Ask Dr. Z

Our physician treated a common iliac aneurysm using a non-covered stent; he used just a plain peripheral stent. Would this be reported with the endograft iliac aneurysm repair code (34707), or would we report a stent placement code (37236) and the cath placement code?

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?

Can you give me the correct Facility Coding guide for the creation of the Ellipsys AVF graft? Please include ICD-10-PCS codes as well.

If a provider uses ultrasound guidance for an FNA biopsy but fails to retain image, and this is stated in the report that FNA was done under ultrasound but no image retained, which CPT code should be used? 10005 with mod -74 or 10021?

What CPT code is reported for resection of aneurysm of right femoral popliteal bypass? "Procedure name: resection right femoral popliteal artery aneurysmal degeneration with interposition Dacron graft. Patient had previous fem-pop bypass with great saphenous vein. The pseudoanerusym was arising off the mid superficial artery graft. Incision was made in the thigh and aneursym resected, then Dacron graft sewed end-to-end to the distal portion of the femoral-popliteal bypass. Arteriotomy made in the popliteal artery and embolectomy catheter passed down the peroneal artery, tibial artery, and anterior tibial artery with thrombus removed."

Our cardiologists perform a lot of echo interpretations on patients they have never seen (hospital patients, referred by other providers, etc.). We will frequently see "bicuspid aortic valve" on an echo interpretation in addition to "aortic stenosis." There is an Excludes1 note under I35.0 aortic stenosis that prevents Q23.1 from being reported with it (Excludes1: Aortic valve disorder specified as congenital, Q23.0, Q23.1). How are we to report "bicuspid aortic valve, aortic stenosis"? Going one step further, if patient has bicuspid aortic valve with a mitral and tricuspid valve condition, this same Excludes1 note prevents us from assigning the I08 code with the bicuspid Q23.1. Would these fall under the "exception to the Excludes1 definition as the circumstance when the two conditions are unrelated to each other"? I understand that a provider query is preferred, but our providers are reading these studies only and have no knowledge of the patient for us to query.

I'm sort of on the fence on how to code these. In the ICU the neck was prepped and draped in the usual fashion. The patient was given sedatives and paralytics. Bronchcoscopy was performed by Dr. X and dictated in a separate note. "The neck was anesthesised with lidocaine solution. Tranverse incision was made at the level of the cricoid, and under direct visualization a large bore needle was advanced into the trachea at the second to third tracheal ring. A wire was advanced. The tract was dilated to 38 French, and an 8.0 cuffed tracheostomy was advanced under direct visualization. The cuff was inflated. The patient was ventilated. The bronchoscopy was introduced through the tracheostomy. Bloody secretions were evaluated." I am interpreting this to 31730... is this appropriate? The pulmonologist coded to the brochoscopy... or is it going to be an unlisted type category?

Since these are created for dialysis, would you use the dialysis intervention codes? "U/S guidance was used to access a patent and compressible right radial artery at the wrist using a 5 French slip-cath micropuncture needle and dilator. An image was stored. Through the dilator, a mixture of heparin, verapamil, and nitroglycerin was diluted with blood and gently infused into the radial artery. Next, through the cath, a glidewire was advanced up to the radial artery to the level of the wrist, followed by a 4 French Kumpe cath. An arteriogram of the upper extremity was performed, which included the perforator and veins feeding the cephalic and brachial veins. Next, the Kumpe cath was used to negotiate from the radial artery directly into the perforator vein, and a venogram of the upper extremity was performed into the central venous system. This confirmed a stenosis of the radial artery at the cephalic vein with the cephalic vein stenosis as well. Then cath was exchanged for a balloon, which was used to dilate the radial artery and perforator vein for 90 secs."

"Utilizing fluoroscopic guidance, three passes into the lesion were made using an 11 gauge OnControl biopsy needle system at the T8-9 disc space via the posterior right paramedian approach. Passes were made into the disc as well as into the inferior end-plate of T8. Aspirated tissue was sent for microbiology, including gram stain, aerobic and anaerobic cultures, smears and cultures for AFB and fungi, as well as cytology and pathology. IMPRESSION: Uneventful fluoroscopically-guided biopsy of the T8-9 intervertebral disc space via the posterior right median approach." Should I report code 20225 since end-plate mentioned, or should I report unlisted code 64999 since it is disc space between T8-T9?

I have a question on MRI-guided breast biopsies. Our rads use DynaCAD when performing an MRI-guided breast biopsy procedure. They specifically state the images were reviewed and the procedure was performed using a computer-aided detection system (DynaCAD). Can an unlisted MRI code be used to capture this?

"12-year-old male with congenital heart disease of double outlet right ventricle, ventricle septal defect, interrupted aortic arch, sub aortic stenosis, and hypoplastic ascending aorta. He is status post arch reconstruction, aortic balloon angioplasty, and balloon angioplasty of the RV-PA, pulmonary valve replacement, and pulmonary valve conduit homograft and a 2018 Melody Wave implant. A selective PA demonstrates moderate insufficiency of the Melody Wave; angiography provides severe distal Melody Wave stenosis secondary to moderate sized vegetation. Now - status post successful balloon valvuloplasty of Melody Wave." I am not finding a listed CPT code for a Melody Wave valvuloplasty. Would this be unlisted code 377999? Can I charge 93533, 93566, 93568, 93567 for this patient's cath procedures?

Can a blade method septostomy (92993) be coded with a transvenous balloon septostomy (92992) performed in the same session, or is one bundled into the other?

Can we bill 77002 with 20611 when both US and fluoro guidance are used? I know 77002 is bundled into 76942, but a -59 is allowed.... when fluoro guidance is used in addition to the US guidance, do we bill 20611 alone?

"Patient undergoes rotationplasty, and vascular surgeon performs anastomosis of SFA to popliteal artery and femoral vein to popliteal vein." How would you report this case? Should we use repair code of blood vessel?

"The anterior chest was prepped and draped in the usual sterile fashion. An incision was made over the generator. The capsule was incised, and the generator was removed from the pocket. A device pocket was fashioned. The pocket was flushed with Gentamicin irrigation solution. The generator was implanted in the pocket. The pocket was closed in layers using 2-0, 3-0, and 4-0 absorbable suture. The skin was closed with a subcuticular technique. Successful loop recorder implant pocket relocation." Would this be 33285 or 33999 or 17999 [33285-applicable for reporting implant and explant services associated with older implantable/insertable loop recorder (ILR) devices where medically appropriate]??

"The right internal jugular vein was accessed under real-time ultrasound guidance. The needle tip was visualized accessing the vessel. Permanent imaging was archived in a picture archiving and communications system. A 5 French sheath was placed. A 4 French flush catheter was used to catheterize the left upper arm fistula through the right internal jugular vein access. A fistulogram was performed, demonstrating patent arterial anastmosis. A 4 French angle glide catheter was used to select the left brachial artery followed by angiogram with fistulogram and central runoff. Angioplasty of the 50% pre-existing venous outflow stent stenosis was performed using a 7 mm x 8 cm drug-coated balloon catheter. Angioplasty of the 50% stenoses in both left subclavian and left brachycephalic was performed using a 12 mm x 4 cm balloon." Are the codes 36902-52, 36907, and 36012 for the jugular access?

"The patient is a two-year-old with tricuspid atresia, status-post bidirectional Glenn procedure with continued antegrade flow from the right ventricle. A recent catheterization showed high systolic pressures in the LPA with a high Glenn pressure noted. Pulsatile flow noted in the LPA with systolic pressures up to 18-20 mmHg with a mean gradient of 16 mmHg. There was loss of pulsatility with a mean pressure of 13 mmHg within the SVC. Angiography demonstrated a narrowing in the MPA from a band that was placed. The narrowing was approximately 4 mm. A 6 French delivery system was advanced into the RV retrograde from the pulmonary artery. An ADO 6/4 device was positioned within the MPA and adjusted following angiography. The device was felt to be in appropriate position and released. The pulsatile was no longer noted in the LPA. Pulmonary pressures were elevated at 15 mmHg with no gradient in the SVC." Would you code this with unlisted code 93799?

We have a provider that is doing cerebral angiograms with the approach being via radial artery. The provider states vasospasm was present in radial artery and treated before completing angiogram. What code would we use for the treatment of the radial vasospasm?

Our physicians are performing left and right pulmonary artery thrombolysis using two EKOS catheters, but using only a single access site. Must they use two different access sites (sheaths) to apply the bilateral modifier -50? Or since two catheters were used, one for the left and one for the right, is it appropriate to use the -50 modifier?

Could you suggest a diagnosis code for "microvascular disease" or "small vessel disease"? Many patients with chest pain, but fairly clear coronaries, are being diagnosed with this issue.

How long is a physician's order good for? Our radiology department has always used one year as a rule. Is there definitive guidance from Medicare or the ACR on the acceptable timeframe? 

Would the statement below be sufficient to code 77001? It doesn't mention that the removal itself of the port was guided, just the phrase below, in what appears to be a spot film.

"A fluoroscopic view the chest was obtained saved and archived a single-lumen left subclavian port to be present with the tip at the cavoatrial."

I understand that the physician has to state that he/she is the treating physician (this is for Y-90 mapping). For the cone beam CT coding, this is taken from software that creates CT like volumetric images (not a CT machine) and reconstructs and evaluates at a separate 3D workstation. Can we report code 76380 if CT arteriography of hepatic is performed along with 76377 (providing all documentation is documented for the 3D images)?

What is the code for upper extremity vein mapping prior to the creation of a AV fistula? No Spectral was done. Does the code selection change if it's not done on the same day as the fistula creation and/or by a different physician?

"The greater saphenous vein was identified on the right. It was previously ablated; however, it was ligated. Secondary varicosities off of the saphenofemoral junction were also identified and ligated, including a large redundant secondary vein near the saphenofemoral junction. They were ligated proximally and distally and oversewn with 2-0 Vicryl stick tie. Once this was accomplished, a multilayered closure was performed. Dermabond was placed in the groin. Previously marked varicosities on the right lower extremity were removed with a stab incision. Stab phlebectomy was performed, removing the vein proximally and distally by clamping proximally and distally, transecting, and gently removing the vein. This was repeated down the medial aspect of the leg posterior to knee and the popliteal fossa, calf, and along the shin. 17 more incisions were made, for a total of 18. Once all the varicosities that were marked were removed, copious irrigation and hemostasis was obtained." Would this just be 37765? Provider wants to use 37700 and 37785 also, but the bundle?

"Percutaneous entry with a 6 French sheath placed in right femoral vein and 6 French sheath in right femoral artery. A 6 French wedge catheter was advanced to right heart, and a pressure and saturation sweep was performed. Angled Glidecaths were used to complete the right heart cath. A careful pullback from the LV to descending aorta was performed using a pigtail. The Glidecath was advanced to the innominate vein with hand injection performed, demonstrating the veno-venous collateral. Over a wire the Glidecath was exchanged for a 5 French JR guiding catheter and advanced into the veno-venous collateral, and a 4 mm AVP II was selected and advanced to the venous collateral and device was released. Hemodynamics list: Hep Vwedge, SVC, IVC,RPA, LPA, LV , AAO, DAO, Fontan pressures, transhepatic gradient of 2 mmHg. Cineangiograms lists Hemi-azygous and collateral 1 hand injections." Does 36012 x 2 describe the further selections? Was hepatic wedge pressure performed? Do we need angiography codes 75889, 75605?

Would you please help me with the distinction between 20501 and 49424? Is it just the difference between whether or not a catheter is used to inject the contrast into the fistula?

Patient with chronic afib. Patient went into cardiac arrest and had a biventricular ICD inserted. EP physician wanted to initially do ablation for the afib with insertion of device prior to cardiac arrest as part of a previous plan of care. Next day EP physiscian sees patient - wound check, interrogation, chest x-ray, and EKG performed. Per operative note on this visit: "Patient did well with biventricular ICD implantation yesterday. I reviewed her chest x-ray, ECG, and device interrogation. These are all stable from my perspective. I have left her at VVIR 75 to 120 beats per minute. Atrial lead is in place in case we elect to pursue a rhythm control strategy after she improves clinically. No AV node ablation performed, as her rate control was good and I felt this was not urgently necessary. Her CHF appears to be much improved, though she continues to have some rales. I agree with ongoing diuresis. From my perspective she can be discharged whenever Dr. X and the team feels this safe. I will follow-up with patient in the office in 1-2 weeks as an outpatient for her afib." The physician believes this isn't a post op visit. Please confirm.

Should this be coded 62323 and 77015 or with 62323 only? +70470/CT? "Procedure: The patient was placed in the prone position on the fluoroscopic table. The L3-4 interspace was localized fluoroscopically. The skin overlying the L3-4 region was prepped in the usual aseptic manner. Generous quantities of one percent lidocaine was used for local anesthesia. The L3-4 space was then accessed with a 22 gauge spinal needle. A fluoroscopic spot image was obtained. 10 cc of Omnipaque 300 were injected into the epidural space with confirmation by fluoroscopy. The patient was then placed in the Trendelenburg position in both the prone and supine positions. Confirmation of cranial transit of contrast by fluoroscopy was performed. The needle was removed. The site was dressed with an adhesive bandage. The patient tolerated the procedure well. There was no immediate complication. The patient was then transferred to the CT scanner. FINDINGS: Fluoroscopic spot image demonstrates the needle tip projecting over the L3-4 spinal canal. Technically successful lumbar puncture for CT cisternogram."

Would you code an additional IFR for the RCA in this situation? "The wire was advanced across the left circumflex OM lesion and the iFR was 0.93, consistent with non-hemodynamically significant lesion. We then decided to do IFR assessment of the right coronary artery lesion. We used the same guide and advanced a wire across the right coronary artery lesion; however, the iFR wire malfunctioned and would not give us an accurate iFR result. However, because the lesion did not appear to be significant, we decided not to proceed with any further intervention."

Does an MRCP require documentation of 3D in the report, or does the exam itself (being documented as a MRCP) imply 3D?

There is a similar question already asked by fellow subscribers about dilating a Fontan fenenstration, but I want to run the question by you... do you agree with unlisted code 93799 for stenting a Fontan for stenosis? This patient is in early 20s, and Fontan procedure was done year 2000. There is no fenestration in this patient's Fontan.

If the physician attempts to remove the generator due to possible infection but then changes his mind and puts it right back, can we use the remove/replace code (33228) even though there was no new generator placed, or would this be unlisted? "Given the extremely poor wound healing of this incision I suspected that the pocket was potentially infected as well and considered removing the pacemaker generator and packing the pacemaker pocket. Upon disconnecting the pacemaker the patient became profoundly bradycardic, and I immediately reconnected the pacemaker. Given his dependence on the pacemaker and lack of overt infection I elected to irrigate the pacemaker pocket with warm Clorpactin and placed the pacemaker in an antimicrobial absorbable patch."

Is this sufficient documentation for ablation coding (new EP physician)? "The patient arrived in AF/AFL, and underwent successful double transseptal puncture utilizing intracardiac ultrasound guidance and then completed 3D map of left atrium and pulmonary veins. Patient was cardioverted initially with 200J x 1 with successful conversion to NSR for initial voltage mapping of the left atria Wide area circumferential ablation was performed successfully and without complications, with confirmation of PV isolation with the circular mapping catheter for management of atrial fibrillation.. RF linear lesions outside the PVs were completed at the roof and inferiorly creating a posterior box which terminated an atypical flutter when creating the inferior line. Atrial flutter from the right atria was also ablated. Successful completion of bidirectional conduction block with RF ablation between TV and IVC in cavo-tricuspid isthmus to manage right atrial flutter. Post ablation, there was abnormal SA (cSNRT > 900ms) and AV function, VAD and normal HV function (43ms) and no inducible SVT without isuprel."

I have a question from one of my NIR physicians regarding vasospasm treatment in both vertebral arteries: "I've read about the 3 territories for vasospasm infusions, but in reality there are 4. If there is vasospasm of both vertebral arteries proximal to the point where they merge to form the basilar, infusion of verapamil into one of them won't treat the other. Since I performed therapeutic infusion over 10 minutes each into bilateral vertebral arteries could we justify 61651 as well?"

I have a case where an ESRD patient (AV shunt in left arm) presented to cath lab for upgrade of a dual PPM to CRT-D (primary prevention). The left UE venogram could not be performed due to the presence of the shunt, so the cardiologist opened the PPM pocket, accessed the vein (via the pocket), and performed a venogram, which revealed an occluded innominate-SVC junction. What CPT code would I use for the venous access on this case?

Is it appropriate to bill 27096 and 20552-XU if the provider injects the SI joint using CT or fluoro and performs a sacral PSIS trigger point injection? Since they are treating the same area, I question whether both can be billed.

Are you aware of any specific guidelines for coding diagnoses of restenosis in a stent that was placed greater than a year ago vs. a newer stent? Should the coder use the atherosclerosis diagnosis as PDX followed by the stent restenosis code if the stent is over a year old?

Can you confirm that 20611 is just like 76937 where ultrasound guidance evaluation of potential access site, vessel patency, and real-time visualization of needle entry have to be documented in physician report to code?

"A patient had Impella removed, which created a hemorrhage. The patient was brought back emergently to the lab. Access was obtained, and the physician went directly to the hemorrhage and performed balloon tamponade for 5 minutes and then another 3 minutes. Angiogram was then performed and homeostasis was achieved." Do you recommend using 37246? Then, same physician, same day, different patient. Planned insert/removal of VAD in the same session. Physician did prophylactic balloon tamponade with removal of VAD. Is this balloon tamponade included with the removal?

Patient had a thrombolysis (37211) by Physician A, and repeat evaluation by physician B below. "The groin and existing catheters were prepped in usual fashion. The 4 French cath was then aspirated and flushed, and a right upper extremity angio was done from the brachial artery to the hand. This showed no flow in either the radial or ulnar artery beyond the mid forearm. The patient was prone, and repeat angio was performed, which demonstrated similar findings. I then proceeded to administer aliquots of nitroglycerin and ultimately heparin, tPA, and verapamil through the catheter into the distal forearm. A total of 1000 mcg of nitroglycerin, 5000 units of heparin, 4 mg of tPA, and 5 mg of verapamil were administered. Periodic angiography was performed in between aliquots of medication. Ultimately the final angiogram was performed, which demonstrated significant improvement in flow into the radial and digital arteries and filling of the palmar arch." Would Physician B not get any codes for the repeat evaluation above?

Patient has an external iliac to popliteal graft using Dacron. Procedure includes Fogarty catheter thrombectomies and multiple graftotomies. The only revision synthetic bypass graft code I'm finding is 35883 for a femoral anastomosis. This patient does not have a femoral anastomosis. Another option 35875/35876 is for arterial or venous graft, which doesn't apply to this patient. What code would I use for an iliac Dacron graft thrombectomy?

Can I bill 37242 x 2 along with 37241 for occlusion of LIMA, RIMA, and veno-venous collateral that drained to the coronary sinus? Or would I use just 37242 x 2?

We've been charging/coding our disc biopsies with unlisted code 64999 per your previous recommendation. However, I now see in your most recent publication it states to "use code 62267 if disc biopsy is performed instead of aspiration". Can you please clarify which is the correct code to report for a core sample of disc for diagnostic purposes?

Embolization coils were placed in the interlaminar space to serve as pre-operative localization devices. Would this be considered soft tissue 10035 or unlisted 64999? If unlisted, is the fluoroscopy separately reportable? Procedure note as follows: "INDICATION: Preoperative localization of T10-T11 intervertebral disc space. Local anesthesia (lidocaine) was administered at the site of entry. Under fluoroscopic guidance, a 6 inch 20 gauge Chiba needle was advanced into the interlaminar space between T10 and T11 in the midline. Stylet was removed, and tumor embolization coils (4 and 8 mm) were gradually pushed into the interlaminar space inferior to the lamina of T10. After the placement of the coils, the needle was removed. Sterile dressing was applied. The patient was then taken to computed tomography scan for confirmation of the position of the coils. Successful placement of embolization coils in the interlaminar space at the level of intervertebral disc at T10 and T11."

"Patient had an access from the left groin previously. We advanced an Omni Flush catheter and crossed over to the right common femoral artery, advanced a Supra Core wire beyond the level of the sheath into the right SFA, and advanced a 7 French sheath into the right external iliac artery. We then advanced a wire through the side port of the 14 French sheath, through which Impella device had been placed, and we removed the Impella CP device successfully out of the body. We placed a 12 French sheath into this access site, and continued bleeding around the sheath was noted. We advanced an 8.0 x 40 mm balloon into the right external iliac artery and inflated it to 10 atmospheres to achieve balloon tamponade. Following that, through the wire that has been placed in the right CFA, we performed the Perclose using a ProGlide device. We then advanced the balloon into the common femoral artery access site and performed balloon tamponade for 20 minutes." After Impella removal 33992, I'm not sure what else we can code. Thoughts?

"Occluded right CFA limb of a right axillary-bifemoral bypass. Previous right groin incision reopened. Fresh inflammatory tissue surrounded the graft and femoral dissection. Dissection carried down to SFA and 2nd order branch of PFA. Graft removed from CFA and found with semi organized murky thrombus. Thrombectomy of the right limb of bypass graft with a forgarty to establish inflow, then from CFA, SFA, and PFA. Arteriotomy extended onto the SFA and PFA where occlusive dissection flaps were found, removed, and tacked down with prolene stitches. Arteriotomy was patched with bovine pericardium with extension of the patch onto both the SFA and PFA. Arteriotomy was made into the patch at the CFA, and the bypass was reanastomosed to the patch in an end to side manner." Is this coded with 35876 only? Or with 35302 and 35876?

Attempted to stent the 3rd diagonal from the graft but unable to pass the wire into the diagonal branch due to torturous branch. Can I bill for an attempted angioplasty?

Would this be coded as a delayed graft extension 33886/75959/36247, or 37236/36247 for the IR physician? "History of thoracic aneurysm with Octopus graft, graft balloon component is outside LT renal artery causing type III leak. 3rd order arteriogram through LT renal artery Octopus graft in the type III endograft leak, stent LT renal artery with reapposition of thoracic octopus graft component into the LT renal artery. Stenting performed by IR physician and vascular surgeon. Vascular surgeon performed cutdown LT axillary artery. Access made into the LT axillary artery w/direct puncture. Negotiation into LT subclavian artery, descending thoracic aorta first using Omni Flush catheter within a RT lateral component of graft, ultimately into LT renal artery limb. Placement of a ViaBahn stent. Stent & LT renal graft component then lined with a self-expanding stent. The LT renal artery Octopus graft component is dislocated out of LT renal artery, causing type III leak. Stenting LT renal artery w/re-apposition of LT renal Octopus component into LT renal artery."

Can we report codes 33418 and 33419 for tricuspid valve repair using MitraClip prosthesis? Also, can I charge for the supplies considering it's "off label"?