Ask Dr. Z

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

We are doing a study comparing RFR and FFR and sometimes FFR and IFR. Do we just charge 93571 for the FFR and not charge 93571-52 for the IFR/RFR?

We performed ultrasound-guided bilateral breast cyst aspiration. I don't see that a bilateral modifier is appropriate for 19000, and code 19000 has an MUE of 2. Should this be reported as 19000, 19000, 76942? Or 19000, 19001, 76942? This is for hospital OPPS.

Patient with popliteal aneurysm undergoes stenting of the superficial femoral and popliteal arteries. A stent was placed in the below-knee popliteal artery and deployed up into the superficial femoral, spanning the popliteal aneurysm. Additional stents were placed as extensions. Would this procedure be coded with 37236 only, since only one artery had an aneurysm that was treated? Or would 37236 and 37237 be required?

We bill for the facility. Can we bill 64999 along with 63685 and 63655 for the extra work of the lysis of adhesions? "It was noted that there was extensive epidural adhesions limiting midline placement of the lead. A cephalad laminotomy was therefore undertaken to approach the T8 lamina from a cephalad to caudal direction to dissect the adhesions with microdissection. This added approximately 45 minutes to this procedure and increase the complexity of this procedure compared with a comparable procedure of this kind. Extreme caution was taken not to put any anterior pressure on the thecal sac throughout this microdissection. Once the epidural space had been freed up off all the adhesions, this was followed by placement of the paddle lead placed in the midline behind the T7 and T8 vertebral bodies in the posterior epidural space."

How would I code ultrasound-guided injection of right suprascapular and axillary nerve pulsed ablation?

Provider performed an intra-arterial nitroglycerin injection in the dorsalis pedis after performing atherectomy in the anterior tibial. Can the injection be billed? If so, would it be appropriate to use 96373 for that injection?

Our provider performed endothelial study in clinic. There is a complete two-page report with all the measurements. The final interpretation states, "Normal endothelial function noting a 10.2% vasodilation after release of occluded brachial artery." The crosswalk code for 0337T for 2019 is 93998, Unlisted noninvasive vascular diagnostic study. Please advise if this is a billable service in a clinic setting.

What would be the CPT codes assigned for placement of the AbbVie PEG-J tube for the treatment of Parkinson's disease by an interventional radiologist?

Is there a CPT for this, or would we use unlisted? "The right common femoral artery was then cannulated and a 6 French sheath was placed; another 6F sheath was placed in the left femoral vein. A balloon-tipped temporary pacing catheter was advanced from the left femoral vein to the apex of the right ventricle. Pacemaker capture and thresholds were checked. Careful attention was then focused on placing the pigtail catheter in the anatomic apex of the left ventricle. The pigtail catheter was removed, leaving the Safari guidewire in the left ventricular apex. Valiant Navion 34x34x52 mm thoracic stent graft was advanced over the existing LV guidewire under fluoroscopic guidance to the aortic annulus. The stent graft was then manipulated so that it could be seated distally at the STJ. It was then deployed during rapid ventricular pacing at 200 beats per minute. The graft was implanted in the ascending aorta so that it extended from the STJ to the origin of the innominate artery. There was no encroachment on the ostium of the innominate artery." 

if a patient has a CTA coronary and shows blockage in the coronaries, and we fix that vessel, I know we cant charge the diagnostic... but can we charge for the LHC pressure since the CTA can't give us that information but no coronaries?

What codes you suggest for this injection? "DX: Eosinophilic granuloma of left clavicle. Therapeutic methylprednisolone injection into the lesion. With Ultrasound guidance a 18-gauge needle was directed into left clavicular lesion. 1 ml of 40 mg/ml Depo-Medrol was injected into the infusion mixed with 2 cc of 0.25% bupivacaine. Successful methylprednisolone steroid and anesthetic injection into the left clavicular lesion."

May I report code 93623 when the documentation states, "Drug challenge was administered to assess for dormant PV conduction and triggering sites." It also states, "Pulmonary vein isolation was confirmed for greater than 30 minutes following ablation despite challenge with isoproterenol, adenosine, and left atrial pacing and recording to confirm entrance and exit block into and out of the pulmonary veins." I am receiving conflicting information about if this will suffice.

This is a diagnosis question on coding encounters for chronic pain control. In the official guidelines for ICD-10-chapter 6-b-(b)-(ii)-Sequencing of Category G89 and Site-Specific Pain Codes, it is understood that if patient is coming in for chronic pain control management that G89.29 is assigned first. The question we have is with “site-specific pain codes”. Do we still use the site-specific pain code(s) if the definitive reason for the pain is known? Example: chronic low back pain for epidural with findings of lumbar spondylosis.

Physician completes 93656. 93657 is documented. Physician then states, "We then provided adenosine to permit CIT mapping. Two additional sites of interest were found in the low inferolateral LA as well as the mid anterior LA. These sites displayed rotational activity - mechanism of arrhythmia independent from one another and independent from the primary AF mechanism. These sites were sequentially ablated, with lesions delivered as described below." Physician requests 2 units - 93655. Is this sufficient documentation, or would a specific arrhythmia need to be documented?

I would like clarification on billing for a cardioversion performed in the ED. NCCI chapter 11 states, "Physicians shall not report 92960 for emergency cardiac defib. CPT 92960 describes a planned elective procedure." Does this indicate that if a patient comes to the ED, and they are not in CODE, but merely in afib or flutter and discovered at that time, and they performed a CV, is this separately payable with a signed consent?

What CPT code we would use for the removal of the AV graft stent? "1) Antegrade and retrograde ultrasound-guided access to the right forearm AV graft (image stored x2) with fistulogram and left brachial arteriogram. 2) Foreign body retrieval, arteriovenous graft covered stent removal. 3) Pharmaco-mechanical thrombolysis of AV graft. 4) Percutaneous transluminal angioplasty of arterial and venous anastomosis with completion fistulogram. PROCEDURE: Through the antegrade sheath, wire access was obtained through the arterial limb stent graft and into the venous limb of the graft. A 10 mm Gooseneck snare was advanced over the wire. The stent was constrained with manual compression on the skin and captured with the snare. The snare and sheath were removed as a unit over the wire. Covered stent graft was removed in its entirety. Successful retrieval of the constrained indwelling covered stent in the arterial limb of the graft. The previously noted iatrogenic graft-venous fistula is no longer present. Successful arteriovenous graft thrombolysis."

What procedure code would you recommend for this procedure? "History: Laminectomy and post surgical seroma. Body radiology consulted for aspiration of the fluid. PREPROCEDURE IMAGING: Sonography of the lumbosacral spine was performed with the patient in the prone position. A permanent image with ultrasound guidance was recorded and stored in patient,s medical record. INTERVENTION: Standard Timeout procedure was performed. The patient was draped and prepped in the usual sterile fashion. 1% lidocaine was used for local anesthesia. Under real-time imaging guidance, a 20-gauge spinal needle was inserted into the  fluid collection.  20 cc's of serosanguineous fluid was aspirated. Images were obtained documenting ultrasound guidance. The needle was then removed and bandage applied. A specimen was sent for culture and gram stain. There was no immediate complication. IMPRESSION: Ultrasound guided aspiration of fluid collection in the postlaminectomy bed. Approximately 20 cc of serosanguineous fluid was aspirated and submitted for microbiology analysis."

Routine exchange of ileal conduit stent catheter done 6/12/19. Patient returned 6/18/19 with suspected dislodgement of same stent/catheter. "Retrograde pyelogram through the existing catheter confirmed dislodgement. Catheter was cut and removed over 0.035 guidewire. With the aid of a 5 French Glidecatheter, a Bentson wire was able to recanalize the ileal conduit, and catheter was advanced into renal pelvis. This confirmed with small injection contrast. Catheter was removed, and a new 10.2 French catheter was placed. Pigtail locked in renal pelvis. Infusion of contrast confirmed appropriate positioning." I don't think this supports 50684 since a complete description of the renal collection system is not present, only confirmation of dislodgement. I coded only 50688, 75984. Is that correct, or should I add 50684, 74425?

Would code 36573 or 36572 be correct to use if a PICC was inserted using ultrasound guidance and tip confirmation was made with the Sherlock 3CG System?

I have two questions: When a doctor indicates a patient has peripheral arterial disease, do you automatically code this to atherosclerosis? For the case below, since it states "multiple risk factors for atherosclerosis", it would seem to me the patient does not have atherosclerosis yet. However, a coder is stating this should be coded as I70.261, and I'm not sure I agree. "Preoperative diagnosis: Peripheral arterial disease. Right foot gangrene. Multiple risk factors for atherosclerosis. Postoperative diagnosis: Same. Procedure: Right femoral to popliteal bypass with 6 mm. Estimated blood loss: 100 ml. Complications: None. Patient tolerated the procedure well. Grafts/implants: 6 mm Propaten. Findings: The graft was tunneled deep to the sartorius muscle. End-to-side proximal and distal anastomoses were performed. An oblique right groin incision and right medial thigh incision were made. Both incisions were carried down through the subcutaneous tissue using a combination of sharp dissection and electrocautery."

This is for a complete traumatic amputation of the extremity at the elbow to revascularize the arm prior to re-attachment. I'm looking at either 35236-22 x 2 or 35523 and 37799. What are your thoughts? “We began with a reversed greater saphenous vein interposition bypass graft. Proximal anastomosis was sewn in a continuous fashion using 6-0 Prolene suture. Both brachial artery proximally and saphenous vein were spatulated. Once the proximal anastomosis had been performed, the distal anastomosis was performed in the ulnar artery in a continuous fashion using 6-0 Prolene suture. We decided to perform a distal brachial vein to proximal basilic vein interposition bypass with a saphenous vein. We used this similar approach. The vein was then sewn in place with a 6-0 Prolene suture. There was a brisk antegrade flow of the vein once the proximal anastomosis and distal anastomosis were performed. Next,the more proximal anastomosis of the basilic vein in the upper arm was then performed. This was also performed with a 6-0 Prolene suture after the artery and vein have been spatulated.”

We are looking at bringing in some new technology to treat PE clots and DVT clots and want to get your input as to whether or not these qualify as mechanical thrombectomy devices. The company is called Inari Medical, and one of the technologies we are looking at are the FlowTriever system. The FlowTriever is used to treat pulmonary embolism. This system uses a syringe with a valve and negative-pressure to suck out the clot. Any remaining clot is then pulled out through some self-expanding mesh discs through a catheter (see animation on website https://www.inarimedical.com/flowtriever/). The Inari coding guide indicates we should bill CPT code 37184 for this, but we are questioning whether this qualifies as a mechanical or aspirational thrombectomy device? For cases where the entire thrombus is collected by the suction syringe, there would be no need for the use of the expanding metal disc part of the procedure. Can we still bill CPT code 37184 in this scenario?

We are seeking clarification on the meaning of the “(primary procedure)” designation in CPT. CPT 33020 states “Pericardiotomy for removal of clot or foreign body (primary procedure)”. We have extensively researched and are unable to locate the meaning of this. Any insight you can provide would be greatly appreciated! Thank you.

A patient with an ICD presents for elective cardioversion for A-fib. Cardioversion is first performed through the ICD; this was unsuccessful. Cardioversion was then performed externally, with success. May the facility code both cardioversions (93799 and 92960) for this visit?

The patient initially had an infusion catheter put in through a percutaneous brachial approach. Now patient is back for the infusion cath removal (37214) two days later; however, for the surgeon to safely remove the long sheath he has to do an open brachial exposure and repair it. Can I also submit code 35206? 

Main pulmonary angiogram. Selective left pulmonary angiogram. Selective right pulmonary angiogram. Right lower lobe pulmonary angiogram. Mechanical thrombectomy left pulmonary artery. Mechanical thrombectomy left lower lobe pulmonary artery. Mechanical thrombectomy right pulmonary artery. Mechanical thrombectomy right lower lobe pulmonary artery. Mechanical thrombectomy right upper lobe pulmonary artery. Pulmonary pressure measurements. Questions: 1) Can we get the diagnostic if the patient had a CTA and there is no change in status? 2) I know we only get 37185 / case but 37185 can we get for multiple branches being treated? 3) Can we code for each catheter placement with multiple branch treatment? 4) Is there still Medicare coverage issues?

Successful PCI of LAD and diagonal, initially treated with main branch stenting (3.0 x 30 mm in LAD, post-dilated to 3.25 mm) and provisional balloon angioplasty of diagonal however the diagonal branch did require stenting after this. Therefore, reverse mini-crush technique used with 2.5 x 15 mm DES placed to diagonal, crushed, final kissing inflation with 0% residual and TIMI 3 flow in both branches There is a bifurcation lesions-successful-crush technique. Would 92928-LT and 92929-LT be appropriate here for the intervention? I've not seen a crush technique before.

I have a question regarding pre and post EKGs (93005) when billing with the following codes due to NCCI edits: LAA 33340/TMVI 0483T/ MVR 33418, 33419/TAVR 33361. Is it ever appropriate to charge EKGs performed before and after with modifier -59 for either of these procedures? Our facility wants to charge these before and after EKGs with TAVR/TMVR/TMVI and LAA procedures. What is your guidance for the proper coding?

"TCAR US assessment was performed and skin was marked. The CCA was noted to be suitable for access above the clavicle with no calcifications. Distance from CCA at the clavicle to the lesion was measured at 8 cm. The ICA stenosis was noted, and the skin was marked at the level of the disease. Next with US guidance, the left CFV was accessed with a micro sheath, and over wire exchange it was upsized to 5 French sheath." Can code 76937 for access of the common femoral vein and US assessment prior to TCAR be separately reported along with 37215?

We are having a hard time determining if this should be 2 or 3 levels. "The endplate of the L5-S1 level was identified. I then proceeded to utilize a 27 gauge, 1 1/2 inch needle and injected 1 mL of 2% lidocaine at each target location on each side. I then proceeded to utilize a 22 gauge Quincke needle, and directed it to the first sacral ala on the right. After bony contact was made and after negative aspiration, I proceeded to inject a 1 mL solution containing 0.2% Ropivicaine and PF Dexamethasone. The same procedure was repeated at the L4-5 junction at the superior articular process and the transverse process, as well as the L3-4 level. This procedure was repeated on the opposite side resulting in a bilateral L4-5 and L5-S1 medial branch nerve block with local and steroid." To me he's injecting 3 levels, but his last statement makes it seem his intention was to only block 2 levels.

"Patient scheduled for CVC tunneled catheter exchange. Wires placed through each of the catheter lumens into the SVC under fluoroscopy. Blunt dissection and superficial sharp dissection around the catheter were performed. Despite this, and despite with vigorous traction on the catheter, the catheter would not come out. Likely this is due to dense adhesions around the cuff, which is deep in the thigh. Therefore, the catheter was left in situ and no further attempts were made to try to extract the catheter." We have different opinions about coding this scenario. Since no new catheter was used and procedure was stopped without removing the existing one, can we code this with 36589-74 instead of the scheduled procedure 36581-74? Please advise.

Procedure performed 1. Right femoral and left femoral arterial access 2. Left femoral venous access 3. Temporary pacemaker placement and removal 4. Aortic valvuloplasty with a 20 mm balloon 5. With a transcatheter aortic valve replacement 23 mm sapien 3 valve 6. Balloon angioplasty of the right common femoral artery 7. Art Line.

Would the professional CPT code for this case only be 33361, as the other elements are included in the procedure?

We have a doctor who did common and internal carotid angiography for roadmapping prior to sampling the petrosal sinuses bilaterally. I know any venography and venous catheter placements are bundled with 36500 and 75893. Is the same true for the arterial system, or can both the carotid angiography and the venous sampling be coded together?

I hope you can help us with this matter. In 2018 under question 11313, you have responded that we cannot bill 76937 US guidance with EP or cardiac Procedures. Do you have any updated information if we can do that now? We do not get an edit when submitting charges, but we wanted to make sure that it's appropriate to bill 76937 with diagnostic, interventional cardiac, EP ablations along with pacemakers and defibrillators.

I have two questions regarding the billing of intraoperative TEEs when performed by someone (cardiologist) other than the performing provider (interventional cardiologist) and there is a complete separate report. Why is there an NCCI edit that you cannot bill 93355 with 33361, 33340, 33418, 93580, and all other structural heart procedures? What is appropriate way to code/bill? Second question, how would you code an intraoperative TEE performed during a cath lab procedure that is not a structural heart procedure? The cardiologist is documenting a complete separate report and is not the performing provider. Would you bill 93312, 93320, 93325, 93318, or something else?

Our providers will typically do a palmar arch evaluation in the CABG preplanning phase. There are a couple different codes being contemplated for this exam, and I would appreciate your input. The text of the exam reads, "Left palmar arch evaluation: The left palmar arch is complete per color Doppler and pulse wave Doppler. No significant plaque or stenosis observed in the left radial artery. Impression: Complete palmar arch. No stenosis of left radial artery." We are looking at 93971-LT versus 93922-26-52. What are your thoughts?

The cardiologist performed a TEE prior to a planned ablation to evaluate for thrombus and used as guidance for the transseptal puncture for the ablation performed by the electrophysiologist. He gives details for findings prior to the puncture, details of the transseptal puncture accomplishment, and details following the puncture. Can we bill 93355, or should this be 93312?

When physician performs IVUS on IVC (37252) bilateral RENAL veins, CIV, EIV, and EIV, can we append modifier -50 to 37253?

Codes 50390/74470 are for aspiration of a renal or pelvic cyst. What would we use for needle aspiration of a perinephric fluid collection?

Do we use CPT code 93975 for a duplex study on two original kidneys and one transplanted kidney blood flow?

When uterine fibroid embolization is performed for clinical indications of “uterine leiomyomas with dysfunctional uterine bleeding and pelvic pain” or “uterine fibroids causing menorrhagia and pelvic pain”, would you assign 37244 or 37243 for the embolization? Per CPT guidelines, embolization for uterine fibroid would be coded 37243; however, CPT also states to code for the most immediate indication for the procedure, which in these instances was the abnormal bleeding.

Please explain the difference between codes Z01.810 and Z01.818. My understanding is if a patient has an OV and EKG with a cardiologist to clear his heart for surgery being done by another physician (the surgery is any type of surgery), you would use Z01.810, and my understanding is to use Z01.818 when a cardiologist just reads an EKG for preop work that was ordered by another physician for clearance for any type of surgery. Please give me examples for each code. 

If a patient has fistulograms performed of three different abscesses and injection of contrast, and findings are documented at all three abscess sites, can you bill 76080 x 3?

Would it be appropriate to use code 34705 for the Nellix EVAS, or should we use unlisted?

Are there situations where fentanyl alone can be used as a sedative or for moderate sedation? While I am sure it would not be the preferred method, is it possible with certain medical conditions?

The prostatic artery may be selected for embolization to treat BPH (37243) or prostatic hemorrhage (37244), but if patient has BPH and bleeding, which code I should use? If patient has cancer, and also cancer causes bleeding, which code I should use?

"CLINICAL HISTORY:  Liver masses. Patient had biopsies done on the left and right hepatic lobes." In the past you've advised to add modifier -22; this modifier is not valid and not on the approved HOPD list. The code is allowed up to three times per day according to Code Correct. We are hospital based; will 47000 x 2 be okay, or what do you recommend?

A 13-year-old with bicuspid aortic valve and moderate aortic stenosis and moderate regurgitation by ECHO, with recent chest pain, is undergoing right heart cath, retrograde left heart cath with ascending aortogram. Is the cath to be coded with 93531 (congenital right/left cath) or 93453 (non-congenital right/left heart cath)?

"Catheter was passed from the RA to LA and pulmonary veins." Is this statement sufficient enough to report code 93533 in a common atrium?