control of bleeding. I can't find any code close to what he did (coronary bypass to control the bleeding).

A patient has a history of bleeding from the dialysis catheter insertion site. The doctor performs an assessment and finds no active bleeding. The doctor places gelfoam around the cath to prevent bleeding. No guidance was used. How should this be coded?

There is an NCCI edit on codes 37228 and 11043. What would be the rationale for billing both together? It is not clear to me why a debridement and a lower extremity intervention would be bundled. 

"An 8 x 39 mm VBX stent was advanced into the terminal aorta and deployed just above the bifurcation. This was post-dilated to 10 mm with a 10 x 40 mm Charger balloon. Next, bilateral kissing iliac stents were advanced through the sheath, 6 x 29 mm stents bilaterally. The stents were positioned just inside of the aortic stent and simultaneously deployed. These were slightly over-dilated. Retrograde injection through the sheath demonstrates wide patency of the aortic stent and bilateral common iliac stents." I coded 37221-50 for this case; is this correct? I did not report code 37236 for the aorta stent placement based on previous advice. Just want to make sure this is still your recommendation.

I'm unsure how to code the following scenario: "Rate of pericardial drainage noted to be minimal over last 48+ hours. Drain clamped for nearly 24 hours, and opened this morning with no significant output. Echocardiogram with small global pericardial effusion, with inability to express fluid via drain. Drain disconnected from pigtail catheter. Attempts made to unclog by flushing saline, which flushed easily, with inability to briskly garner return from pigtail catheter. On three occasions, attempts made to unclog catheter tip with 0.035" j-tip and then 0.035" striaght wire under sterile conditions, with no change in drainage. Total of approximately 10-12cc saline flushed in and not returned. Trace amount pink-tinged serous fluid returned with aspiration. New drainage bag hooked up and left to gravity. Patient tolerated exchange and attempts to unclog wire well."

I need your thoughts please. Patient has a thrombosed left fem-fem bypass. Surgeon knows this prior to surgery. He proceeds to perform a thrombectomy of the fem-fem bypass. Once this is completed, he notices significant irregularity just proximal to the distal anastomosis within the PTFE graft. He tried and could not get additional clot. He ends up ballooning and stenting this area due to residual stenosis. Because of inflow/outflow, I know I cannot bill for both the thrombectomy of the graft and the stent. Which one would you bill for? I chose the thrombectomy, 35875, over the stent, 37226. I interpreted the inflow/outflow to mean that once the surgeon performed the thrombectomy, any intervention performed to the artery above and/or below the graft (in this case the stent) would be content and not billable. Honestly, a person could talk themselves into billing either way. Can you explain how to interpret this so that I do not get confused in the future?

I'm trying to understand further the reply given to a scenario where two carotid stents are placed ipsilaterally. I have a case where a stent is placed on the left side both in the internal carotid and the common carotid. They are both placed from a femoral approach. To be honest, these codes are hard for me to understand. Would 37215-LT x 2 be appropriate? I thought only one stent per side was allowed. Why mention 37218?

A patient diagnosed with dilated cardiomyopathy (LVEF 45%), chronic atrial fibrillation with rapid ventricular rate paroxysmal AV block with 3 second pauses, and tachy-brady syndrome came in for a cardiac resynchronization therapy pacemaker implant, coronary sinus venography, cinefluoroscopy, and AV node ablation. My question is in regards to the pacemaker insertion. How would you code the below scenario: 33208, 33207, unlisted, or other? "An electrode was advanced to the right ventricular septum… The electrode was anchored to the underlying fascia with a single stitch of 0 silk over the collar. A 9.5 French peel-away sheath was placed in the central venous circulation utilizing the retained guide wire in the vein. The coronary sinus ostium was found to be occluded. A small middle cardiac venous branch was not able to be cannulated either. The patient was not a candidate for an epicardial LV lead, and it was opted to pursue cardiac resynchronization with two RV leads. The first lead was placed on the RV septum, and the second lead on the RV apex."

In question ID 8519 (answered in 2016) regarding a delayed extension of an intraperitoneal catheter extension, the example states that the exit site is the left upper quadrant, but the CPT description is for remote Chest exit site. I can't find any resource the clarifies the remote chest exit site can include an upper abominal quadrant. To be fair, our cases perform the extension at the time of initial placement (49324) but for future coding and auditing purposes, can you let us know where this clarification comes from and why we can code 49325 for an extension into the abdominal area?

If the doctor does an ax-fem graft with Propaten and then a fem-fem bypass graft with cadaver vein, would you combine these and bill 35654 since they are both non-vein? Or should an ax-bi-fem be made of one graft in order to bill 35654? I see no edits when billing it as two separate grafts (35621 and 35661), but it feels like it should be bundled to one code. 

The IR physician performed a bilateral mechanical thrombectomy in the lower lobe of the pulmonary arteries and also placed an IVC filter during the same encounter. Can we bill for the US guidance used for selectively catheterizing the pulmonary arteries, or would is this inherent to the IVC filter placement since it was performed at the same time?

"History: Patient with a previously created RT brachiocephalic AV fistula with severe stenosis that required an interposition graft who now suffers from elevated pressures during dialysis. Pre-op fistulogram showed widely patent SVC, IJ, and cephalic veins, but high grade occluded subclavian vein with the inability to be recanalized endovascularly. Operation: Incisions made and RT cephalic and IJ veins identified and dissected. Subcutaneous tunnel was created between the cephalic and IJ veins that an 8 mm ringed PTFE was brought thru. Venotomies made in both the cephalic and IJ veins and end-to-side anastomosis were created. There was no palpable thrill in the bypass graft or in the IJ vein. Retrograde fistulogram showed stenosis of the AV fistula. 5 French sheath was placed in the AV fistula, and the stenosis was angioplastied with a balloon with brisk thrill throughout the AV fistula." Are codes 36832 and 36902 correct? Or should it be an unlisted CPT code? If unlisted, what CPT codes are comparable to this procedure?

The provider performs an SFA to popliteal bypass. Via the same incision they perform a thrombectomy of SFA, profunda femoral, and external iliac arteries. They are billing 35656 and 34201-59, stating that the thrombectomy can be billed because they took place outside of the inflow/outflow of the graft. Is that correct? Would external iliac not be included in the inflow/outflow?

Physician attempted AV fistula revision (36833). He was unable to complete due to significant stricture. He did perform several embolectomy catheter sweeps to remove significant thrombus. He then created a new AV fistula (36830). Can we bill for 36833 with a -53 modifier and 36830?

Is there a code for pressure measurements of the celiac artery obtained during an angiography? "Pressure measurements in the celiac artery showed pressure of 107/62 mmHg with a mean pressure of 81 compared to a pressure of 170-70 mmHg with a mean pressure of 103 in the aorta."

Would it be appropriate to bill multiple endarterectomies in this case through one incision? "Anterior common femoral arteriotomy was made and carried proximally. Endarterectomy with freer elevator of common femoral artery was performed with patch angioplasy. Profunda did not back bleed. Profunda was opened and endarterectomy performed of anterior branch into ostium of posterior branch with patch angioplasty. SFA was explored in the first portion. Foreign body Angioseal was removed from SFA. Endarterectomy of first portion of SFA with patch angioplasty was done on SFA as well." Could we code 35302, 35372, 35371 with separate arteriotomies and patch angioplasties? Would foreign body removal be bundled into the endarterectomies?

A patient with an AV graft undergoes open thrombectomy of the graft, along with balloon angioplasty and stenting of the axillary vein. Selective cath and thrombectomy of the radial artery are also performed as follows: "....Fistulogram was performed, which showed evidence of persistent thrombus in the proximal AV graft. There was also evidence of thrombus at the origin of the radial and interosseous arteries. Wire was then directed in the radial artery under fluoro guidance. A Fogarty balloon was then passed into the proximal radial artery, and a thrombectomy was performed until all clot was evacuated. A completion angiogram was performed of the left forearm and hand that showed no residual thrombus and improved flow through the radial, interosseous, and ulnar arteries." We have 36833 for the open thrombectomy with axillary angioplasty and stenting. Is the radial artery thrombectomy to be reported with 34111? 37186 and 36215? Would we also need code 75710?

When coding a diagnostic test, such as an echocardiogram, and the patient has mitral, tricuspid, and aortic insufficiency, we are to use the combination code I08.3. However, what code should we use when a patient has all of the above PLUS pulmonary insufficiency? Since pulmonary insufficiency defaults to nonrheumatic, we would ordinarily choose I37.1, but the "excludes" note under the I08 codes tells us we cannot code both an I08 code with an I37 code. What would be the proper code(s) to use if all four valves are involved?

I have a two-part question regarding the use of the -25 or -57 modifier. We have cardiologists, interventional cardiologists, and electrophysiologists in our group. It is not uncommon for a patient to have an appointment with one of the cardiologists, and end up getting scheduled for a procedure by either the IC or EP doctors. Typically, the cardiologist and the IC or EP physician will discuss the case, and then schedule the patient for the procedure, without a separate appointment with the IC or EP. Question 1: If the procedure is planned, can the IC or EP bill for a visit on the date of the procedure/surgery? Technically, this will be the first time the patient is seen and examined by the IC or EP, and the final decision to proceed with surgery is made. Question 2: If so, can they bill a consultation (non-Medicare), or are they required to bill as the admitting/attending provider?

Code 75574 is for CTA of heart with coronary arteries; however, we have a physician who is documenting that the coronary arteries are "not well visualized, please refer to coronary angiogram," or only stating to "refer to a coronary angiogram for exam of coronary arteries." Would we use 75574 in this case, or is it more appropriate to use code 75572, which is a CT scan with contrast, not CTA code? The radiologist is coding 74174 for their portion of exam. 

Regarding the previous Q&As about billing open thrombectomy with open angioplasty or open stent placement, the advice was to bill 36833 for revision. We have been using 36833 instead of 36831 for open thrombectomy with open stent or angioplasty in the dialysis circuit. We have received several denials from Humana and Healthsprings after they have requested and reviewed the procedure notes. They are stating that all angioplasty and or stent placement in the dialysis circuit is bundled and we are billing 36833 in error. The only guideline we can find in CPT states open dialysis circuit creation, revision, and or thrombectomy (36818-36833) bundles peripheral segment angioplasty and or stent placement (36901 36902 36903) However dialysis circuit central segment angioplasty or stent placement may be reported separately (36907 36908). Is there any CPT guidelines or any other references that we can use for the appeals to show that we are correct in using 36833 for open thrombectomy with open stent or open angioplasty in the dialysis circuit? 

Patient has a brachiocephalic AVF with a pseudoaneurysm and infected stent. The pseudoaneurysm is opened, hematoma expressed, and sac debrided. The remaining cuff of vein is ligated. Another incision is made, and cephalic vein/stent is freed up proximally and distally and removed in entirety. Would this be a revision of an AVF since it all occurs in the AVF? How would I code for the excision of the stent/cephalic vein in the AVF?

If the native RC is stented with a drug-eluting stent, and the right PDA is angioplastied via the graft, would we be at C9600-RC and 92938-RC? Or is C9600 not a primary code for 92938 (and we need to use 92937 instead)?

The patient came in for removal of a malfunctioning peritoneal dialysis catheter and creation of a fistula. The catheter was removed. Then creation of a fistula was attempted. From the op report: "We made a transverse incision over the antecubital fossa and dissected down. The cephalic vein was dissected free and ligated at the perforators. Attempts to flush the vein noted is to be under high pressure. I passed a vessel dilator without success and attempted to pass a 4 mm balloon which caused injury to the vein requiring ligation. We attempted to dilate the vein towards the wrist without success. At this point there was no possibility of fistula and the wound was closed with a 3-0 and then 4-0 Monocryl. We will need to reassess his venous system and possibly perform an upper arm graft. I need to discuss this with the patient prior to proceeding." How should the attempted fistula be coded?

Doctor performed mechanical thrombectomy and angioplasty of left subclavian and axillary veins. I asked if this was one long lesion of the subclavian/axillary OR was it separate lesions in both vessels. He responded it was one long lesion. I billed only 37248 because it was one lesion crossing two vessels. "A 14 x 40 balloon was inflated in the subclavian, deflated, and pulled back into axillary vein." Should I have billed 37249 also?

How do we handle a case where a CT lung biopsy was ordered, but during the CT localization process the lesion is no longer present. We have been charging for 76380, but this requires a -QQ modifier in order to be paid by CMS. The decision to do the CT limited was not decided until the exam was done, so how do we bill this out? Should we bill 77012 and 32405 (-73 vs. -74 depending before or after sedation was given)?

Would it be appropriate to bill 37242 for placement of a microvascular plug in bilateral branch PAs for flow restriction in a patient with cardiac history significant for small left-sided structures and hypoplastic aortic arch? Basically, achieving the same effect as pulmonary banding.

What would be an appropriate code for TEVAR with use of Knickerbocker technique?

If the documentation for the pro-fee report does not state the joules used but only indicates pre/post diagnosis, post condition stable in sinus rhythm, and an Impression that states "successful direct current cardioversion," would that be enough information to support the code? 

What code(s) would you suggest for a failed intraperitoneal port evaluation using dye and fluoroscopy?

I work for a group of vascular surgeons who have started using AmnioFix bio-cellular matrix. This is how it is documented in the report: "The AmnioFix was then injected into the subcutaneous tissues along the length of the incision." Is this something they can be paid for, or would it bundle with the procedure? What code would you recommend?

I work for a children's hospital, and there is some confusion about when to bill a pelvic x-ray vs. a hip x-ray. Here is an example of one I see all the time. "Examination: XR Pelvis 1 - 2 views. Imaging Technique: 2 views of the hip/pelvis are submitted. Findings: The bony mineralization is normal. The joint spaces are symetric. The acetabula appears normally formed. Hips are normally located. No fracture or intrinsic bone lesion is seen. The visualized soft tissues are normal." Should this be billed as a pelvis or a hip x-ray?

I have a laparoscopic repair of a traumatic diaphragmatic hernia. "The omentum involved was retracted back into the peritoneal cavity and hernia sack dissected and removed. Sutures were used to close the defect." Entire procedure was laparoscopic. Should this be coded as 43281 or unlisted 49659? Hernia was not para esophageal.

Can we bill for the brachial artery exposure? What is the code? "Brachial artery was identified, dissected free, and then controlled proximally and distally with vessel loops. The artery was then accessed using micropuncture kit, which was subsequently upsized over the wire to a 5 French sheath. Then an Omniflush cath and guidewire were used to enter into the subclavian artery and down to the descending thoracic aorta. A Benson wire and a 90 cm 6 French sheath were then advanced over the wire and positioned just into the right limb of a previous aorto-bi-femoral bypass. Of note, the original bypass did have separate limbs that went to the external iliacs as well as right internal iliac artery aneurysm sac and into its main branch. I advanced 4 French catheter through the primary aneurysm sac and into this first branch vessel. I then advanced Lantern cath for coil deployment into the main branch, and I began to deploy coils up to the point that there were multiple branching points, which would also be occluded. I then packed the main aneurysm sac with multiple coils. Deployment of eight separate coils, which consisted of packing and POD coils."

Can I submit 93621 with following report? "Under ultrasound guidance, the right femoral vein was cannulated with an 8 French sheath through which a 20-pole deflectable catheter was positioned in the right atrium and coronary sinus, a 6 French sheath through which a quadripolar catheter was positioned at the His bundle, and another 8 French sheath through which the ablation catheter was placed in the RV apex. A left heart transseptal puncture was performed in standard fashion utilizing intracardiac echo, fluoroscopic guidance, and hemodynamic monitoring. Left atrial pressure was measured and was 5 mmHg. A Baylis radiofrequency needle was used for transseptal puncture utilizing RF energy of 10 Watts over 2 seconds. A heparin drip was administered through the transseptal sheath. Serial measurements were made to target an ACT at >300 seconds. Mapping was performed with the HD GRID and ablation Tacticath SE. 50 watts used targeting LSI 5.5-6."

I am billing for a physician who's doing a WaveLinq in the hospital. I am billing only his pro fee. I was told to use 37241, 36215, 76937, 75820, 36901, and 75710, but I remember reading an article from you that the physician should bill 37799. I could use some guidance here.

Our coders are struggling to agree on how to code this procedure. We cannot come to an agreement of the best suited codes to use. "Patient has left brachiocephalic fistula that has two aneurysms that developed two ulcerations. Physician performed incisions in vertical fashion, excising the aneurysm and excessive skin on two aneurysmatic area, one above the antecubital area and the other in the distal upper arm. Incision taken down to the dilated aneurysmatic vein. Vein entered, skin and ulcer were excised in both lesions. Aneurysmatic vein wall then excised so about 1 cm of conduit on each incision. Closed venotomies on each incision. Clamp released for flow thru fistula. Then punctured access in mid upper arm, placed sheath, obtained shuntogram which showed the cephalic arch had a stent and vein was present. Superior vena cava was patent but innominate vein 80% stenosed. Angioplasty performed; sheath removed site closed."

Should you report 93454 if there are only pressures taken of the aorta?

We have purchased an EOS imaging machine for our bone length studies (77073). With this new imaging system our ortho docs are wanting to bill left and right knee 73560, pelvis 73521, and left and right tib/fib 73590 in addtion to 76377 3D when performed. Total of 6 CPT codes. Does this sound okay as far as billing is concerned?

Can you please advise correct coding? 49400, 74190 and 49999? The patient reports the catheter has been functioning well up until last week, at which time there began difficulty at withdrawing fluid. He presents today to Interventional Radiology for evaluation and repositioning, if indicated. Under fluoroscopy, the catheter was seen to loop upon itself in the left lower quadrant, with its tip projecting over the sacrum. Contrast injection with the catheter in this position outlined bowel loops in the left lower abdomen, and although contrast could be freely injected, none was able to be aspirated. Following this, a 0.035 glide advantage guidewire was introduced through the catheter, exiting the catheter tip, and with gentle advancement of the guidewire, the catheter tip was able to be repositioned such that it eventually projected over the iliac crest. Additional contrast injections comfirmed proper tip location and function." Please advise best coding for this case.

We had our first RELIEVE HF study patient using the V-Wave Interatrial Shunt (for advanced HF patients with preserved or reduced left ventricular ejection fraction who remain symptomatic despite the use of guideline directed medical and device therapies). It involves an RHC, transseptal puncture, and placement of a left to right shunting system. I am thinking the creation is similar to a atrial septostomy 92992, and the device would be charged similar to a stent in the chamber, which would be 93799. I'm curious to hear your thoughts.

Can you assist with this difficult case? "We selectively engaged the RIMA, LIMA, lateral thoracic artery, bronchial arteries, and thyrocervical branches and performed selective angiography as well as vessel embolization in each of those vessels (to shut down collaterals)."

Per prior education on CPT code 33477, caths, fluoro, imaging guidance, etc. are included in this CPT code. This question is regarding “3D Rotational Angiography of the conduit/PA branches w/Rendering and Post Processing w/simultaneous RV pacing at 190 bpm.” Can 3D rotational angiography be billed with 33477? Can anything be billed for the RV pacing?

I'm looking to verify tube replacement codes. My understanding is that the initial placements of both PTEG and PTEJ tubes would be an unlisted code (43999), and tube checks would be coded 49465 (question ID #10351). What about tube changes? Can I code 49450 and 49451, or are these unlisted as well?

We are receiving denials for billing 36561 and 77001-26, 76937-26 together. I have not noticed this happening before; it seems to be recent. Our NCCI edit program is saying 77001, 76937 require a primary code, and it does not recognize 36561 as a primary code. Is this a correct denial? Did something recently change? I can't seem to find any recent information on it.

"The patient's right arm PICC was removed over a .018 wire. A new PICC was placed; however, it was not able to enter SVC. This was exchanged for a midline; however, there was no blood return. Subsequently the left arm was prepped, an image with ultrasound was obtained, and an attempt at PICC line insertion was unsuccessful. In turn a 3" midline was placed with good blood return." My question is, should we charge PICC exchange with a modifier (36584-52) or mIdline placement (36140)?

"Patient had carotid endarterectomy (35301) and three weeks later returned due to infection. Saphenous vein is harvested, neck opened, and Dacron patch removed. Area was washed, phlegmon was removed, and vein was sewed as patch angioplasty." How do we code this: as exploration for post of infection (35800) or as endarterectomy (35301)? Neither feels right to me.

Our coding department wants to use 50561 for this procedure. I'm questioning this since the procedure was not done through an endoscope. Can you please advise? "Contrast is injected via the existing nephrostomy tube. Via the nephrostomy tube, a 10 mm vertebral basket is advanced into the collecting system of the kidney. Manipulation of the basket was utilized to successfully catheter and removed a 6 mm x 5 mm urinary tract stone. Further injection of contrast via a 9 French sheath shows no further filling defects within the collecting system. Contrast is seen to pass into urinary bladder without obstruction. The sheath is removed and sterile dressing applied along with Steri-Strips."

I am reviewing a case where the physician needs to relocate the patient's pacemaker from the right to the left due to radiation treatment. In the process the physician removed the RV lead and inserted a new RV lead, but attached the lead to the existing generator. Is it appropriate to report 33222-XU for the generator relocation, with 33234 for lead extraction and 33216 for new lead insertion?

"The segment of reverse saphenous vein was anastomosed to the obtuse marginal #1 with a 7-0 Prolene suture in end-to-side fashion. This was followed by a side-to-side anastomosis to the ramus. The proximal anastomosis was created with a 6-0 Prolene suture in end-to-side fashion. There was only a short remaining segment of saphenous vein. A proximal end was anastomosed to the diagonal with a 7-0 Prolene suture in end-to-side fashion, and the distal end was sewn to the mid LAD with a 7-0 Prolene suture in end-to-side fashion. The left internal mammary artery was then anastomosed side-to-side to the saphenous vein and the diagonal anastomosis with a 7-0 Prolene suture in a side-to-side manner. There was no valve to consider in this segment. Finally an end-to-side anastomosis was performed between the left internal mammary artery and the distal LAD with a 7-0 Prolene suture in end-to-side fashion." Surgeon says she did a CABG x 5 (3 mammary to artery and 2 saphenous vein grafts, 33535 and 33518). Does the vein interposition affect these codes, and if so, how?