Ask Dr. Z

I’m new to vascular coding. I need help with CPT code for left common carotid exploration with primary repair (35301 vs. 35701). "Neck was prepped. Physician made incision as followed the sheath down through the sternocleidomastoid divided by bovie technique. Vein was transected then suture-ligated with problem suture. Common carotid was identified and sheath entering through it was exposed. A pursestring suture was placed. The sheath was removed. Prolene was tied successfully, closing the arteriotomy."

Patient with TOF and pulmonary atresia s/p BT shunt comes in for evaluation of shunt and pulmonary arteries as well as embolization of collaterals. The embolizations are straightforward, but it does not seem that there was any heart cath performed. No documentation of catheter placement in any heart chamber and no pressures recorded. The only reference is in the title of the report, which says, "Left heart catheterization." Catheter travel documented is from left femoral artery access to aorta, innominate, subclavian, BT shunt, and ultimately pulmonary arteries as well as collaterals branching from aorta. Since the coding is very dependent on whether or not a heart cath was performed, what would you recommend if it turns out that it was not performed?

What is the appropriate CPT code for a thoracic epidural steroid injection using a transpedicular approach?

We have a patient who presented for an ultrasound-guided breast biopsy. This was based on prior mammogram and ultrasound showing breast asymmetry. The prescan for the biopsy showed no discrete finding for biopsy. We would normally charge/code for the intended procedure and attach either -73 or -74 modifier; however, the physician then ordered additional mammographic images to further evaluate. Would you recommend charging for the US-guided breast biopsy with the -73 modifier based on the reason the patient presented and original order? Would you also charge the patient for the mammogram unilateral? Or would you only charge the patient for the complete unilateral mammogram?

What would the CPT code be for skin perfusion pressure testing? Report states "Skin perfusion pressure testing was performed of the left lateral foot to assess tissue perfusion at the location of the patient's wound. The contralateral right lateral foot was evaluated for comparison. Impression: Skin perfusion at the lateral plantar surface of the right foot is 75 mmHg, and at the lateral plantar surface of the left foot it is 67 mmHg. These values indicate adequate perfusion for healing." I have considered 93998, but since it wasn't a true vascular study I am wondering if a low level EM would be more appropriate?

Can an angiogram to access AV fistula with poss RLE covered stent or placement of coils be done in an office setting or hospital only?

What is the CPT code for embolization of the lingual artery and the facial artery?

I was wondering if we can charge fluoro guidance 77003 with 64999 for the following procedure. "Image Guidance: Fluoroscopy. Following needle placement at midline, placed through the coccygeal ligament andadvanced into the presacral space; contrast dye 1 cc injected here spreads B, to retroperitoneal structures without vascular uptake. Images saved."

For facility charging is the Mynx device separately billable in addition to the procedure?

"Using fluoroscopic guidance, a 25 gauge needle was advanced to the location where the gluteus medius and minimus tendons attach to the greater trochanter. A small amount of contrast was injected to confirm position of the needle tip. Subsequently, a mixture of Depo-Medrol 80 mg and lidocaine was injected at each site." Is this a hip joint injection?

If patient comes in with atrial tachycardia, atrial flutter, and atrial fibrillation, and all three mechanisms were ablated, what determines which should be the primary CPT code? Supraventricular tachycardia ablation (Atrial tachycardia), Atrial Fibrillation Ablation (pulmonary vein isolation), Additional ablation of discrete arrhythmia (atrial flutter ablation), Electrophysiology Study, Electroanatomical 3D mapping, CS/LA pace and record, intracardiac echo, transseptal left heart catheterization, programmed stimulation after IV drug infusion.

What CPT code(s) would be best for a left femoral vein to right femoral vein PTFE crossover bypass graft with construction of left SFA to saphenous branch AV fistula?

Would we use unlisted code 33999 for subclavian TAVR? And since percutaneous would you use the comp code of 33361, or use 33363 as comp code? Patient underwent successful transcatheter aortic valve replacement via left subclavian approach (percutaneous).

Is it appropriate to report codes  93286/93287 (peri-procedural device evaluation pre/post procedure for pacemaker/ICD) with VT (93654) or PVI (93656) ablations? I just noticed a parenthetical statement in CPT that states do not report in conjunction with each other. I was not aware of this and wanted to get your opinion.

What do you charge for MRI/MRA of the brachial plexus?

After left ACA aneurysm was embolized with Woven Endobridge device, clot was found at left ICA on subsequent angiogram. Thrombectomy was done with Soliaire. Can I code 61624 and 61645 together?

Regarding vasospasm during intracerebral intervention, does the provider have to mention that it's not "iatrogenically-induced vasospasm" in order to bill codes 61624 and 61650? "Case background: Ruptured right posterior inferior cerebellar artery. Under roadmapping technique, catheter was advanced over 5 French inner and Bentson guidewire into the right VA. The inner catheter and guidewire were removed and the guide catheter double-flushed with heparinized saline solution and connected to continuous heparinized saline flush. 3 mg of verapamil was slowly infused for ten mins into the right VA for treatment of vasospasm. Endovascular coil embolization of right posterior inferior cerebellar artery aneurysm was then performed." The vasospasm part is where I'm confused to code or not (didn't hit NCCI edits). Is it normal to have vasospasm before any intervention done? Or everytime there's vasospam prior to intervention we can't code the vasospasm? What if the intervention is on left ICA and the vasospasm treated is on left VA... can I code it in this scenario?

Patient has an infected AVG. This required a partial explantation of the medial limb of the graft. Are we allowed to bill 35903 with or without a modifier for the first partial removal since the entire graft was not removed? The patient returned two weeks later, and the remainder of the AVG was removed.

Our surgery coders are instructed to use the chest x-ray report to confirm the final catheter tip location when it's not documented in the op report. Is this enough documentation to support code 36556 as it pertains to the final tip position? Or do we still need our surgeons to document that they actually reviewed the x-ray report themselves to confirm that the tip is in the correct central vasculature in order to report 36556 per CPT guidelines? Your previous response talks about documentation requirements for billing the imaging guidance and PICC lines, which is not what we're asking here.

I believe this is not separately reportable for both provider and facility but I wanted to confirm. Patient with a low left lower lobe lung nodule presents for a CT-guided biopsy. The left phrenic nerve block to be performed immediately prior to the biopsy to decrease diaphragm motion.

What is the difference between codes 33863 and 33864? From what I understand they both replace the aortic root and both replace the proximal ascending aorta with a tube graft. Both require the coronary arteries to be connected to graft.

Not sure how to code this: 35226 & 35860? "Evidence of infected stents. Pt opened and after dissection and lysis of adhesions Vascular clamps were placed in the proximal external iliac artery just distal to the origin of the internal iliac artery. The external iliac artery was transected at this level. The proximal end of the patent external iliac artery was then oversewn with suture in initial horizontal mattress fashion & subsequently the artery was folded over onto itself & secured with a running suture. This gave excellent hemostasis to the proximal end of the external iliac artery. Likewise, the distal external iliac artery was clamped & transected. The distal end was also oversewn with suture in a horizontal mattress & then folded over onto itself & secured for complete hemostasis. The intervening segment of the external iliac artery was then opened longitudinally to a very large phlegmon & thickened eschar tissue. Both of the intervening infected external iliac stents were removed."

DEXA BONE MINERAL DENSITY WHOLE BODY COMPOSITION. 32-year-old male. The calculated total body bone mineral density is 1.244 gm/cm2. The calculated percent fat is 15.1%. Please let us know how we can code it.

Would this be coded with 47490-52? "Injection into the biliary catheter was done for a cholangiogram. Then over a guidewire the internal/external biliary catheter was converted to a cholecystostomy tube under fluoroscopy. F/U cholangiogram was performed."

Need help with this portion of case, wondering what your suggestions would be? "Upon arrival to the Cath Lab, the patient was noted to have very low flows on the ECMO circuit. Despite aggressive volume resuscitation and vasopressor administration, the patient remained in refractory shock. Her abdomen was distended upon arrival to the Cath Lab and this progressed throughout the case. Aspiration of the left arterial sheath demonstrated that the blood return appeared very dilated, and we fear that the patient had suffered a severe bleeding event. We really turned our attention to interrogation of the ECMO cannulae. A rim catheter was used to selectively engage the right iliofemoral anatomy and an angiogram was performed which demonstrated a well-placed and positioned arterial ECMO cannula. Using the modified Seldinger technique, a 6 French sheath was then placed in the left common femoral vein alongside the venous ECMO cannula. A venogram was performed which showed contrast extravasation outside of the vascular space at the level of the cavoatrial junction."

Please advise on how to code a Dobbhoff advancement. "Contrast material was instilled through the existing Dobbhoff tube. The existing Dobbhoff tube is in position within the distal duodenum. The tube is then advanced (under fluoro) to the distal second portion of the duodenum, but fails to advance any further distally." Can I code for a reposition, or should I just code the fluoro?

How do you code the catheterization on this case? "Left radial access was obtained. The left anterior division of internal iliac was catheterized. Multiple attempts were made to gain access to left prostatic artery including Sniper microcatheter and Fathom microwire; however, the left prostatic artery was not cannulated or embolized at this time. Subsequently the right anterior division of internal iliac was cannulated. The prostatic artery was subselectively cannulated. The balloon on the Sniper microcatheter was inflated, and embolization of the right prostatic artery was performed to stasis with 300-500 micron embolic microparticles." Will this case be reported with codes 36247 and 36248? Or 36246 and 36247?

Per Ask Dr. Z #7655, US guidance for paracentesis & thoracentesis, there is no requirement that the doctor state that imaging was performed of the needle entering the fluid collection. But your IR book, pages 517-519, #8 advises that imaging modality is used to guide placement of needle/cath into area to be drained, must be performed in tandem with the drainage procedure. Please clarify, which is correct? Also, would a statement of "US: Yes" in a paracentesis report support a paracentesis with US guidance?

Our provider contacted the SCAI, The Society for Cardiovascular Angiography and Interventions, to dispute our recommendation that CPT 76937 is NOT billable with any cardiac (congenital or non-congenital) cath or ep procedures per ZHealth recommendations. The SCAI stated, "There is nothing preventing billing congenital cath w/ 76937 and the RUC database description of work does not address any issue with using this code for vascular access during a cardiac cath. All of the CPT guidelines clearly state the catheterization codes ARE NOT excluded. The congenital cardiac cath codes 93530-93533 DO NOT include imaging guidance for vascular access in the DOW(?) and are therefore allowed." With this information and explaining the NCCI Policy Manual instructions, how do I further justify, not billing CPT 76937 with cath/ep procedures if the provider documents properly?

How would this be coded? "Lower extremity vein mapping shows the thigh veins, the greater saphenous to be of good quality on the right leg down to just below the knee where the minimum diameter is 2.8 mm. In the calf, it falls to 2.8 to 2.4 mm. On the left side, diameter is good to the distal thigh and then at the knee, it drops to 2.3 mm and is as low as 1.9 mm in the calf. IMPRESSION: This study shows adequate diameter of greater saphenous veins in the thighs with the right proximal calf saphenous vein usable as well."

Three vessels for access, then: "The AngioVac device was prepared and advanced through the dry seal sheath into the upper IVC. The device was cycled. Under direct ultrasound guidance, numerous passes through the right atrium were performed to engage the clot. These attempts were ultimately unsuccessful. The AngioVac device was removed." What's the code going to be when it's not a coronary artery?

What CPT code should be reported for a balloon redilation of a previously placed stent for aortic coarctation? The patient is a 13-year-old who has had multiple procedures for aortic coarctation, including most recently a P3110 stent placed four years prior. The procedures documented on this visit included R/L heart cath, ascending aorta angio, descending aorta angio, RV angio, pulmonary artery angio, and balloon dilation of the existing stent. (The coarctation stent was redilated first with a 15 mm ZMED balloon and then with a 16 mm ATLAS balloon, inflated to 10 atmospheres.) Is there a specific CPT code for the balloon redilation of the stent, or would this be an unspecified code?

We billed out 93287 on a UB and we are receiving an edit stating: "This claim has only incidental services reported. Per the CMS Addendum B table, the HCPCS codes present are either a Status Indicator N or other non-payable Status Indicators. Claim must contain at least one payable HCPCS." This is the only charge on the claim and the first time we have ever received this edit.

The physician is using a Gore Excluder endograft and lists a 14 mm x 7 cm bridge on right along with a contralateral limb on the right. Would the bridge be included with the Gore endograft or some type of an extender?

Please advise if I am able to bill for removal of suture material for this case: "TECHNIQUE: Suture material noted in the lateral aspect of the port incision site acting as nidus of infection. Region of redness/cellulitis was centered at the site of the suture, with the medial aspect of the incision appearing well-healed and without evidence of infection. The decision was made not to remove the port given there was no evidence that the port itself was infected including no fevers, elevated WBC count, or positive blood cultures, but to remove the suture material causing the infection and continue antibiotics to treat the cellulitis. The chest was prepped and draped in sterile fashion. The indwelling suture material was removed, and a sterile dressing was applied. IMPRESSION: Successful removal of suture material from the lateral aspect of the port incision site. This is likely acting as a nidus for cellulitis, and the cellulitis is expected to clear with a continued use of antibiotics."

How do you bill IVUS with left heart catherization, and what are the CPT codes?

This is a profee coding question in a teaching facility setting. Physician A (general surgeon) places a CVC at bedside without imaging guidance. We assume that the tip cannot be confirmed at bedside because the final position is not documented, although CXR is ordered by Physician A. Physician B (radiologist) then reads the CXR and confirms that the tip is in the correct central vasculature. Is this enough documentation to support 36556 (the op note without tip confirmation and CXR confirming tip position, that is)? Or do we still need Physician A to document that he/she reviewed the CXR to confirm final placement in order to report cpt 36556 in full (without modifier 52)?

"Patient with a history of pulmonary stenosis, prior balloon valvuloplasty x2, and failed transcatheter valve placement. PROCEDURES: 1) RHC. 2) Angiography: RVOT and branch pulmonary arteries. 3) Hybrid, transapical, transcatheter pulmonary valve replacement. Subxiphoid midline incision performed, exposing the RV apex, pursestring suture placed. 18 gauge needle advanced through the suture and through the RV free wall into the RV cavity. Guidewire positioned in the ventricle and needle exchanged for a short sheath. Positioned a guidewire in the distal LPA. Transaortic Edwards delivery sheath positioned in mid RV. Sizing balloon used and then an S3 valve advanced over the guidewire and through the sheath and across the RVOT. Valve deployed. The guidewire and sheath were removed and the pursestring suture tightened, repairing the RV free wall access site. A mediastinal drain was placed." Should we use 33477 or 93799 because of the hybrid transapical approach? Any other recommendations?

I have a procedure where patient has 80% stenosis just at the origin of an aorto-bi-fem bypass. The stents are placed half in the aorta and half in the aorto-bi-femoral graft. I am not sure what CPT codes to report for this procedure.

We have a new general cardiologist who will be sitting for his Nuclear Medicine Certification within the next month. He has started reading nuclear scans and is having them over read by one of our certified cardiologists. Can this be billed under the general cardiologist, or would it need to be billed under the Nuclear Certified providing the over read? Does the documentation need to include information about both providers?

For hospital billing, does revenue code 278 require a HCPCS for each line item? Or is it okay to bill an implant under revenue code 278 without a HCPCS?

Patient has ICA occlusion. It was treated with thrombectomy and angioplasty of cervical portion of the same vessel. Distal embolic protection was used for angioplasty. Can we code both procedures, or only thrombectomy?

If a patient has biopsies done on multiple breast lesions via the same puncture site, would this be one code, or would we be able to use the add-on codes for the additional lesions?

If a provider does the near infrared fluorescent cholangiography with cholecystectomy can you bill 47563? My thought is no because the radiologist is only injecting the dye. Your thoughts?

I am seeing two opinions how to bill for Spinraza injection. First way is to bill as 62323 (injection of diagnostic or therapeutic substance) vs. billing as 96450 (chemo administration into CNS, includes lumbar puncture). I understand 96450 includes the lumbar puncture, but if billed as 62323 can the LP be bill separately?

In your opinion, is this op note complete and acceptable? It appears to be truncated, and we are seeking your advice on how to educate the physician to improve his documentation that he states is complete. "OPERATIVE PROCEDURE: AV node ablation. PREOPERATIVE DIAGNOSIS: Atrial fibrillation, which is difficult to rate control. INDICATION FOR PROCEDURE: Briefly, the patient is a pleasant 66-year-old gentleman with persistent atrial fibrillation, which is difficult to rate control. The patient is undergoing AV node ablation along with pacemaker placement. PROCEDURAL DETAILS: After informed consent obtained, the patient was sedated and the right groin was prepped and draped in the usual fashion. An 8 French sheath was put in the right femoral vein, 8 French sheath was upgraded to a long Agilis sheath, and ThermoCool catheter was placed by this sheath into the AV node location. AV node ablation was performed at 35 w. Successful AV node ablation noted presence of paced beats. After ten minutes of observation, the AV node did not recover, so sheaths and caths were pulled. Successful ABL."

What code would I use for a VATS procedure with a mini thoracotomy? "A thoracoscopic port was placed in the eighth intercostal space in the anterior axillary line. Initial surveillance was made and extensive adhesions noted. An additional port was placed in the fifth intercostal space in the anterior axillary line. The visualization was difficult given the adhesions. Therefore, this port site was enlarged to a mini thoracotomy in a muscle-sparing fashion. Sufficient adhesions were taken down to the upper lobe and some to the lower lobe leaving the lungs at the diaphragmatic level untouched. This allowed sufficient mobilization to realize that the fissure was totally incomplete except for a rudimentary line on the surface of the lung. The mass was palpable and was spanning the fissure. It was resected as a wedge specimen using an Echelon flex 45-mm stapler with thick tissue loads. Mediastinal lymph nodes were harvested from paraaortic position as well as levels 2 and 4. There were no hilar or subcarinal lymph nodes encountered. ProGEL was applied."

Would a failed attempt at treating an acute MI require a -53 modifier on 92941? There was no stent placed, and the angioplasty failed to restore flow.

What procedures must be done to support 93620? "Ex: The patient was brought to the electrophysiology lab in the fasting state. The patient was then prepped and draped in sterile fashion. 1% local lidocaine was infiltrated into the subcutaneous tissues in the right inguinal crease overlying the right femoral vein. Venous access was then obtained using modified Seldinger technique, on the right, with placement of a 4 French sheath. A quadripolar catheter was inserted via the 5 French sheath and positioned in the RV apex. A EP study was performed with attempted arrhythmia induction. Programmed electrical stimulation was delivered from the right ventricle with up to quadruple extra stimuli from the RV apex only. Also ventricular burst pacing was performed. No sustained ventricular tachycardia was induced." Should this be coded as 93603 and 93612, or is there enough to support 93620?

Our doctor performed the stereotactic core needle biopsy of anterior left breast cluster of calcification at 1 o'clock and on posterior left breast cluster of calcification at 1 o'clock. We would bill 19081 and 19082, or just 19081?