Ask Dr. Z

Could you tell me if it would be appropriate to report 93797 or 93798 on an inpatient claim for phase 1 cardiac rehab?

Right heart cath (93451) with bike exercise (93464) was performed, along with ICE (93662) and enrollment in Corvia trial. Since the intervention was randomized, and I do not know if an implant was placed or not, do I still report code 33999 with comp code 93580? If I can report code 33999, do I code separately for the exercise bike and ICE? 

What CPT code should I use for this procedure? 93724 or 93624? "Syncope with paroxysmal tachycardia; suspicion for ventricular tachycardia. Previously implanted dual chamber pacemaker. Persistent atrial fibrillation. Programmed ventricular stimulation utilizing the pacemaker. Transthoracic cardioversion of atrial fibrillation. Interrogation and reprogramming of previously implanted dual chamber pacemaker system. Program stimulation via the pacemaker system with ventricular lead in right apical region was performed, utilizing single, double, and triple extrastimuli, long-short sequencing, and burst pacing. Aggressive program stimulation port Foley was utilized to try to induce ventricular tachycardia. No ventricular tachycardia was inducible. Adhesive electrodes were placed anteriorly and posteriorly on the thorax. Shock was synchronized to the QRS complex. End expiratory biphasic technique was utilized. A single 360 joule shock was successful in reverting a-fib to atrial paced rhythm. Pacemaker system was interrogated after the cardioversion shock."

The provider wants to bill for the chordal sparing with the replacement code 33430. What CPT code would be used for setting a fee for the 33999 to bill the chordal sparing? "TITLE OF OPERATION: Mitral valve replacement with a 27 mm Carpentier-Edwards Magna Thermafix bovine pericardial bioprosthesis with preservation of the posterior mitral valve leaflet and cords. A left atrial vent was placed via the right superior pulmonary vein. Waterston's groove was developed, and a standard left atriotomy incision was made. Exposure of the mitral valve was good. A Frigitronics cryoprobe was used to perform a modified Maze procedure. The base of the left atrial appendage was oversewn internally with a 4-0 Prolene suture. The mitral valve was inspected and found to be structurally normal. The anterior leaflet and cords were excised. Pledgeted sutures of 2-0 Ethibond were placed around the mitral annulus in an everting fashion. The mitral annulus sized to 27 mm bovine PATHOLOGY SPECIMEN: Excised anterior mitral valve leaflet."

CPT code 35703 for release of right popliteal artery? Or 35226? "TITLE OF PROCEDURE: 1. Release of right popliteal artery. 2. Intraoperative duplex ultrasound, confirmation of appropriate release of the popliteal artery. A 19year old patient with R Popliteal artery entrapment. She had undergone prior fasciotomy with no relief from her symptoms. Preoperative workup with a duplex ultrasonography demonstrated obstruction of the popliteal artery with plantar flexion.A lazy-S shaped incision was made across the popliteal space. Subcutaneous tissue was divided. The fascia was divided. The overlying crossing veins were divided. The nerve was carefully preserved and the popliteal vein was retracted. Deep and lateral to the vein was the popliteal artery. The artery was then carefully freed up all the way from well above the knee joint to its bifurcation into the anterior tibial and tibioperoneal trunk."

Does code 33999 include fluoroscopy, or can 76000 or 76496 be reported in addition to 33999?

What MCC drives the payment to MS-DRG 23 vs. 24?

We had a patient come in through the ED, and the doctor ordered a CT and an ultrasound. The patient started drinking the contrast while having the ultrasound. The CT was then canceled. Can we charge for the oral contrast? 

If a physician placed an iliac branched endograft in the left common/external/internal iliac for an iliac aneurysm, but patient does NOT have aorto-iliac aneurysm nor exisiting aorto-iliac graft, is it 34707 or 34718? We think according to photos in CPT book and also instructions that we can't use 34718 because that is only if they already have an aorto-iliac endograft in place. We thought 34707 would be used for IBE in left iliac when there is no previous aortoiliac endograft. Is this correct? Or can 34718 be used as a stand-alone IBE without previous aorto-iliac endograft?

With the revision to CPT code 64400 this year, can we report up to three units unilaterally if all three branches (ophthalmic, maxillary, and mandibular) are injected? Or does the revision to the code only allow for one unit per side regardless of the number of branches injected? I read the code description as the former, but we are seeing some conflicting coding guidance published about this code, and we are looking to confirm. 

Can you please advise on how to bill for profee services for an echo that is done during TAVR? The report has both pre and post TAVR findings. The echo is either read by the same cardiologist performing the TAVR or a different cardiologist from the same group. And then there is another echo done two hours after the TAVR procedure. Again, the echo is either read by the same cardiologist performing the TAVR or a different cardiologist from the same group.

What other codes can I bill besides 36838 and 36901? "In terms of the arm, I exposed the brachial artery a little bit more than 7 cm proximal to the anastomosis to the brachial artery of the graft. I then made a longitudinal incision to expose the anastomosis to the graft and exposed the brachial artery just beyond that. I went ahead and harvested right greater saphenous vein through a continuous thigh incision. The incison was closed in layers. The proximal anastomosis was done end to side with the vein to the brachial artery again about 8 cm proximal to where the graft comes off the artery. It was sewn end-to-side to the vein. After proximal suture line end-to-side, I distended the vein and tunneled it in the soft tissue. Ligated the native brachial artery just beyond the takeoff of graft and did an end-to-side anastomosis distal to that to the brachial artery. Suture line end-to-side. There was a good pulse in the graft and the radial pulse feels normal. Puncture sheath in graft, through distal incision, I did a subtraction angiogram, which showed the graft to be widely patent without any stenosis."

Can in-person programming and ICM interrogation be billed together for same date of service (93284 and 93290 with a qualifying modifier)? I have not found an NCCI edit that states not allowed, but Medicare denies 93290 as inclusive to 93284. I do not feel like modifier -51 is appropriate to append to the ICM. What would you recommend?

I have an op note, and code 39545 is billed with 32663, 31622, and 32674. The diaphragm repair is denied by insurance. Op report states the diaphragm "is a little bit high riding" and also "a little bit in the way and was going to be a hindrance to take down the inferior pulmonary ligament. Due to this, a diaphragm plication stitich was placed and used to retract the diaphragm inferiorly." Does this phrasing support the code definition of 39545?

Can you please advise on the correct billing of a transcatheter aortic valve replacement (33361)? "Through a 14 French sheath (34713)... was placed in the left groin." The parenthetical notes in CPT do not seem to allow this.

Is documentation of compression and/or other maneuvers required in the reporting for 93970/93971?

My physician is wanting to bill codes 36830 and 36558 with C1750 for HeRO graft. Is this correct?

Can you bill 37721 and 11042 on the same leg? I believe we should not; however, my physician thinks otherwise. "Yes it’s the same side, but the sites are totally distinct and separate. The iliac artery and fempop arteries are not the same site as the heel, nor are they contiguous with the heel. Moreover, these are completely different procedures on completely different structures – excisional surgical debridement of a foot wound and endovascular revascularization of iliac and fempop arteries."

If contrast is given through drainage tubes, G-tubes, arthrograms, can we charge for the supply of the contrast? I know that we can't charge for oral/rectal contrast given but not sure about through other routes.

Is using floseal, aminofill, or surgical billable? I have a provider who wants to bill for using all three of these items when closing a thromboembolectomy and on other open procedures. Is this billable? Shouldn't it be bundled into the closure of the procedures? If they are billable, what CPT codes would you use?

Received a denial stating that code 35351 was documented in the record. Here is what was documented: "9 x 40 balloon angioplasty balloon was advanced into the common iliac artery and used to provide control. Distal external iliac artery was clamped distally. Longitudinal arteriotomy was made with a 12 blade and extended proximally distally with the Potts until adequate endpoints have been achieved. Thin endarterectomy plane was created and plaque was passed off. 5-0 Prolene and bovine pericardial patch was used to create left external iliac patch angioplasty. There was excellent distal external iliac pulse at this point after balloon control was withdrawn."

I am wondering how you would code this ablation procedure. 1. Pulmonary vein antral ablation was performed to isolate PV antral regions with bilateral PV isolation (PVI) confirmed on HDX mapping electrogram. 2. Additional linear ablation was performed at the left atrial (LA) roof to achieve bidirectional LA roof conduction block. 3. Additional linear ablation was performed at the left atrial (LA) lateral wall from the mitral annulus to the LPV anterior carine to achieve bidirectional LA anterior block. 93656 for the PVI then 93655 x 2 or 93655 & 93657.

Provider documents a summary of his arteries/veins bypassed in the header section of his operative note and in an operative summary but does not always describe the details in the body of the operative note. Do you have any recommendations on submitting charges when documented like this? This has been reviewed with the provider, but he does not want to addend his notes.

"The sternal incision was made and divided. Patient was placed on bypass. To begin, the mid distal LAD bridge was divided using a combination of sharp dissection and cautery. There was several bridging veins across the bridge that had to be ligated as well. Once this was completed, attention was then paid to the RCA. It was a 2 mm vessel and was isolated and opened. A segment of vein graft was anastomosed here. The remainder of the CABG procedure took place." Along with the appropriate CABG CPT codes, what CPT would you use with the myocardial bridging? Documentation does not support CPT 33507.

"A patient with Ebstein’s anomaly status post TV repair x3 with RV dilation and dysfunction in the setting of significant paravalvular leak with direct communication between the right atrium and right ventricle presents to cath lab for diagnostic RHC and assess of right-sided defect. The interventional cardiologist performs a RHC and turns the case over to an electrophysiologist to perform assessment of the TV and perivalvular leak under transesophageal guidance. The EP provider crosses the defect with a steerable octapolar mapping catheter and positions it in the area of His potentials, which was directly adjacent to the previously placed wire crossing the perivalvular leak. The cath was advanced through the perivalvular leak and both His potentials and R bundle potentials were recorded. Fluoroscopic imaging confirmed that the perivalvular leak was directly adjacent to the area of His potentials. This info was relayed to the team, and at this point the decision was made to not place a device in the perivalvular leak due to the concerns of causing AV node injury." How is this reported?

In review of question ID # 13757 dated 3/25/20 with response from Dr. Dunn, I am asking for clarification and an explanation for correct coding when placing a stent or providing an angioplasty to the PDA. Previously an unlisted procedure code was recommended for use. Is it now your consideration that CPT codes 37236 and 37246 better describes these procedures?

Which code best fits this procedure, 36818 or 36821? Does a pocket creation count as tunneling? "Medial longitudinal incision was made above the antecubital fossa and deepened with electrocautery. The cephalic vein was identified and skeletonized with sharp dissection, with side branches tied with 4-0 Ethibond ties. The brachial artery was identified by pulsatile palpation medially and the overlying biceps fascia incised. The artery was carefully separated with sharp dissection. The brachial artery was dissected free along a 4 cm length. Vein was transected distally, and the end portion was longitudinally cut to create a foot plate. The vein was then dilated with serial dilations to 4.5 mm. Profunda clamps were then placed proximally and distally on the brachial artery. Arteriovenous fistula was then created as end of vein to side of artery anastomosis. Proceeded with closure of the arm incision. Vein was approximated under the subcutaneous pocket that was created."

We have been seeing a few of these cases come through, where the patient has an IABP percutaneously inserted through the axillary artery and a PTA balloon inserted in case of rupture and/or to tamponade during catheter insertions/removals, and sometimes performed in order to help the IABP maneuver through the artery. My question is would this still be 33967 for percutaneous IABP insertion? Can you charge for any type of extremity angiogram (75710) when performed, or would that be mapping? If there was a narrowing that was seen (subclavian/axillary) and described 70%, can a PTA and extremity angiogram be charged? Lastly, can a removal of a femoral IABP be charged as 33968 at the time of the axillary artery IABP insertion if it was a different session than the initial femoral artery IABP insertion?

"A selective coronary angiography was performed for a patient with aortic stenosis. Catheterization was performed from the right radial artery and advanced into the aortic root from the right subclavian. Then a selective angiography was performed, and findings for the coronary angiography are read including LM, LAD, RI, LC, and RC." Is 93454 the appropriate code for this procedure? Does a code need to added for the aortic root? There are no findings for the aortic root.

What CPT codes would be appropriate for right upper lobe anterior segment wedge resection and right upper lobe apex wedge resection secondary to profound bullous emphysema? Surgeon is suggesting 32666 and 32667. This was done at the time of VATS parietal pleurectomy (32656). In addition, intercostal nerve block (64420?) with 0.5% marcaine with epinephrine was done. Is this billable?

Patient had recurrent problems with lead dislodgement and was admitted for removal of displaced and dislodged pacemaker system with placement of a leadless ventricular pacing system. How would you code this?

For what many may call a babygram or kiddiegram, NOT for foreign body. A single AP view of the chest and single AP view of the abdomen, one exposure and single image for infants. Can we charge 71045 and 74018?

I have a surgeon who loves lap proc. He wants to do a biopsy of sacral mass laparoscopically. The only code we can find is 49010. I gave him 49321 but he says this is not retroperitoneal. Other than an unlisted code have I exhausted the options?

In question #13631 on Feb 24 you identified OUR method of placement of an InterStim electrode as percutaneous (64561). Cath lab supervisor insists that our method is open/incisional (64581) because she believes a layered closure is used. According to our documentation, the physician makes an incision “through the fascial layer” next to the directional guide, then inserts the lead introducer sheath with dilator over the directional guide. After the electrode (quadripolar lead) is placed, a second incision is made posterior to the iliac crest at the site where the tunnel and lead exit the body “into the subcutaneous tissue.” Closure is only described as “with 0 vicryl subcuticular sutures and 4-0 monocryl skin sutures.” I believe that “subcuticular suturing” normally involves suturing the dermis, the layer immediately below the epidermis, making this a simple, non-layered closure. Does the closure method described above, or any closure method, justify the use of 64581 when the electrode is placed percutaneously as described in question #13631?

If a patient underwent an OHT but the aortic coarctation was repaired years ('05) before the transplant was performed ('20), would we use the congenital echo code, in this case a follow-up 93304 or 93308? Our pediatric docs still consider this to be a congenital condition. If the congenital heart is removed/transplanted with another heart, then the congenital condition no longer exists, correct? What is an example of a residual condition that remains in order for congenital echo codes/cath codes to be used ,and should the provider document the details of the residual congenital defect remaining?

Can you report code 75630 for an abdominal aortic aneurysm and 36252 for selective bilateral renals for renal artery stenosis?

The group of cardiologists that I am employed with is now seeing COVID patients at our local hospitals. Most have issues with SOB/respiratory failure/cardiomyopathy and have tested positive for COVID. My question is would I need to append U07.1 on the CMS 1500 form to document the patient as having COVID? Basically, what would be the proper way to document COVID for cardiology? With all of the recent changes with COVID codes, I am quite concerned that I am not documenting properly.

How is intracranial DSA coded?

"Patient is seven days status post thoracoscopic right upper lobectomy. Patient has a persistent air leak, and a blood patch is attempted to help seal the air leak. The patient was positioned with the affected side exposed. A venipuncture was performed in the right inguinal region and an anesthetized area where 1 cc of 1% lidocaine was used and 50 cc of blood was drawn. The chest tube was prepped and the blood injected into the chest tube through a 22 gauge needle using sterile technique. The chest tube was then clamped as close to the skin exit site as possible and the patient rolled into several different positions including steep Trendelenburg, to allow the blood to coat all surfaces of the lung." Could you please help with the coding on this procedure? I was thinking of reporting unlisted code 32999.

I am considering using atrial fib I48.9 and adding additionally ACID status Z95.810. Or maybe I should use Z45.02 encounter AICD management as primary diagnosis? Please recommend primary diagnosis for observation visit. Patient came to ED due to having shock from his sub-q AICD. Cardiology consult gives final dx- Device interrogation showed ICD shock for atrial fibrillation with exceeded 200 BPM.

Would bilateral sacroiliac joint block including medial branches L4 and L5 and the lateral branches of S1 and S2 be coded as a sacroiliac joint block (64451) or as a lateral and medial branch block (64640-50, 64640-50, 64493-50)? "A 25 gauge Quincke needle was passed atraumatically to make contact with the periosteum just lateral to the junction of the superior irritating process in the L5 transverse process, superior reticulating process and sacral ala and the neuroforaminal opening at S1 and S2 using intermittent fluoroscopy on the right side. At this point a steroid solution consisting of 0.5% bupivacaine containing 5 mg of Kenalog per mL was slowly and incrementally injected after negative aspiration, through each needle. The procedure was needed on the opposite side."

I see that an unlisted CPT code is recommended for the Basilica procedure. Is there any recommendation for the PCS code for the Basilica procedure?

TAVR/TAVI requires two physician operators, and all components of the procedure are reported with modifier -62. When two physicians work together as primary physicians with distinct skill sets needed for TAVR/TAVI, each physician should report his or her distinct participation by appending modifier -62 to the appropriate procedure code (33361-33365). My question lies in the documentation requirements. We know what SHOULD be documented, but what is REQUIRED to be documented to support both providers? Is it REQUIRED for both to have separate operative reports or just by the nature and mandate that two surgeons must perform the TAVR/TAVI - that documentation in one operative report would be compliant even if the operative report didn't actually say which MD performed which part?

PB side is billing two separate lines 36245-50 for bilateral segmental artery angiograms at levels L3-L4. The hospital side is not accepting this CPT coding. HB edit that says: 36245 units of service greater than one is inappropriate for bilateral procedure reported with a modifier 50. Any advice?

When a patient presents for a GJ tube replacement because the tube "fell out" and required gaining access into the established gastrostomy tract and then basically doing the work of a G to GJ conversion, how is this most appropriately coded? Should we use 49452 as a typical GJ tube exchange, or 49450 + 49446 to reflect the additional work performed compared to a GJ exchange over full wire access through an existing GJ tube?

My provider treated a left carotid for stenosis. Once the provider had placed the stent (DPD) he performed balloon angioplasty within the stenotic portion of the stents. The angioplasty revealed wide patency of the distal common and proximal cervical left internal carotid artery without any residual stenosis. Can the office bill for 37215 and 61624 for the left carotid?

Our radiologist used a 22 gauge needle into the lymph node, and a total of 1 cc of STING agonist solution was injected throughout the lymph node using ultrasound guidance. What CPT codes can be used for the injection and the guidance portion of the procedure for a clinical trial study?

We have some that are billing only for the assistant. Should 33508 be billed twice, once for the physician and once for the assistant? Which would be appropriate?

Would the following be correct codes for selective imaging? Right femoral artery access > left internal iliac artery (36248) -> left common femoral -> left profunda artery -> branch of left profunda artery (36247-furthest order) Imaging: 75736 for internal iliac, 75710 for basic leg, 75774 for profunda branch imaging

What is the CPT code for laser-assisted transgraft embolization of aortic aneurysm sac with ONYX? "Aortogram was obtained which confirmed type II endoleak. This appeared to originate from an upper pair of lumbar arteries at cephalad portion of the aneurysm sac. Decision was made to perform a laser-assisted transgraft embolization of the aneurysm sac. The 7.0 French Oscor twist conformable sheath was then directed against the wall of aortic endograft in the region of the paired lumbars and through the sheath a 0.8mm Spectranetics laser catheter advanced against the wall of the endograft and with multiple laser pulsations the laser catheter was able to be advanced through the wall of the endograft and into the aortic aneurysm sac. A mailman wire was then advanced through the Spectranetics laser catheter and into the aneurysm sac. Next Echelon microcatheter was advanced over the mailman wire into aneurysm sac. Next multiple vials of Onyx were injected into aneurysm sac. After completion of Onyx inj, Aortogram revealed no extravasation from transgraft defect...."