Ask Dr. Z

I have an EP physician performing LV pacing and recording (93622) post PV ablation with the adenosine administration. He reports: “The ablation catheter was placed in the LV and adenosine was administered in two separate 12 mg doses. There was no evidence of latent conduction in either the left or right sided veins.” I am not coding 93622 in this scenario – is this correct?

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?

"Under CT guidance a 17 gauge introducer needle was advanced to L3/L4, and aspiration was done, but there was no fluid return. Four core biopsies were obtained with an 18 gauge SuperCore system. Samples were placed in sterile jar and sent for microbiology." Would this be 62267 or an unlisted code?

During an attempt to create an endovascular AV fistula, the physician performed a balloon angioplasty of a lateral branch of the cephalic vein to try to disrupt the valve in order to allow the deep system to fill the superficial system, allowing him to proceed with the endo AV fistula creation; however, it was unsuccessful. Would it be appropriate to code for the balloon angioplasty in this setting?

I see a lot of patients come in for routine dialysis catheter exchange with ESRD, and I code this as Z49.01, N18.6. My reviewer recommended to me that I should add Z99.2 as well. My view is that Z49.01 includes the fact that the patient is on dialysis, and there is an "excludes 1" between these two codes stating they should not be reported together. Her view, which I can see as well, is that there is a "code also" notation under N18.6 stating to add the Z99.2. She also pointed out that Z49.01 doesn’t give the full picture because it doesn’t state if the patient is on temporary or chronic dialysis. For example, if patient had a temporary dialysis catheter and was coming in to have it replaced with a permanent catheter, Z99.2 would help explain that the patient needed chronic dialysis. What are your thoughts on this?

If the provider performs CPT 19083, which includes guidance, and 38505, which does not include guidance, can you bill 76942 for the guidance used while completing 38505?

Aorto-bi-femoral bypass was graft was done, and endarterectomy was required in aorta to facilitate an adequate anastomosis. Would this endarterectomy be separately billable?

This question pertains to facility coding. In our hospitals when patient is referred for hysterosalpingography the gynecologist comes in for the catheterization and injection portion of the procedure (58340). The radiologist is responsible for the S&I (74740). Should we have both specialties providing separate notes for their respective portion of the procedure? Or would you say if the radiologist dictates a note describing the findings and also and mentions that gynecologist was present that is sufficient and compliant documentation for billing both codes?

Some providers have indicated a need to perform 3D rendering prior to placing a gastrostomy tube. They indicate this is needed in order to determine a safe route to the stomach. Since placement of a gastrostomy tube includes image guidance, I do not believe 76377 is separately reportable. Can you confirm?

How should we code a T12 costovertebral joint injection? "Under fluoroscopic guidance, a 22 gauge spinal needle was advanced into the right T12 costovertebral joint.  A mixture of 1 mL of DepoMedrol 80 (80 mg/mL) and 1 mL 0.5% ropivacaine was injected. The 22 gauge needle was positioned just under the right T12 rib, and an additional 2 mL 0.5% ropivacaine and 1 mL of dexamethasone (10 mg/mL) was injected."

Is arteriography for the lumbar arteries subjective to the reason for the exam? We sometimes see the doctors select L1-L4 and branches off the lumbar arteries to look for bleeds. If the dx is Flank hematoma from a fall and they don't mention spinal process in the findings, would this be coded 75705 or 75726? (There is evidence of active extravasation from a lateral branch off the right L3/L4 lumbar artery-dx right flank hematoma.)

When a 93459 is the intent, but the catheter is unable to be manipulated across the aortic valve, may we still code the 93459? The attempt was made. If so, do we need to add modifier -52? Selective coronary angiography with graft angiography was what ended up being performed. I'd appreciate guidance stating if 93459 or 93455 is most appropriate.

I see an answer from 2018 and just want to be sure the guidance has not changed. A cardiologist goes to the EP lab to shoot the coronaries during an ablation (usually a VT ablation) - we would not bill for the coronary angiogram. The cardiologist cannot bill either. (If called to do angiogram for sudden onset of CP - can we bill?)

Would this be considered an occlusion or embolization and substantiate the use of 61626 head or neck and R&I 75894? If not, what CPT code would you recommend and why? "Local anesthetic was applied in the marked incisions. With the help of ultrasound, we introduced an 18 gauge needle in the venous lake anteriorly in the right side lateral to his nose, and back bleed was seen. We then injected contrast and confirmed under fluoroscopy that we were inside the vascular malformation. Then using Sotradecol we injected the venous lake without difficulties under fluoroscopy. We turned our attention to the posterior part of the vascular malformation, we introduced an 18 gauge needle in the venous lake. We then injected contrast and confirmed fluoroscopy that we were inside the vascular malformation. Then using Sotradecol we injected the venous lake without difficulties under fluoroscopy. After the second injection of Sotradecol the vascular malformation started to become edematous, which was expected given the Sotradecol."

Can 93623 be coded for review for hibernating myocardium post ablation?

When a vascular surgeon is called in to a procedure due to bleeding, and performs direct suture repair of both the iliac artery and the iliac vein in the same surgical site, can we report code 35226 twice for the repair of the artery and the vein?

If my provider performs a fistulogram and angioplasty in the peripheral segment (venous anastamosis), then also obtains femoral access due to 100% occlusion of the innominate vein and performs angioplasty, am I correct in assigning 36902 without modidifer -52, 36012, and 37248? And what about if he does a complete fistulogram via AVF and finds patient to have total occlusion of subclavian, gains access through femoral, and performs angioplasty of subclavian? In these instances are we okay to report catheter placement with intervention code via remote access as well as 36901 or 36902 without modifier -52?

Would you code a TIPS revision or mechanical thrombectomy and thrombolysis? Day 1 patient had thrombosed TIPS, and they performed a mechanical thrombectomy and overnight thrombolysis. Day 2 patient had another mechanical thrombectomy with thrombolysis cessation. All procedures were within the TIPS region.

Would the following be 20670 or 20680? If 20680, would you please explain why? "Patient was brought to the operating room and induced under anesthesia. He received Ancef and vancomycin for antibiotic prophylaxis. Sternal wound was prepped and draped in standard sterile fashion with chlorhexidine. Timeout was observed per standard guidelines. Previous upper median sternotomy incision was reopened, and the fistulous tract was tracked down to the third manubrial wire. Further dissection continued to fully dissect the upper three manubrial wires as well as the top sternal wire completely. We sent some deep cultures. All three wires were cut and removed without any incidents. The bone itself looked well-healed with no evidence of any purulence or gross infection. The wound was then irrigated with antibiotic solution and approximated with absorbable Vicryl sutures for the deep layer to cover the bone and then several more layers of Monocryl sutures. The edges were infiltrated with lidocaine Marcaine mixture. Dressings were applied, and patient was awoken from anesthesia and transported to recovery room in fair condition."

When a doctor takes out an infected pacemaker or ICD and talks about how much tissue was debrided, I bill code 11042 with an -XU modifier along with the 33235, 33233 for pacemaker or 33244,33241 for ICD. However I was recently told that per NCCI the debridement is included in the surgery. Is it included only if the debridement is done for surgical approach? Is it better to use modifier -22?

If a physician does not provide a start and stop time or state the exact number of minutes, but rather states "face-to-face moderate sedation time was 'approximately' 20 minutes", is this acceptable in order to report code 99152?

Bilateral pulmonary thrombolysis is initiated via two separate accesses/catheters via the right CFV. Is it appropriate to code 37211-50 in this instance, or does it have to be two separate veins (i.e., right and left)?

We have a congenital cath patient with an interrupted IVC with catheterization and imaging done of the azygos vein. Is unlisted 76496 the best code for this imaging?

Day #1: Patient had a dual PM upgraded into biventricular PM with only an LV lead inserted. CPT 33229, 33225. Day #2: Patient returned to the OR due to LV lead dislodgement. Repositioning attempted but unsuccessful. LV lead was then replaced. CPT 33234, 33224. Both procedures occurred under the same facility encounter. For facility coding, would it be appropriate to report the LV lead replacement on day #2?

A patient had an IABP placed for cardiogenic shock the day before but due to malpositioning they are brought back the next day. During the session on the following day, the kinked malpositioned IABP is removed and a new IABP inserted (33967 and 33968-XU). During maintenance of pressure for homeostasis, the IABP again dislodged due to the acute angle of the arterial insertion site. The IABP was removed (33968-XU,76) and another new IABP inserted (33967-76). Per CPT Assistant, Nov 2011, both the insertion and removal may be coded when done during the same session for this type of scenario, but would you code the IABP insertion and removal twice each with the appropriate modifiers or only once?

I see conflicting info on submitting 61645 and 37215 (with DEP) together. In some of these Q+A's on this site it says bill both, but #47 instruction states this: 47) Cerebral artery thrombectomy code 61645 bundles ipsilateral catheter placement, diagnostic imaging, thrombolysis, intracerebral balloon angioplasty, and/or stent placement, vasospasm therapy, and follow-up imaging." I just would like to know what is correct. I know some of the advice was older, but I'm wondering what your take on this is now?

If myelopathy or radiculopathy is not mentioned, but the statement is "lumbar spondylosis", do you report ICD-10 code M47816 or M47896?

Would you charge 93657 or 93655, or both, for the following ablation(s) post PVI (93656)? "PVI successfully performed and entrance/exit block confirmed. Post PVI, pacing in LPV induces atrial fibrillation that then organizes into an atrial tachycardia. Intra-atrial septum is ablated, and arrhythmia is terminated. Additionally CFEs are ablated, and ablation of LA roof is performed for the potential development of LA flutter." How do you code these types of arrhythmia post PVI that start out as Afib but then morph into something else that would be captured by 93655 when there is only one site of ablation and both arrhythmia are terminated?

Our provider selectively catheterizes the left superficial femoral artery from a right femoral approach. Pulling back from there they catheterized the left hypogastic artery. Should this be 36247 and 36246? Or 36247 and 36248?

We have a patient who is having his dual lead pacemaker generator replaced and an open epicardial lead placed. We are coding 33202 for the epicardial lead placement; however, I'm unsure about using 33221 vs. 33229. CPT Assistant is stating 33221; however, it does not state the removal of an existing pulse generator, whereas 33229 does.

Could you please clarify "inpatient-only" category for code 33477. Does this mean the intervention should only be done during an inpatient stay? I have a case where the procedure was done in hospital outpatient setting. Will reimbursement be affected by this?

A patient with peripheral vascular disease/foot ulcer/gangrene was scheduled to undergo angiography/intervention of the bilateral lower extremities. (Doppler evidence of disease.) After moderate sedation was given, the cath lab tried to gain arterial access but was unable to. From the cath report: "Procedures performed: Moderate sedation initial 15 min. Technique: Intro micro stiff kit was used to get arterial access. New intro micro stiff kit used to get arterial access. Access aborted. The access area was covered with a dressing." The immediate post-operative notes (two) state the following. "Attempted angiography, unable to obtain access secondary to patient uncooperative, unable to sedate." "Attempted angiography, unable to obtain access secondary to patient movement despite attempts at conscious sedation. Patient is s/p CVA and difficult to sedate. Patient continued to move legs despite attempts at conscious sedation. Procedure aborted." What would a hospital code in this instance?

Is code 58805 or 10160 most appropriate for the following? "TECHNIQUE: Percutaneous ultrasound-guided aspiration through 5 French Yueh catheter. Sterile; 1% lidocaine for local anesthesia. Location: Left lower abdominal quadrant and right lower abdominal quadrant. Needle size: 5 French Yueh. Fluid amount/Color: 1.4 L total fluid; 300 mL yellow fluid from the right lower abdominal quadrant and 1.1 L yellow fluid from the left lower abdominal quadrant. Complications: None. Laboratory: None. Successful ultrasound-guided percutaneous therapeutic aspiration of recurrent symptomatic ovarian cyst."

Physician completes 93656. 93657 is documented. Physician then states,"We then reintroduced the HD grid cath. All veins were confirmed to be isolated. The superior posterior wall was also isolated by the balloon (posterior roof line created due to ongoing AF) AF persisted. The CIT mapping data was then assessed. There were two additional sites re-entry (micro-atrial flutter rotating about a phase singularity - distinct mechanisms of arrhythmia from the previously ablated AF) These sites were located in the low posterior wall inferior to the LIPV as well as very close to the transseptal site on the fossa. Both sites were sequentially targeted for ablation with the tacitcath." Physician requests two units 93655. Is this sufficient documentation, or would a specific arrhythmia need to be documented?

My provider performed coronary angiography, bypass graft angiography, and cinefluoroscopy of mechanical prosthetic aortic valve as follows: "Left wrist catheterized with 11F. Diagnostic coronary angiograms performed in multiple projections....(findings then delineated). Cath used to cannulate LIMA graft to LAD for angiograms....(findings then delineated). I performed cinefluoroscopy of mechanical prosthetic aortic valve and was only able to visualize one leaflet moving as expected. Second leaflet was not mobile or visualized in any view. I became concerned that he had partial prosthetic thrombosis...." As this point, another provider entered the cath lab to perform TEE, and the procedure continued on from there. Am I able to submit 93455 with 76000 for the prosthetic valve fluoroscopy, or is the 76000 included in the 93455? CodeCorrect says it is billable with a modifier, but I do not know whether this would constitute a situation where that would be appropriate.

Can you please advise on the CPT selection for the following scenario? "After the administration of subcutaneous lidocaine, using fluoroscopic guidance in both the AP and lateral projections, two spinal needles were inserted to the level of the periosteum to the right and left along the sacrococcygeal fracture site. To ensure that the spinal needles were appropriately placed, a small amount of contrast was injected in each spinal needle without evidence of extravasation into the rectum, bladder, or adjacent productive organs. With appropriate placement of the spinal needles along the right and left sides of the sacrococcygeal fracture site 10 mL of 0.25% bupivacaine and 1 mL of Celestone (12 mg per 2 mL) for a total cocktail volume of 11 mL was injected within the periosteum of the fracture site bilaterally for a total volume 22 mL." While researching to find an appropriate code, the injections site of periosteum is not an option. Would you agree with unlisted code 96379?

Are there specific requirements for charging an MRA like there are for a CTA? I have not been able to locate information on anything specific. I see 2D time of flight in the reports but other physicians use other verbiage. Is there a standard?

We have a provider who is regularly trying to bill for a repeat left heart cath, sometimes 93458, but often 93452, within a month of a previous heart cath. Most of these patients do not have a change in clinical status but are coming back for a planned intervention. The provider is now adding this statement to try and support this: "Repeat left heart catheterization was done to guide post procedural hydration; however, complete repeat angiography was not performed due to angiography having been performed less than 1 month previously." We have not seen a statement such as this with any of our other providers. Do you have any guidance or requirements for supporting the billing of a repeat heart cath within a week or month of a previous cath? Is guidance for post procedural hydration supported?

Please clarify when the interventionalist cardiologist can bill for the pre-procedure E&M, Consult, H&P, or Critical Care service when he consults a patient in the hospital and does a procedure (i.e., cath/stent/PCI) in the same day. Can you provide examples of what would be considered significant and separately billable to allow billing for both the E&M service and the procedure? Our providers insist since they have never seen the patient they need to evaluate and make a decision whether to perform the procedure (even when this is a STAT Cath, Code STEMI or a transfer from another hospital with a direct admit order to treat and transfer back).

Patient was here for an angiogram with possible intervention. The procedure was explained in the pre-procedure area. The patient agreed. Once patient was in procedure room on the table, but before any anesthesia, the patient decided he did not want to have the procedure done, and he wanted to go for a second opinion. Would billing 75710-73 be appropriate? Thank you.

We have a surgeon who wants to bill 93882 for a limited carotid ultrasound for the measurements done immediately prior to making the incision for the TCAR procedure. While we understand the clavicle and depth measurments are required to determine if the patient is a candidate for TCAR, the timing of this while the patient is on the table seems not to be the ideal process. The patient has already had a pre-op carotid ultrasound prior to scheduling where these measurements could be captured. Would you consider this a valid charge, or would you consider the ultrasound for sizing and measuring at time of intervention (93882) included in 37215, or should we code it additionally? The physician is also documenting and charging for 76937 for the ultrasound vascular access guidance. 

I work for a Cardiovascular & Thoracic group and our surgeons frequently perform Robotic VATS procedures and wanted to know if there is a CPT/HCPCS code to capture the robotic portion of the service they provide. Unfortunately, S2900 is not reimbursed by any of our commercial carriers or by our Medicare contractor. Your feedback is much appreciated. 

In your book, you note not to report 94621 with 93015-93018. If there is a separate indication for the cardio stress test and a separate report, is it ever appropriate to report 93018 and 94621-26 together?

Would 71250 be appropriate for this? We are preparing to activate a new service within CT: Veran Navigation that will assist CT surgeons to localize pulmonary lesions in the OR. To accomplish this a CT scan is performed prior to the patient entering the OR space. The data from said scan is then downloaded into a navigational system for use in the OR. Is this billable?

When an IR provider is performing AAA repair, let's say using CPT code 34705, and a general surgeon is necessary to perform the bilateral arterial cutdowns, how do you bill the general surgeon's part of the procedure? In the cases we are seeing, the general surgeon performs the arterial cutdowns, leaves, and then returns at the end of the procedure to close the wounds. With 34812 being changed to an add-on code it has come into question what is the most appropriate way to report the general surgeon's service. Should we be using an unlisted code for the general surgeon?

How would you code a completion coronary angiogram done in the OR by the cardiologist immediately after a CABG to assess the patency of the graft used? Would you code this as 93454? "Left radial artery accessed using ultrasound guidance. A 6 French sheath was inserted into the artery. The LIMA was engaged using a 6 French VB-1 catheter. This concluded our procedure. The patient tolerated the procedure without any complication. TR band was applied over the access site. Widely patent LIMA graft to the LAD with mild to moderate disease distal to the touch down site."

Can a liver elastography be performed with either a complete abdomen ultrasound 76700 or a limited 76705?

I have a Y-90 that was delivered in segment 2 and 3 of the left hepatic artery. Billing is requesting 36247 and 36248 removed because "embolization states it includes all 'mapping' and it appeared from the notes that they were finding their way to the site to insert the brachytherapy.” Can you please advise?

Heart catheterization for pulmonary stenosis or partial anomalous pulmonary venous connection. Would you code as congenital or use a non-congenital heart catheterization code?

For the new Ellipsys, we have doctors going to start. Do you have any quidance for the new AVF creations? Are we years away from codes and just use catheters?