Ask Dr. Z

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"?

Can these two (US ABD complete and US elastography) be billed together if they were done at the same time?

What stent code would you use for stenting of the external iliac artery for bleeding (not atherosclerosis)? The physician is calling it "active extravasation," which was resolved by placing the stent.

Please see following medical record: Right and left heart catheterization, congenital, Angiography - SVC, left PA , RIMA and LIMA, then coil embolization both of RIMA and LIMA. Can we report 37242 and 37242-59? Or only report 37242 once? We report 93564 for angiography for IMA; is right? Also, should we report the cath replacement for 37242 and 37242-59 (I mean 36216 and 36217)?

"A patient undergoes drug-eluting stenting of the LAD for stenosis (CAD). Non-flow limiting dissection is noted post-procedure, and this is treated with placement of an additional stent." How would this procedure be coded? Would it be appropriate to report 93799 in addition to C9600?

"Linear wide area circumferential ablation was done in the pulmonary vein antra of both the right and left pulmonary veins. Complete encirclement was done with power controlled up to 40 W in the anterior aspect of the LA and 30 W in the posterior aspects of the LA. Subsequently, a Lasso catheter was placed in the LSPV, and pacing from the CS was done to identify PV potentials. Ablation at the earliest site of the PV potential terminates conduction to the PV. This process was repeated for the LIPV, RIPV." Please note during the ablation in some areas of the antra, there was significant bradycardia, suggesting ganglionic plexi were also ablated. Does this documentation support 93657 or 93655 in addition to the A-fib ablation?

I'm wondering if I can bill together 61650 and 37215. I checked NCCI edits and it didn't hit for any edits. This is what the provider did: "Placement of a Infinity 088 guide catheter within the left common carotid artery. Follow-up angiogram of the neck via left CCA contrast injection showed severe 85% focal stenosis involving the proximal to mid cervical left internal carotid artery. There is a meniscus sign indicative of clot/soft plaque. Additionally, there was severe tortuosity of the cervical mid to distal left ICA leading to this surgery to be extremely difficult. Navigation of a 035 Glidewire past the stenosis within the cervical left ICA. Follow-up angiogram of the neck via left CCA contrast injection showed severe spasm involving the cervical left ICA. Intra-arterial infusion of 5 mg of verapamil into the cervical left ICA over 10 minutes time. Then navigation and deployment of a 3 mm spider distal embolic protection device to the petrous left ICA. Then the 035 Glidewire was subsequently removed."

Is this enough to code 93657? "There was evidence of recovery into the upper PVs and the posterior LA wall.PV potentials were blunted. A 4-pole irrigated contact force tip ablation catheter was advanced into the LA. 3-D mapping with the NAVX system was used to create a model of the LA and PV's. The left PV's isolated with relative ease (wide posterior ablation).The RIPV posteriorly directed was very challenging. To isolate the RSPV, Ablation was extended onto the roof and septal aspect. Ablation was necessary on the posterior carina. Isolation was confirmed with bidirectional block into each PV.Burst pacing was performed in attempt to induce atrial flutter. This induced an atrial flutter (CL 300 ms - earliest activation on CS1,2). Entrainment from CS1 ,2 -- yielded a PPI 70 ms. Thereafter the flutter degraded into AFIb with variable LC and activation.This was cardioverted.Attempt to reinduce AFL continuous yielded AFib. Additional ablation was done along the roof."

How is access common femoral artery with stenting of carotid artery coded? "OPERATIVE PROCEDURE: Patient prepped and draped in the usual sterile fashion. Ultrasound was used for right common femoral arterial access and placement confirmed with fluoroscopy. A wire was advanced into the aorta and catheter advanced into the arch. Using an angled glide wire and glide cath, the right innominate and then subclavian was selected. A stiff wire was advanced down the subclavian and into the brachial artery under direct visualization and a 7 French x 90 cm Ansel sheath was advanced into the innominate. We had been giving heparin since the start of the procedure in compliance with neurology stipulations. With the sheath in the innominate, angiograms were obtained and the exact location of the port entrance was identified. An 8L x 29 mm VBX stent was advanced with some difficulty through the sheath and positioned across the area of injury. Cutdown and angiogram was taken through the port for confirmation of positioning. The stent was deployed and the port removed. Angiogram demonstrated a small leak, so the stent was post-dilated with a 9 mm balloon."

If a nurse places a PICC line using US guidance (but does not keep a permanent image), and then a chest x-ray is done to confirm tip location (with permanent image), is this enough to report the "with imaging guidance" code? Or would this be coded as 36569?

"We started the procedure by locating the left arm cephalic vein fistula. Access was achieved, and a 5 French was advanced without difficulty. Left brachiocephalic AV fistula angiogram and central venogram done, and a recurrent stenosis at left cephalic arch was noted and crossed with torque wire. Balloon angioplasty of cephalic arch with 8 x 40 mm Charger balloon (36902). Completion angio shows excellent flow via cephalic arch without residual stenosis. We then noticed presence of chronic clot adherent to proximal cephalic vein at aneurysmal segment without complete occlusion. Another access was done with micro puncture kit and proximal location and upsized to 8 French. We utilized an 8 French LIMA guide for suction thrombectomy and were able to remove some clot from cephalic vein. Completion angio shows some residual clot at cephalic vein without any flow compromise. Repeat duplex US shows residual clot, which was not able to be removed with suction catheter." For the thombectomy, since it is being done via a separate access site, would this be 36905-59 or 37187-59?

We are trying to bill an MRI elastography, and the insurance companies are saying it needs a primary CPT code. Isn't this a stand-alone code, or would it be appropriate to bill an MRI abdomen with it?

A patient had a ruptured internal carotid artery secondary to radiation and malignancy of the right neck. A carotid stent is placed to repair the rupture via femoral exposure. The physician stated it was more in the cervical carotid area than intracranial, so my question is would this be stent placement 37236 or carotid stent 37216 (no flow device was used) since it was treating hemorrhage?

My provider performed dual chamber pacemaker interrogation in order to attempt pace termination of patient's atrial flutter. Pace termination was unsuccessful in converting him to normal rhythm. Is 93724 still reportable? It seems like this would be similar to cardioversion, which is reported even if it's not successful. My nurses are wanting to change the 93724 to a regular interrogation charge when the termination isn't successful. Can you please advise? 

I had an auditor tell me we can bill for abandoned access in certain cases for cardiac caths. Is this true? Example: "The area of the right wrist was anesthetized with 1% lidocaine injection. Using a micropuncture needle, the right radial artery was attempted to be accessed; however, on ultrasound it was noted to be occluded. The left wrist was then anesthetized, and using a micropuncture needle the left radial artery was accessed and a 6 french Terumo slender glidesheath was inserted using a modified Seldinger technique. Radial cocktail was then given interarterially." They then performed a LHC. Can we bill 36140 for the abandoned access in this case and the LHC? In any case? 

I'm not sure how to code this. Is this an unlisted code for bypass? Does the obturator portion have its own code, or is that included in procedure? "An oblique incision was made in the right lower quadrant and deepened through the subcutaneous tissue. The fascia was divided and the anterior sheath out laterally. After this was performed, the transversalis muscle was divided. Access was then gained to the retroperitoneal space here, and the Omni retractor was inserted. The bowel contents were retracted to the midline without entering the abdominal cavity. The common iliac artery on the right side was isolated with vessel loops, just after the origin from the aorta. The external iliac artery was diseased, although it did have a pulse in it. The obturator canal was then dissected out, and then a medial incision was made in the thigh distal to the groin and deepened down to the sartorius. Once this was performed, the dissection continued superiorly from here, and then a clamp was passed from the groin incision through the obturator canal into the abdomen under direct..."

"We then advanced a balloon occlusion catheter (Scepter) into the anterior tibial artery, and arteriogram was performed. The Scepter catheter was advanced into an inferiorly oriented division. From this location we performed three separate injections of 2 mL of EtOH with the occlusion balloon insufflated and an ankle tourniquet applied over 10 minutes followed by 10 minutes of non-injection. We performed arteriograms from this location in between injections. We then redirected the Scepter into the superior branch and 2 mL of EtOH were again injected over 10 minutes, in the same fashion." Procedure is for lower extremity AVM. Is embolization coded to 37241 or 37242?

"In an office, type 2 endoleak communicates with lumbar artery located at right posterolateral aspect of the sac. I attempted to catheterize the lumbar artery but could not get the catheter to advance over the wire into it. I aborted further attempts and placed coils immediately adjacent to the origin of the lumbar artery. Entire endoleak was coil embolized. While coils were deployed I periodically injected small amounts of thrombin." Can I code for the drug - thrombin?

Can you provide some tips/guidance on how to distinguish a diagnostic TEE from TEE monitoring when a surgeon provides TEE findings during a cardiac procedure such as a CABG/valve replacement? I will often see surgeons provide baseline TEE findings (e.g., after opening the chest, they note that a TEE probe was inserted either by themselves or the anesthesiologist, and the TEE reveals normal left ventricular function, no pericardial effusion, and severe mitral regurgitation). In this example, if the patient came to the OR for a planned mitral valve replacement due to mitral regurgitation, and all I had were those findings, I would think this is just a baseline/confirmatory study that is part of TEE monitoring (they will use the TEE again after valve replacement to ensure resolution of the regurgitation and preserved LV function). Am I correct in my assessment? In contrast, would a diagnostic TEE require a decision to intervene or a change to the plan based on the findings of the TEE (similar to an angiogram/venogram during intervention)?

"Patient presents with bilateral hydronephrosis, and the plan is to place nephrostomy tubes. Once access is achieved into the left kidney, purulent material is identified upon injection, and this is aspirated and sent for cultures. Nephrostomy tube is then placed. Right-sided placement goes routinely without any issues." Can you code 50390/74425 in addition to 50432-50 for the left-sided aspiration?

What exactly does an auditor look for when a physician is coding IVUS? An example is a physician reports IVUS in the right and left common femorals, iliacs, tibials, etc., and the documentation states "patent". Or, it may list them out with ">50 %". Is this sufficient?

"Proximal RCA RFR was 0.94, and FFR was 0.93 with IV adenosine, which are both non-significant." Since the RFR is approved in 2019, and I am not finding coding rules on this topic, would this be reported as 93571-RC (for FFR) and 93571-52-RC-XU (for RFR)? Or should I report 93571-RC (FFR) and 93572-52-RC? Or only 93571-RC (FFR) assuming that the RFR would be bundled into the FFR?

Per CPT, "Up to two coronary artery branches of the LAD (diagonals), LCX (marginals), and right (posterior descending, posterolaterals) coronary arteries are recognized." Can you please explain what this means and how it impacts CPT coding for coronary interventions? Does it mean that only branches with these names are eligible to have their interventions coded? For example, if the physician performs an angioplasty in the mid RCA and then angioplasties a branch of the RCA - but not a PDA or a posterolateral - may we report 92921 in addition to 92920? Also, if, for example, the PDA branches off the LCX instead of the RCA, can we still consider it to be a branch for interventional coding purposes?

I'm looking for guidance for diagnosis sequencing for inpatient cardiology visits. In particular, principal diagnosis [i.e., reason for admission (non-cardiac) vs cardiac diagnosis]. Auditor has told us that the reason for admission should be the primary diagnosis, not the reason for cardiology consult/treatment.

"Patient with Pleurx chest drain had it aspirated with removal of 650 ml blood tinged fluid under aseptic technique. Contrast agent was injected under fluoroscopy, which accumulated at the site of previous fluid entrapment within pleural compartment. Digital images were recorded. This fluid was evacuated; 1000 units of heparin in 10 mL of saline were injected. Tube was clamped, and dressing was applied. Findings: Satisfactory lysis of fibrin occluding the Pleurx drain." How would this be coded?

Would codes 76856, 76830, and 93976 be supported for this exam? "EXAM: US PELVIS TRANSVAGINAL AND TRANSABDOMINAL DOPPLER Exam performed with color and spectral Doppler analysis. Reason for exam: Pelvic pain, rule out torsion. UTERUS: Size: 7.6 x 4.6 x 4.3 cm. cm Parenchyma/Anatomy: Retroflexed. Uterine Pathology: None. Focal Mass Lesion(s): Normal. Endometrial stripe: 6.3 mm. Endometrial Findings: Normal RIGHT OVARY: Size: 4.3 x 2.6 x 2.7 cm. Blood Flow: Normal color flow with spectral waveform. Findings: Follicles < 2.5cm. LEFT OVARY: Size: 4.7 x 2.6 x 2.5 cm. Blood Flow: Normal color flow with spectral waveform . Findings: Simple Cyst,3.5 x 2.2 x 2.1 cm. Transvaginal exam performed to better visualize the adnexa. IMPRESSION: 3.5 cm left ovarian cyst. Multiple right ovarian follicles. No evidence of ovarian torsion."

We have this question coming from Rev. Cycle. Can you help us answer it? Look below. Is this service bundled into procedure or separate billable? If billable what is the CPT code? This exam though is only a post CT scan (low dose/non-diagnostic) to validate the placement of the fiducial (which is placed in IR and then the patient comes to CT for this post scan). It does not get a diagnostic radiologist read. The images are used to count the vertebrae of the spine to validate that the fiducial was placed in the correct location.

I can't find the code for hepatorenal bypass with PTFE graft. Help!

My provider wants to bill the following as a repair indication for procedure: "Patient was having thrombolysis and was noted to have decrease in hematocrit and hemodynamic decompensation. Patient was found to have a retroperitoneal hematoma and has a right femoral sheath that had been upsized to a 6 French sheath to avoid further potential bleeding. Description of procedure: Patient was prepped under sterile and controlled condition. Incision was made in the right groin and dissection carried down to expose the area where the sheath has entered the femoral artery. Sheath was removed. The sheath insertion site and femoral artery were repaired by means of 5-0 prolene. Hemostasis was obtained and wound was irrigated thoroughly with irrigating solution. Platelet gel was applied on the wound. The wound was subsequently closed in a double layered fashion with absorbable suture and skin approximated in subcuticular fashion. Dermabond was applied, and patient left the OR to be monitered in ICU." How would this be coded. Just a removal or a repair?

"Transverse incision made, cephalic vein dissected free and ligated. Next aponeurosis of the bicep tendon is open and the brachial artery controlled with vessel loop, arteriotomy performed and vein ligated. Circumferential anastomosis with 6-0 prolene completed." I feel this should be billed with code 36821, but the physician feels this is code 36818. We have had payers deny stating that a subcutaneous tunnel of the vein must be performed in order to bill code 36818. What truly constitutes the transposition of a vein since tunneling and/or two sites do not always have to be done during 36818?

Patient was brought in for TEE + cardioversion. Following the TEE, the patient's device was interrogated, programmed, and the patient was burst paced out of a-flutter via CRT-D. Is converting the patient included in 93287, or would I add 93799?

What are the guidelines for using C1887? Catheter, guiding (may include infusion/perfusion capability). Would you assign this to regular diagnostic catheters used for imaging? Or is it meant for catheters that are used to do interventions?

Patient comes in with aphasia and has CTA, which shows occlusive thrombus distally within the M1 branch of the right middle cerebral artery, with reconstitution of M2 branches and non-occlusive thrombus within the basilar tip. Patient is taken to IR suite, and a thrombectomy and stent placement are performed of MCA. He also states, "I did look of the left vertebral of the demonstrated nonflow-limiting basilar embolus, which I decided not to treat." I coded 61645 and 61635, and I need to know if the vertebral angiography should be coded as diagnostic. I don't think we would code it because it was know,n but others say it should be coded because he looked at it and decided not to treat. Please advise.

What is the code for left masticator space core biopsy? "The patient was placed in a supine position on the CT table. Limited images were performed to select a trajectory into the left masticator space. CT images confirmed the Spencer lesion. The skin was prepped and draped in sterile fashion. Skin anesthetization was achieved with local anesthetic. Axial images were obtained with a needle in place confirming trajectory planning. Using intermittent axial imaging, a guiding needle was advanced to the masticator space. The inner stylette was removed and the matched biopsy device advanced through the guiding needle. Biopsy was performed. The needle was removed. Post biopsy images were performed. Biopsy Device: Bard Mission, 20 gauge. Specimens: Three cores were performed yielding Linear non-fragmenting specimens, which were placed in formalin and delivered to the pathology department. IMPRESSION: CT-guided core left masticator space biopsy."

Left femory puncture. Right common iliac angiogram performed for trauma. No extravasation found. Right internal iliac angiogram performed without extravasation. Right L3 and right L4 lumbar arteries injected without extravasation. Would the correct coding be 75710, 75736, and 36246, and for right L3 and right L4, 75726 x 2 and 36245 x 2?

When performing an SVT ablation our physician documents in the header of his report that 3D mapping as one of his procedures. In the body of the report, however, documentation only states entrainment mapping via the coronary sinus catheter and the ablation catheter confirmed that the isthmus between the tricuspid valve annulus and the IVC was involved in the reentrant circuit. He does not specifically state 3D in the body of the report. My understanding is that entrainment mapping can either be standard or 3D. Am I correct? If so, can the header of the report be used to clarify the type of mapping performed (even though we never code a procedure directly from the header)? 

I am asking for further clarification regarding your recent response to question ID# 12673. For the billing cardiologist who only provides a pre and post report for TEE for CABG and does not state probe placement occurred per the CPT descriptor, would it be appropriate to bill 93318-52? Or should 93312 be used instead?

Probably a pretty basic question regarding cath placement, but for some reason I find it a bit confusing. When accessing a branch vessel (i.e. greater saphenous or gastrocnemius vein), and we advance into a larger vessel (i.e., ipsilateral femoral vein), does that cath placement in the fem become 36011, as opposed to the 36005 that it would be had we accessed it directly?

Can angio/stent be coded in addition to fem-pop bypass for these vessels? "A right fem-pop bypass graft was performed. An 8 mm PTFE graft was used, an arteriotomy was made in the common femoral artery, an end graft to side artery anastamosis was performed. An incision was made in the popliteal artery, an end graft to side artery anastamosis was created. On preop angio, a significant stenosis was noted in popliteal artery behind the knee and PT artery take off that would need intervention after the bypass to maintain above the knee target for better graft patency. Through the proximal graft, I accessed it with micro access needle for angiogram. The right external iliac artery and proximal anastomosis are patent with excellent flow. I turned the sheath around directed distally a RLE angio was performed, excellent flow through the bypass with patent distal anastomosis. The behind knee Popliteal artery has a moderate (60%) stenosis. He has 3 vessel run off via the peroneal and ATA and PTA arteries. But there is an 80% orificial PT artery stenosis. PTA balloon of the popliteal and PT arteries were made with resolution of stenosis."

I know coding for the trunk is tricky. If a stent is placed in the tibial/peroneal trunk and then both the posterior tibial and peroneal arteries are angioplastied, do I only code 37230 for the stent placement? 

"A small hand injection in the left atrium via the transseptal needle after crossing the septum demonstrated adequate position in the LA cavity." Does this sentence in the congenital cath report justify reporting 93565?

My cardiac surgeon places an antegrade elephant trunk descending thoracic endograft by deploying the graft via an open aortic incision during a concurrent open ascending/arch replacement. Approach is sternotomy with transection of the ascending aorta. The vascular co-surgeon then gains access via femoral artery and threads a guidewire up to the area of transection, where it is exteriorized. The elephant trunk endograft is deployed antegrade by direct visualization, followed by completion of the ascending/arch graft replacement. There is confusion over whether the descending thoracic graft should be billed with 33880/33881 because it is an endograft (regardless of approach or direction of deployment) or if it should be billed with 33875 because it is an open approach for graft placement. Can you advise?

Patient had a His bundle lead and an RV lead placed with His recording. Would this be considered "mapping," or can we bill 93600?

Which CPT code should be used for an ultrasound of the temporal arteries, 93880 or 93886?

CPT Assistant states that it is inappropriate to report 93750 (LVAD interrogation) in conjunction with insertion/replacement codes 33976, 33979, and 33981-33983. Are all interrogations in the entire inpatient encounter included, or should interrogations that occur after the date of service of placement be additionally reported?

We are having some debate regarding what it means when a "new post operative period" begins. If a doctor does a 90-day procedure on 07/01 and then an unrelated 90-day procedure on 7/15, according to CMS global surgery booklet, a new global period begins. Does this mean the original 90-day procedure global has stopped and the clock is completely reset? Or does this just mean a "new global period starts" for the new unrelated procedure and the previous procedure is still in its 90 day period? (The new global period does not affect the previous surgery but allows for 100% payment for the newest procedure.)

When an interventional radiologist places a nephroureteral catheter for nephrolithiasis and the urologist doesn't perform the nephrolithotomy procedure until a week or so later, does the interventional radiologist bill 50433 or 50437 in this case?

Is the new category III code 0544T considered a Lampoon procedure?

How would you suggest I bill recanalizations performed with multiple CTO wire without angioplasty? 1) Recanalization of the left iliac vein (successful). 2) Multiple attempts to recanalize the PDA to create AO-PA shunt (unsuccessful). Should we reporte unlisted code for both or 37248-53/37246-53?

Patient taken emergently to the OR for bleeding from left neck. Right transfemoral access with left carotid angiogram. Stent-assisted angioplasty using Viabahn stent graft of the internal carotid artery. Deployment of stent graft abated all bleeding. Would this be billed with unlisted code 37799?