Ask Dr. Z

I'm hoping you can help clarify. My cardiologist is positive that we can bill for 3D ICE vs. 2D. I've told him that 93662 is not specific to 3D vs. 2D but he states the 3D is more expensive and time consuming, so we should be able to bill for it. He recommends using 93662-22 but I disagree. Is there a way to bill for 93662? Should we submit a CPT application for use of 3D?

Can we bill 93971 for upper extremity dialysis access mapping for Medicaid instead of using the G0365 vein mapping code? I am aware that we should use the G0365 for the initial mapping. Also, if a patient has an AVG or AVF creation and it has failed, can we bill the G0365 a second time for vein mapping?

Patient referred due to bouts of prolonged bleeding after dialysis. Would the most appropriate ICD-10-CM code be T82.838 for hemorrhage/bleeding or T82.898 for specified complication?

So many times we get post procedure chest x-rays and it is unclear as to why it was ordered. Therefore, we do not know if it a confirmation of PICC placement or CVC.... Our physicians do check placement usually with fluoro or spot imaging in the angio suite. This is noted in the procedure report. If a CXR is performed (for example) 30 minutes post procedure. It is not clear as to why it was ordered and it is ordered by a different treating physician. Can we bill it, or is that still considered inclusive of the PICC or CVC? Yes, the radiologist will notate the line placement because it is the elephant in the room so to speak.

We sometimes see documentation that reads that catheter was advanced into CS "for assessment of LA activation and LA pacing." Physician never mentions recording. Is this documentation enough to support 93621?

Can I code the aspiration of CSF fluid (62272/77003) and an unlisted code for fibrin glue patch? Or blood patch 62273? If unlisted code, would the unlisted code be spine procedure unlisted CPT 22899? "I used fluoroscopy to mark the puncture site for a dorsal approach through the left L5 laminectomy to the left L5 level epidural space. I advanced a 20 gauge Touhy needle to the left L5 epidural space, confirming correct position of the needle tip by contrast Isovue M 4 cc injection. I then aspirated 30 cc of blood tinged fluid. I injected 2 cc of Isovue-M contrast showing the needle still in the correct position and then I injected 20 cc of fibrin paste."

"A 2.2 cm CP covered stent mounted on a 16 mm x 2.5 cm BIB balloon was implanted in the proximal aspect of the RV to PA conduit (5ATM). After this stent was implanted, my doctor did balloon angioplasty again. The CP stent was future balloon dilated with a 16 mm x 2 mm Vida up to 14ATM." I know we cannot report balloon angioplasty before we implant the stent, but my doctor usually does balloon angioplasty again after he implants the stent. Should I report this balloon angioplasty (92997) ?

I was instructed to use CPT codes 20206, 76942 for the fat pad biopsy. This is a sample of the documentation from a radiology report we get: "An image was saved and sent to PACS. 2% lidocaine was used for anesthesia and a dermatotomy incision was made. Multiple fat globules were removed using forceps and placed in formalin and sent to surgical pathology for analysis." Could you please verify the correct coding for this procedure? 

Patient presents with biventricular ICD …. Due to her current condition(s), the physician decides to change to a biventricular pacemaker and uses the existing leads. When you gave an example in January 2018 transposing the type of generator change, your printout states to code the PM generator removal (33233) and the ICD generator attached to existing leads as 33240, 33320, or 33231, as appropriate. This would imply the opposite coding would be 33221 and 33241. Can you provide any insight?

"Diagnosis: Thrombosis common femoral artery and separate thrombosis of superficial femoral artery with dissection. Procedure performed: Thrombectomy of common femoral artery and endarterectomy of superficial femoral artery, which was oversewn with Prolene suture and encompassed the origin of the profundus femoris artery. Xenograft patch was performed in diamond-shaped fashion with running sutures." Would this be billed with 35302 (superficial femoral artery code) or another thromboenderectomy code, since this appears to encompass the profunda artery? And would you report code 34201 for thrombectomy of common femoral artery separately? (All performed from same incision.)

The patient had a biventricular ICD implanted, but prior to placement the physician did a RHC with O2 SATS because of class III CHF U stage III renal insufficiency to adequately manage pressors and diuretics perioperatively. Can we charge 93451 for the RHC?

Our provider performed aortic balloon valvuloplasty in conjunction with a co-surgeon. Codes billed are 92986-62 and 33210. How do we bill for this encounter since modifier -62 is not allowed on 92986?

"Prograde right and left heart cath was done. Diagnostic catheter was positioned in the RV apex, and a right ventriculogram was done. Using this image as a guide, 5 French JR 2.5 catheter was positioned in the right ventricular outflow tract and selective angiogram done here. 018 roadrunner wire was advanced through the catheter and across the pulmonary valve in the pulmonary artery. The 018 guidewire was advanced to the right lower lobe pulmonary artery and a 5 French sheath advanced over the guidewire, and the main pulmonary ateriogram was done. After careful assessment of the anatomy 12 mm long Palmaz blue stent pre-mounted on a 6 mm balloon was advanced over the guidewire into the sheath. The balloon was inflated across the pulmonary valve, and the stent was implanted extending from the RV outflow tract and across the pulmonary valve and into the main pulmonary artery." What code best describes placement of the stent? 33999 or 93799?

I know I will be using unlisted code 37799 for the AV fistula creation, but what embolization code if any would I code? Or should that be part of the unlisted code? Also do I bill separate for the catheter placements for the fistula creation or should that be part of the unlisted code? "A 5 French catheter was then introduced through the venous sheath and into the brachial vein. Transcatheter embolization of the brachial vein was performed with a single 8 mm coil in order to encourage fistula flow through the perforator vein and into the superficial access sites. Post embolization angiogram demonstrates successful embolization with diminished flow through the brachial vein."

Following cardiac ablation, programmed atrial stimulation is performed through the patient's existing ICD. No arrhythmias can be induced with programmed electrical stimulation performed at baseline. Is there any additional CPT code to report for this procedure?

With the middle meningeal artery on opposite sides of the head, are these two separate surgical areas? Is 61624, 61624-59 appropriate? We recently had the same procedure done bilateral for acute subarachnoid bleed.

What is the most appropriate CPT and diagnosis code for the following scenario? "Indications: Transfer patient from outside facility after a piece of wire broke off in the left femoral artery during cath lab procedure. Post-op diagnosis: Retained wire left common femoral artery Procedure: The patient was taken to the operating room where the left common femoral artery was explored through an extension of the previous surgical access site. The subcutaneous tissue appeared to have some hematoma formation. The section of the wire was identified and easily retrieved. A 5-0 Prolene repair the entry into the common femoral artery. There was no attempt at exploring the common femoral further. Furthermore, the arterial signals at the left ankle remained a hyperemic and biphasic in nature, indicating that there was no evidence of distal embolization. The wire was submitted for gross inspection. The subcutaneous tissue was closed with 3-0 Vicryl. The skin was brought together using 4-0 Monocryl. Blood loss was less than 50 mL."

Are 75807/38790 considered base codes for 76377?

In 2018 there was an error regarding use of 34812 with 34710. Code 34710 was not listed as a parent code for 34812. Has this been corrected? What is the status of this now? The 2019 CPT Codebook still does not list 34812 as an add-on code for 34710.

Due to Palmetto & CMS retiring their LCD on 8-23-19, with no new guidance given currently, what is your stance on how this will be handled in the future due to new technology? I am specifically interested in it being done in conjunction with echocardiograms.

I have been advised that 93298 is only for professional charges for the remote ILR check. We did one at our hospital. The RN downloaded the electronic data, analyzed it, and created a report that the cardiologist reviewed and signed. Her work was the same as if the patient came in and had a face-to-face device check, except that the data was captured remotely and transmitted electronically. Can I charge 93298 perhaps with a -TC modifier? I feel it is important to capture the work and time that our RN expends to perform this service. If I cannot submit 93298, what code do you suggest? Or are we out of luck?

When right L2/L3 and left L4/L5 are injected, are these coded as bilateral or add-on for the opposite site since a different level?

"Repaired popliteal artery to popliteal vein acquired fistula. Subcutaneous flaps developed superiorly and inferiorly. Fascia entered. Lesser saphenous vein ligated. Dissection to incise the deep fascia. Careful dissection to isolate popliteal vein and popliteal arterires proximally. Level of fascia identified and distal extension of exposure between stress of gastrocnemius performed to expose distal vein and distal artery. Pop both ends of the artery were separate feeding into common aneurysmal dilatation between artery and vein. (CPT 35190.) There was no way to primarily repair fistula using simple closure. Using vertical superior incision aspect of vertical superior incision, the GSV harvested. 10 cm piece removed. Piece reversed and anastamosed end-to-end to popliteal artery proximally and end-to-end to pop artery distally. Next GSV anastomosed end-to-end to the popliteal vein distally." Is 35190 correct? What do we use for the A) popliteal artery interposition bypass graft, and B) popliteal vein interposition bypass graft using the greater saphenous vein?

Our organization allows departments to report G0269 closure device; HOWEVER, our coders do NOT append a modifier to bypass the edit for additional reimbursement, as we understand this is a packaged service. We report all procedures performed under the OPPS, as long as coding guidelines permit. To our understanding, reporting all procedures performed within guidelines support CMS with future decision making regarding MUEs and packaging status for example. Regarding 76937 ultrasound guidance, currently, you do not receive an edit with 93458 and 76937 for HOPD billing. The current 2019 NCCI Policy is only addressing physician billing. Should the facility continue to report ultrasound guidance when performed with cardiac, coronary, EP, PPM/ICD procedures? Please advise on facility reporting to ensure our healthcare organization is reporting services appropriately.

Would you bill both 21615 and 21700 for this? Can both be billed through the same incision, or must it be separate incisions? It feels like you would have to divide the muscle to remove the rib so it should be inherent. However there are no bundling edits, and I can't find anything saying you can not bill both. "We began by making a supraclavicular incision...We then divided the anterior scalene muscle...We continued our dissection down the anterior scalene muscles to where it inserted on the 1st rib...Then an elevator was used to elevate the periosteum and expose the rib from the clavicle all the way to the cervical vertebrae. We then used a small oscillating saw to divide the rib in 2 places. This small piece of rib was passed off and then we used the rongeur to continue our dissection anteriorly and posteriorly. We used bipolar cautery whenever we were cauterizing the anterior scalene muscle. We did have to divide part of the middle scalene muscle...We reapproximated the sternocleidomastoid...We then closed the platysma in a running fashion."

A patient had a biventricular pacemaker with only an RV and LV lead. They removed the RV lead and placed a new one, kept the existing LV lead, and changed the generator. I believe I should code 33249 and 33233 to account for removal of the pacemaker generator and implant of the new ICD generator and RV lead, but what code would I use for the RV lead removal? Could I use 33234, even though that says it is for a single-lead system?

Procedure was repair of aortic dissection with tube graft and aortic root replacement and tricuspid valve replacement. At the end of the procedure the physician tunneled an LV lead into a subcutaneous or likely subpectoral pocket because the likelihood of needing a pacemaker was high due to tricuspid replacement and double valve surgery. Pacemaker was not inserted at this time. Code 33225 can only be billed with pacemaker codes and defib code, as it is an add-on code. Can the cardiothoracic surgeon bill for this, and if so what code would you recommend? Would it be 17999 unlisted?

When lower extremity revascularizations are performed in office setting (pos 11) under moderate sedation, are we allowed to bill for Q9967, J3010, and J2250 as well? Example: 37225-LT, 37252, 37253, 75625-59, 75710-59, 76937, 99152, 99153 x 3, Q9967, J3010, and J2250. Of course appropriate documentation for the moderate sedation and amounts of the drugs would be listed in report... I'm just not sure on the rules for billing the drugs themselves, and I can't seem to find any information from Palmetto GBA (AL). Thanks so much for any guidance.

Patient is seen for his post transplant surveillance. He had an echo that showed mildly dilated RV with mildly reduced systolic function. He has moderate tricuspid regurgitation. The physician performs a right and left heart catheterization with biopsy. I know we do not code 93451 with the 93505; however, would it be appropriate to code right and left heart catheterization with angiography (93460) or left heart catheterization with angiography (93458) along with 93505 in this case? We are starting to see more cases like this, and I want to make sure we understand correctly.

I know if all the components are there and Doppler/color flow are noted, we bill 93306. I also know when to be a 93308 and 93307. What I am unclear on is: all components are there and there is only mention of 2D/MMode and spectral Doppler. Can you then bill 93307? Or is this 93308/93321?

We have a new physician who is using SPY Elite fluorescence imaging machine. Is there a specific CPT code for fluorescence angiography, if no prior imaging of this extremity was performed prior to this exam? Below is an example of his dictation. "U/S guided antegrade puncture of RCFA. Selective arteriography of the right SFA, popliteal and trifurcation Superselective angiography of the right AT Fluoroangiography pre-PTA of the right foot with Green Indocyanine. PTA of the right AT with 3x200 balloon at 14 atm. Repeat fluoroangiography with indocyanine green after PTA. Findings: Large ulceration, deep, of the dorsum of the right foot. Non healing for several months. Fluoroangio showed reduced perfusion of right 1st toe and R dorsum of foot. Angiography showed multiple critical stenoses of the right AT. 3mm PTA of R AT. Fluoro post PTA showed improved perfusion to 1st toe and dorsum of foot."

Would CPTs 36581, 36595-5952, 75901 or 36581, 77001 be appropriate for the following procedure? "The right neck was prepared and draped in sterile fashion. The patient's existing catheter was prepared and draped. A wire was passed through the catheter into the inferior vena cava under fluoroscopic guidance. The catheter was removed through the existing tunnel. A 10 mm x 4 cm balloon was placed through the existing tunnel into the lower superior vena cava and right atrium. Balloon angioplasty was performed with the intention to remove any residual fibrin sheath in the lower superior vena cava and right atrium. The balloon was removed. The patient's catheter was replaced with an identical line. The catheter was flushed and sutured into place. There were no immediate complications. A final spot radiograph shows the tip of the catheter to be in the right atrium."

Is VATS parietal pleurectomy included when doing VATS resection-plication of bullae/blebs, or can I bill for both codes 32655 and 32656? If so, do I need to use a modifier?

We have just begun to do these cases in our Hybrid Suite. The advisement by the company rep is to use code 33315. We are currently using 33999. I want to be sure that we are coding these cases appropriately. Has the way these procedures are coded remained the same or changed for 2019?

Recently our physicians have been performing dFR instead of FFR. For facility coding we have been using 93571 with a -74 modifier for outpatient procedures. What would you advise we use to report this procedure?

My doc did an angioplasty for a chronic occlusion of the left innominate vein before placing a CVC. "Occlusion/Vein" in the ICD book brings me to thrombosis, I82.B21. Do I code for CPT 37248 for stenosis (he doesn't use the word "stenosis," only "occlusion"), or do I code 37187 because of the DX occlusion says? The doctor says this is not a clot/thrombus. Can I code 37248 with I87.1 since an occlusion is 100% stenosis??

Can I report CPT codes 92941 and 92943 in an "elective status" scenario? Or only in "emergency status" situations? If the patient has a CTO and goes in for an elective PCI, is it okay to report code 92943?

How would you recommend coding the following? I am thinking 20501 and 76080. Is the aspiration separately codable? "Under real-time imaging guidance, a 5 French access catheter was inserted into the lateral thigh fluid collection. 50 mL of thick nonpurulent fluid was aspirated. Specimen was sent to microbiology for further analysis. 10 cc of Omnipaque 300 was then injected into this cavity under fluoroscopy. No communication to the joint space was seen to joint space side. Permanent images saved in the patient's medical record. 1) Technically successful aspiration of left proximal, lateral thigh fluid collection. Specimen sent to biology for further analysis. 2) Contrast study of the left proximal lateral thigh fluid collection revealed no communication with the left hip."

I am being told this monitor can be programmed to be used up to 7 days. However, the CPT description states: "...remote attended surveillance center for up to 30 days." If this monitor is used up to 7 days and not 30, do I need to add modifier -52 when only 7 days were monitored?

Does the physician have to be in the room for the hospital to bill a barium swallow (74230)? If they are not, what can they bill? What about the professional component?

"Needle entry into AV graft, diagnostic angiogram of graft revealed large false aneurysm, which compresses the true lumen by 60%, as well as stenosis in mid portion of the graft. Stent deployed to repair stenosis and simultaneously exclude false aneurysm. Skin was anesthetized over false aneurysm and needle placed directly into false aneurysm to fully drain. Seal was not complete, so balloon was inflated in stent to exclude false aneurysm. Second time, a Yueh catheter was placed to drain. 0.7 cc thrombin was injected directly into false aneurysm to dwell. No further leakage to aneurysm - successfully thrombosed. With incision and drainage, clot was removed from false aneurysm. Incision was closed with suture. Next, angioplasty was performed to treat stenosis in mid portion graft." What CPT codes can be assigned for this case?

"Diagnosis: Left arm AV graft pseudoaneurysm with very thin overlying skin. Procedure: Loopogram with stent placement and revision of left arm AVG. A 5 French micropuncture needle was used to access the AV graft at the apex, and the micropuncture sheath was inserted. A loopogram was performed, revealing the large pseudoaneurysm at the arterial limb. An 8 French sheath was then inserted and exchanged over a J-wire, then a Bentson wire was inserted across the lesion. A 7 mm x 10 cm Viabahn covered stent was deployed across the area of the pseudoaneurysm, and balloon angioplasty was performed. Repeat imaging revealed resolution of the pseudoaneurysm. Wire/sheath were removed. A 4-0 Prolene U stitch on an RB needle was performed. Next, the area of the thin overlying skin was removed in elliptical fashion, and then the healthy skin was closed with 3-0 nylon vertical mattress sutures in an interrupted fashion." Should we code separately for removal of skin, as the stent was placed percutaneously? What code(s) should be used?

Our physician performed a CT-guided core biopsy of the right S1 pedicle soft tissue mass. The soft tissue mass eroded the right S1 pedicle yielding fragmented cores. Would this be coded 20206 instead of 20220?

"Patient came in for redo MVR, TVR, and insertion of Impella LD. A 10 mm Gelweave graft was then anastomosed to the distal ascending aorta using running 5-0 Prolene suture. The graft was brought out the left neck near the sternal notch. The Impella LD was then inserted and positioned in the ascending aorta. The aortic cross clamp was removed. The patient was deaired, rewarmed, and weaned from bypass in the usual manner without difficulty. The Impella was appropriately positioned across the aortic valve with excellent hemodynamics. All cannulae were removed and all sites oversewn." Do you recommend an unlisted CPT code?

Is there a simple statement that tells me when an angiogram (other than a completion angiogram) and/or an aortogram can be billed with LE revascularization due to occlusion?

What is the correct code for transcatheter RF septotomy of the congenital cor triatriatum sinistrum?

I have a patient with a pseudocyst of the pancreas, and the attending placed two indwelling drainage catheters. Would that be 1 or 2 units of 40405?

"I made a transverse incision at the arm crease, identifying the cephalic vein. I skeletonized the cephalic vein down to the forearm and up on the arm to allow for a tension-free transposition. I then began dissection of the brachial artery. We then identified that the brachial artery was a little more deep and lateral, and we began mobilizing the brachial artery. We got vessel loop control of the brachial artery. I divided the cephalic vein down on the forearm. I then beveled the end of the cephalic vein with appropriate length for tension-free transposition. We applied clamps to brachial artery and made an arteriotomy. We then transposed the cephalic vein onto the brachial artery, end-to-side anastomosis with 7-0 Prolene." Provider is saying this is 36818, but I don't think the documentation supports 36818. Please help.

Does this following technique support the assignment of 34812 for placement of Impella (33990) via cutdown? "Cath was inserted in the LFA. The performance level equalled P9. Cardiac output equalled 3.6 L/min. Comments: Left common femoral artery was punctured under ultrasound guidance. A 6 French sheath was placed, and the arteriotomy was subsequently pre-closed with one perclose device. The arteriotomy was then upsized with serial dilations to the 14 French short impella sheath. The aortic valve was crossed with an Al-1 catheter, and the Impella was advanced through the catheter into the LV with subsequent uncomplicated Impella insertion. At the end of the case the Impella was slowly weaned to P2, and, after 5 minutes of hemodynamic stability consisent with pre-PCI values, the Impella was removed and the arteriotomy closed with the single perclose and an angioseal device without significant bleeding."

Multiple blunt injuries with hepatic and splenic lacerations. Patient presents for embolization of the splenic artery and the right and left hepatic arteries. Would you consider this to be two separate organs and code 37244 x 2, or one surgical field and code 37244 one time only?