Ask Dr. Z

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

We are currently struggling with this code combination because we cannot figure out if this has sufficient documentation to report codes 27095, 75325 or what we could bill if not. "Diagnosis: right hip degenerative joint disease Patient was taken to op suite, transfered to table in supine position. MAC anesthesia administered. Right anterior hip region was prepped. Xrays brought in and marked level of the trajectory of the femoral neck. 18 gauge spinal needle introducted bilateral from the neurovascular bundle and directed down to head-neck junction under x-ray guidance. Isovue was then injected and got a positive hip arthrogram. This was followed by injection of Celestone and Naropin, needle tract injected with lidocaine upon withdrawl." What is required documentation for 75325?

What CPT code(s) is the most appropriate for this procedure: 33990, 34716, or 33975? "PROCEDURE: The patient was induced with general anesthesia, and the neck, chest, abdomen, groins, and legs were prepped and draped in the usual aseptic manner. An incision was made in the right infraclavicular space and dissection carried down to the subclavian artery. After heparinization, a partial occlusion clamp was applied, and a 10 mm Dacron graft was sutured to the subclavian artery in an end-to-side fashion using the 6-0 Prolene suture. The patient had extremely poor vessel tissue that easily dissected away from the wall of the vessel. Once the anastomosis was complete, the end of the graft was tunneled out subcutaneously to a more lateral position to the right shoulder, and the Impella 5 L left ventricular assist device was inserted under fluoroscopy in standard fashion. We shortened the graft down to the level of the skin at the exit site and anchored the device in position. The infraclavicular incision was irrigated and then closed with sequential layers of Vicryl suture."

What are the CPT codes for insertion of a biventricular pacemaker with RV lead, LV lead, but no atrial lead?

Our cardiologists are using the Penumbra Catheter system to perform coronary thrombectomy. Since Penumbra is a mechanical device, should we report code 92973?

Can we bill for atherectomy (e.g. 37225) when using the DABRA laser system from RA Medical Systems? It was cleared by the FDA for crossing chronic total occlusions, but it is not clear to us that it was ever cleared as an atherectomy device.

Does the patient have to have a biliary stent in order to code a removal of biliary drainage catheter? (They are using fluoro guidance.) The patient presents for tube check with possible removal of cholecystostomy and ultimately removed it... I would report code 47537 correct?

Can I report code 77012 more than once for a biopsy at multiple sites? "Initially, attention was directed to the medial left clavicle. Under intermittent CT fluoro, a 15 gauge biopsy set was used to penetrate the proximal cortical bone and obtain a 1.5 cm core of left clavicle. This was sent for tissue culture and PCR testing. CT fluoroscopic imaging documented appropriate needle placement and bone. (20220, 77012) Attention then directed to the sternoclavicular joint. Under intermittent CT fluoroscopy, a 16 gauge Cook guide needle was advanced to the edge of the sternoclavicular joint. 2 separate 18 gauge 2 cm cores were obtained. Positioning was confirmed with CT fluoroscopy prior to biopsy. Cores sent for tissue culture and PCR testing. (20220, 77012) Attention then directed to the medial left manubrium. Under intermittent CT fluoroscopy, a 15-gauge Bonopty biopsy set was used to penetrate the proximal cortical bone and obtain a 1.5 cm core of left medial manubrium. This was sent for tissue culture and PCR testing. CT fluoroscopic imaging documented appropriate needle placement and bone. (20220, 77012)"

"Patient received in cath lab for treatment of ruptured sinus of Valsalva aneurysm. A right heart cath with hemodynamics was done, and the ruptured aneursym was closed with an Amplatzer Duct Occluder." This was initially interpreted as treating an aneurysm, so code 37242 was charged. Question is now being raised if an unlisted code should be used instead. Can you please advise of your opinion of this?

I have a patient who had infrarenal aortic stenosis and a stent was placed. Novitas Medicare does not cover I70.0 for 37236. I was going to appeal with records since the LCD never addresses aortic stenosis but wanted your advice. Have there been any coding changes, or do you think this is an error as well?

How would aortography due to AAA during a heart cath for chest pain be coded?

During a CABG, my doctor did a biopsy of a periaortic lymph node. This is the first time I have seen this. His documentation states: "As I was dissecting out the ascending aorta and periaortic tissues prior to cannulation, there was a large periaortic lymph node noted, and this was resected using Bovie cautery and sent to Pathology for permanent." Would this be coded as a 38750? I checked NCCI edits, and it is not a column 2 code for 33533. If it is billable, should I use a modifier -51 on the 38750?

I have never coded a stem cell injection in the spinal vertebrae. The levels injected were T8 -T9 and T9-T10 for degenerative disc disease of the thoracic vertebrae. Would I code as a bone marrow aspiration?

What are the documentation requirements for the category III CPT code 0523T? Does the use of the proprietary software need to be stated? Does "3D functional mapping of color-coded FFR values" need to be stated? Is "an FFR angio further confirmed this with a value of 0.50.” sufficient to use this code? Can non-invasive procedures be coded from use of the software name alone?

Patient came to the department for a ureteral stent placement via an existing nephrostomy catheter. The doctor tried for quite some time, but was unable to get past the obstruction. He decided to stop trying to place the stent, and just changed the nephrostomy tube. He wants to bring the patient back in 4 weeks to try again. We charged for the nephrostomy change (50435) at this time. I was always told to code to the highest level of the completed procedure. Our billing department wants us to charge for the attempted ureteral stent (50693-52). What is the correct way to code this? And is -52 the correct modifier? If we charge for the attempted ureteral stent placement, I assume that we would drop the nephrostomy change.

Intra-arterial infusion of verapamil was done two separate times in a day on two different territories (right internal and left internal). Infusion time was more than 10 minutes for both treatments. Can we bill 61650, 61651 for the first treatment and 61650, 61651 for the second treatment on the same day? This is a Medicare patient. 

Are codes 34705 and 0254T allowed to be billed together if performed?

Patient with existing PA sensor (CardioMems) device coming back for recalibration. Do you still suggest unlisted 93799 for this?

In order to report 93620, if the physician is in the coronary sinus and states the AV node function is normal, does he actually have to say they were in the His bundle to get full credit for 93620? This is, of course, assuming all else was done in the code description.

How should intravascular lithotripsy for peripheral vascular disease be reported? Description of procedure from report: "We confirmed placement of a 0.014 Quick-Cross and confirmed that we were in the dorsalis pedis artery beyond the occlusion. We then used the shock wave lithotripsy catheter to break the calcium in the dorsalis pedis vessel as well as anterior tibial artery using serial pulses. Contrast injection confirmed luminal gain, and this was then touched up with balloon angioplasty. We placed a 3.5 x 4 mm balloon in the dorsalis pedis and brought it up for prolonged inflation."

My providers are doing a six-vessel cerebral angiogram (36224-50, 36226-50, and 36227-50). The provider is also completing bilateral costocervical and thyrocervical angiograms. Would we be able to report 36218 x 4 and 75774 -26 x 4, or are there different codes for the costocervical and thyrocervical levels?

Would you code for the insertion and removal of a Medtronic Linq monitor for ERI in the case below? "Implantable loop recorder removal: The left anterior chest wall was sterilely prepped and draped in usual fashion. Lidocaine 1% local anesthesia was infiltrated over the ILR site. An incision was made over the ILR, and the dissection was carried down to the pocket surrounding the ILR, which was entered. The retaining sutures were cut and removed. The ILR was removed from the pocket. Implantable loop recorder implant: The left anterior chest wall was sterilely prepped and draped in usual fashion. Lidocaine 1% with epinephrine local anesthesia was infiltrated over the ILR site. The provided skin puncture device was used to make a small incision in the anterior chest wall. The provided insertion tool was then inserted into the subcutaneous tissue, and the ILR was injected through the insertion tool, which was then removed. ECG signal was measured and deemed acceptable."

The NCCI Policy Manual states that it is occasionally necessary to perform an epi-aortic ultrasound during a CABG and that you may report CPT 76998 when this procedure is performed. Does the physician have to document something specific to support the medical necessity of coding 76998? I have some physicians that simply state in their operative reports: "epi-aortic ultrasound performed; no abnormalities found." However, I thought the physician needed to document something more regarding the medical necessity [e.g., confirming the patient has extensive arteriosclerosis or a porcelain aorta and it is necessary to perform the epi-aortic ultrasound to find a safe spot to place bypass cannulae, a crossclamp, or a good target for the proximal anastomosis for the bypass graft(s)]. I can't put my finger on any specific authoritative guidelines to support that though. I would appreciate your thoughts on this topic.

I'm currently working with a provider that does a bilateral lower extremity study of deep veins only and bills 93970. Then on another day performs vein mapping on the superficial veins and again bills 93970. Is this correct? My understanding is when 93970 is performed that a complete study includes both deep and superficial veins. I have searched for the documentation requirements for the test and have been unable to find them. Your assistance with how to code and correctly document (with references) this study would be greatly appreciated.

The cath lab in our hospital often performs heart biopsies on patients with transplants. We need assistance in understanding when we can code a right heart cath separately. In an example in your 2019 cardiology reference guide, you mention coding the right heart cath for a patient who had congestive heart failure unrelated to transplant rejection. Could you give us other examples of common diagnoses? It would help us be more clear about when it would be appropriate to code for the right heart cath.

Can you code both a renal biopsy and cryoablation performed at the same encounter? In 2012, you answered that an ablation does not include a biopsy, so it should be coded if performed. Per NCCI: If the biopsy is performed on the same lesion on which a more extensive procedure is performed, it is separately reportable only if the biopsy is utilized for immediate pathologic diagnosis prior to the more extensive procedure, and the decision to proceed with the more extensive procedure is based on the diagnosis established by the pathologic examination. Does this apply to renal biopsy and cryoablation procedure coding at the same encounter? There are no NCCI edits, but we are questioning if the concept of a more extensive procedure performed applies here. Biopsy was performed first, NOT used for immediate pathology, then cryoablation performed. Should both procedures be coded? If so, can you please explain why the NCCI principle would not apply for this situation?

Would code 93650 be appropriate to bill if complete heart block wasn't produced within the study? There was a case in which right bundle branch block was induced, and the AV junction was ablated. Anything "extra" for catheter in basal septal left ventricle when they first went through the anteroseptal region of the right atrium?

What code would I use to unclog an indwelling G-tube using a syringe without using contrast, saline, or fluoro guidance?

I have noticed on some charts that the doctor will document history of paroxysmal atrial fibrillation, then under impression MD will only document atrial fibrillation potentially for a couple months. Can a patient have several different types of atrial fibrillation at one time? How would you code this? I48.91 or I48.0? I want to use I48.0 for specific type documented. Do you agree?

Can we use the mechanical thrombectomy add-on code (92973) when a coronary thrombectomy is performed using the Penumbra CAT RX catheter?

What is the correct ICD-10 code for “elevated bilirubin”? The coding index leads to ICD-10 code R17 using the term “elevated”. This code is located in Chapter 18, which is for symptoms, sign, and abnormal results. Some of my colleagues assign ICD-10 code E80.7 for this indication, which is located in Chapter 4 for endocrine, nutritional, and metabolic diseases.

The patient is going to get radiation for breast cancer on the left side. The physician removed the device, capped the existing leads, and placed a new device on the right side. I have this coded as 33233 and 33208. I am having trouble figuring out what diagnosis code to use. The original pacemaker was inserted for SSS, and that is not supposed to be coded after the patient receives a pacemaker. Would I be wrong if I used Z95.0 and appended an -SC modifier? It doesn't seem like it makes sense coding 33208 with Z95.0. I was looking at Z45.018, but I'm not sure that would be applicable either. Please help!

Micropuncture needle was used to cannulate arterial stump of fistula, and then arteriogram was performed of left forearm. The patient had previous arteriogram earlier that day. I injected dye into the arm with the fistula clamped, but to my dismay got a similar picture as radiology. The dye was sluggishly passed through forearm vessels with the ulnar artery being dominant. The radial and ulnar arteries were carefully dissected out and controlled with vessel loops. The brachial artery was then controlled with a vessel loop. Transverse incision was made in the brachial artery, and a Fogarty catheter was advanced into the radial artery and ulnar artery. Unfortunately I could not pass catheter or extract clot. I injected tPA into ulnar artery, opened radial artery, let tPA out, and then completed arteriotomy closure. The fistula was clamped during this whole time." I'm not sure what code to use since the tPA was not injected in the actual fistula and was not left overnight: 37211 vs. 36904?

"Contrast dye was then carefully injected. This resulted in immediate opacification of the port reservoir and then opacification of the proximal portion of the tubing. There is extravasation of contrast from the disconnected tubing into the peritoneal cavity." CPT codes 43999, 76000. Could you please give an equivalent for the 43999?

Peripheral IVs are placed bilaterally by the nursing staff. Contrast is injected and venogram findings documented. An upper extremity ultrasound is also performed with documentation of brachial and radial artery size only. Both are performed bilaterally. We are thinking 75822 and 93930-52. Is this correct?

"Ablation was performed in atrial fibrillation. The LSPV and LIPV were circumferentially isolated as a common os using RF ablation with first pass isolation. Entrance and exit block of LPVs were confirmed. The RSPV and RIPV were circumferentially isolated as a common os using RF ablation with first pass isolation. Entrance and exit block of RPVs were confirmed. Non PV triggers were observed during or following isoproterenol infusion. Non PV triggers originated from posterior RA and are indicated on electroanatomic map (dark blue tag). Non PV trigger(s) was/were targeted focally along PA posterior wall. Posterior wall isolation was performed (see lesion map) because of non PV triggers and persistence of Afib after PV isolation. Isolation was confirmed with additional RF lesions required after initial first pass ablation. Entrance block and exit block with pacing at 20mA within box was confirmed." Would you report codes 93655 and 93657 for posterior wall ablation when both Aflutter and continued Afib after PVI were seen?

Neointimal hyperplasia of the coronaries has been documented more frequently. Do you have a recommendation for the appropriate diagnosis code?

"Postnatally an echocardiogram demonstrated a very small amount of antegrade flow into hypoplastic pulmonary arteries and this was confirmed by a CT scan. Therefore presents to the cardiac catheterization lab at this time for dilation of her right ventricular outflow tract and possible stenting. Patient with TOF w/severe pulmonary stenosis & hypoplastic central pulmonary arteries. Documentation as follows: series of balloon dilatation of RVOT and MPA are performed with 2mm & 3 mm coronary balloon. Following balloon removal improved slightly antegrade flow although still very poor filling of the distal pulmonary arteries. 3 mm x 12 mm Coronary stent advanced into the pulmonary artery. Series of angiograms performed through long sheath to assist in proper positioning of stent. Once in good position balloon is inflated and stent is released. Impression: S/P pulmonary valve dilatation and stenting with markedly improved flow to pulmonary arteries." Would it be appropriate to bill the 93799 for the dilatation of the RVOT and 37236 for stent?

Our vascular surgeons routinely attempt to bill both 93926 and 93928 post-bypass to assess the grafts, iliac vasculature, renal arteries. They come up as a "0" NCCI edit, but I'm having a hard time figuring out which one to bill since they both seem pretty different to me. I need to be able to explain this to the surgeons, so I am trying to gain a solid understanding of it myself. My question to you is, is there any scenario where we could bill these two codes together? If not, how would I explain this to the surgeons?

We have a patient that we end up clamping and opening the left CFA. We perform an extensive endarterectomy of the distal EIA, CFA, DFA, and SFA. We then introduce a sheath from the left femoral into the aorta and deploy bilateral stents from the proximal to mid CIA to the proximal CFA. This resulted in complete resolution of the stenotic lesions. I’m wondering since there is only one incision for the endarterectomy can I use 35355? In Question ID 11580 you stated that you cannot code iliofemoral if the CFA only had the arteriotomy and plaque was pulled out of the EIA from the common arteriotomy. Also, since the stents are bilateral, CIA stents in a kissing fashion, I think we can bill the 37221-50, due to the endarterectomy being in the EIA, through the SFA, and being in a “separate” area. I am getting pushback to bill each endarterectomy separately. The information I keep coming across states that if it is one lesion, with one arteriotomy you would only code one endarterectomy. As always, I appreciate your professional opinion!

Could you assist with a new procedure for PFO closures? "Via the right femoral vein using intracardiac echocardiographic guidance, a NobleStitch was deployed to close the patent foramen ovale. ICE and right heart cath were also performed." I'm thinking unlisted code 93799 or 33999, but I'm leaning towards 93799. Code 93580 involves an implant, and no implant is inserted. The PFO is closed by stitches.

My surgeon states that I should be billing 34706 for EVAR repair with an aorto-bi-iliac device for an impending aortic rupture done emergently. Is that true?

If our physician performed 93272 twice within a 30-day period, would it be appropriate to bill 93272-26 for the second review and interpretation? Or is the second service not reportable?

If a physician orders a pediogram (76010) for an infant, does the reason for the test have to be “foreign body” only? The baby fits on a 14m x 17 inch film, and the physician is able to view both the chest and abdomen in the film. Parents complain about paying for chest and abdomen when the entire child fits on one film. Examples of reasons for the test: feeding tube placement, line placement, respiratory status, heart murmur. Should the physician order a chest and abdomen for these indications instead?

How would you code this procedure? The Swan was already in place. "The externalized portion of the Swan-Ganz catheter within the sheath was thoroughly sterilized. The tip of the catheter was in the main pulmonary artery. Pullback samples to evaluate oxygen saturations were done from multiple sites in the right heart with the patient on room air. A pigtail catheter was then placed in the ascending aorta, and an aortic root saturation was also done.The Swan was then removed as was the pigtail. All saturations were done with the patient on room air, and he was put back on 4 L of oxygen postprocedure. The radial sheath was removed, and a TR band applied. The Swan was removed and the indwelling triple-lumen sheath was left in. Saturation data: Main pulmonary artery 58.7%, RVOT 55.0%, right ventricular body 57%, RV inflow tract 52%, low right atrium 48.6%, mid right atrium 50%, high right atrium 50.7%, SVC 51.7%, ascending aortic saturation 80%. Ascending aortogram: This was done with a pigtail above the aortic valve, which is a #21 Trifecta valve. The valve appeared competent."

One day post op c-section, the radiologist removes both balloon catheters. No imaging was done other than to assess for closure devices. Would you assign unlisted code 37799 or 76000?

I am having difficulty finding information related to myocardial imaging-infarct avid procedures (CPT 78466-78469). Can you describe what distinguishes them from other myocardial imaging studies? Are these tests not commonly ordered?

Would unlisted code 33999 be appropriate when the MitraClip is used during tricuspid valve repair?

We have a patient with a large scalp AVM (with venous drainage) that the radiologist treats by direct embolization. Prior to the embolization he performs selective imaging of the ECA and introduces a balloon catheter, which he inflates during the scalp injections (37242). Would it be appropriate to report code 61623 for control of blood flow?

Are the iliac veins divided into territories like the arterial iliacs in regards to interventions, or is the iliac vein considered a single vein? And do the coding guidelines change whether ipsilateral or contralateral (interventions)? Example – right femoral vein access with placement of stent in left external iliac vein followed by a second stent placed in the common iliac vein. Would codes 37238 and 37239 be reported? Same codes for ipsilateral?