Ask Dr. Z

We coded a CABG and endarterectomy (codes of 33533, 33517, 33508, and 33572-LD). Insurance denied 33572 for modifier. Modifier -LD was removed and insurance denied again. Are there other factors in coding a CABG and endarterectomy together that we should be aware of? Is there a scenario where coding a CABG and coding the endarterectomy of 33572 at the same surgical session would be inappropriate or bundled?

I was hoping you could help me with some updated information. What I have been reading is 2011 and 2016. Based on the below language, is it enough to bill codes 37224/75716 with modifier -59? " Please note, secondary to the findings on angiography, it was decided to proceed with an intervention, as there was no previous imaging. Angiogram was performed, showing proximal occlusion of the left SFA with reconstitution of the above-knee popliteal artery." I'm trying to make sure that they are clearly showing medical necessity. I am still new at this and want to make sure I am doing these right.

Physician performed an open right femoral artery exposure, opened the femoral artery, and retrieved a long catheter that a cardiologist had broken off inside the artery. At first, I had thought of using code 35703; however, more was involved than exploration of artery. Would I use unlisted procedure code 37799 in this case? I would appreciate any thoughts on an appropriate CPT code to use.

Can you report codes 35703 and 35226 together?

When a lumbar epidural steroid injection is performed in an office (62323), can you also bill for the Kenelog (J3301) and the bupivacaine (J3490) that was injected into the epidural space as well as the Omnipaque 240 (Q9966) for contrast?

When billing 36200 for abdominal aortogram with bilateral lower extremity runoff, BCBS is the only payer that is denying 36200 due to "missing modifier". It appears they are requesting an anatomical modifier. When resubmitted with a "50" or "RT" modifier the claims are processed. All other payers are processing the claim without any modifier on the 36200. I cannot find anything that states this code requires a modifier. Do you have any suggestions? The following is the provider's description of the catheter placement: "Both groins were prepped and draped in the usual sterile fashion. After local anesthesia with 1% xylocaine, the right common femoral artery was entered percutaneously, and a 4 French sheath was inserted with guidewire. A 4 French UF catheter was then inserted and placed in the descending aorta, and aortic angiography was performed under digital subtraction."

Is it appropriate to place Z95.0 in the primary position when coding for a patient with a cardiac device having an MRI? Or is it more appropriate to code the diagnosis first and then the Z code?

Would it be appropriate to add modifier -51 to code 75710 when performed with other services on a given date?

What documentation do I look for to validate that 'recording' was done in the left atrium? I send queries on this every day. Today my response from an EP physician was: "CS pacing and recording was performed. This sentence, "Decremental pacing from the proximal CS showed AVWBCL at 520ms ms with no persistent crossover,' indicates that. This sentence shows CS pacing and recording. There is nothing further that is needed to document that." Dr. Z, can I 'assume' that recoding was done when documentation states,"AVWBCL at 520ms with no persistent crossover"?

If a patient is status post correction of transposition of great vessels, would the cardiac cath code be from the congenital or non-congenital section?

The interventional radiologist and cardiologist performed a procedure to open an occlusion of the innominate vein. The IR doctor tried but was unable to cross the occlusion. He exchanged the catheter for a Termo catheter, and a piggyback guidewire was advanced to the point of occlusion. Next, an Astato guidewire was advanced to the point of occlusion. By separate access, the cardiologist placed a catheter into the SVC to be used as a target. A Bovie was attached to the back end of the Astato guidewire, and electrocautery was performed under fluoro guidance. After multiple passes without success, the decision was made to forego further attempts at recannulization. I coded the cath placements, but wasn’t sure about the electrocautery... 37187, 37799? 

Is it appropriate to use a cath log for moderate sedation times? The cath log has a list of all participants on the procedure such as monitor and an RN's name and then scrub and RN name. Then times are used from start time of Versed and Fentanyl, and end time is the procedure complete time. Is this acceptable?

I'm not sure how to capture the stent insertion by the interventional cardiologist below. "The chest was open by the surgical team. Pulmonary artery band were placed by the surgery team. A 6 French sheath was positioned in the proximal main pulmonary artery. An angiogram was performed for aorta/Pulm arteries. Measurements were made of the ductus arteriosus. The ductus was crossed with an angled glide catheter and a 0.035 rosen wire was positioned in the descending thoracic aorta. Over this wire a 7 mm x 2 cm protege self expanding stent was positioned across the ductus arteriosus. It was deployed in the standard fashion. Flwup angiography demonstrated good positioning of the stent with retrograde flow in the arch. The entire ductus appeared to be covered with good flow into the left pulmonary artery. The surgery team removed the sheath and proceeded with chest closure." Is this unlisted CPT 93799?

We have a physician wanting to start using Sotradecol 3% for pelvic vein ablation/sclerotherapy to treat pelvic congestion syndrome. Would this be coded with 37241 as a venous embolization, or would you go with an unlisted vascular (37799) code for this procedure?

Would congenital cardiac cath codes apply for the following? "24-year-old male with significant past history of congenital aortic stenosis and underwent valvotomy and ligation of small PDA as a newborn. He underwent aortic valve replacement with St. Jude prosthesis in 2003, repeat aortic valve replacement with prosthetic valve in March of 2007. The patient's most recent transthoracic echo showed an ejection fraction of 35-40%, increased gradient through the aortic prosthesis, and severe mitral regurgitation. The patient has been seen by cardiac surgery and currently undergoing workup for possible intervention. The patient was referred for cardiac catheterization as part of his preoperative workup."

"Our physician did excision of infected femoral to femoral graft, excision of left femoral-popliteal infected graft, patch angioplasty of the right femoral artery, and embolectomy of the left popliteal artery. On the left side the femoral anastomosis was isolated and the graft subsequently divided. We were able to clear the origin of the previous deep femoral artery endarterectomy and had sufficient artery for primary closure without impingement on the deep femoral artery. The graft was completely excised. Adjacent saphenous vein was harvested for a length sufficient enough to create a patch for the femoral artery once the graft was removed. The vein was then sewn as a generous patch onto the artery taking generous bites both on the vein and artery." Would I report codes 35903 and 35903-59LT for the excision of the two grafts? Would I report code 35256-RT for the patch angioplasty of the right femoral artery? Would I be able to code for the embolectomy of the left popliteal artery?

What is the correct coding/charging/billing for a patient where it took three consecutive days to complete the ordered procedure of MRI w/wo contrast (72158) because the patient could not tolerate the scan for longer than 15 minutes at a time. There is one order, and one written report. The written report documents that the exam had to be done on three different days because of the patient’s condition. The first two days were the without contrast component of the scan and the third day had the contrast administered.

If a LINQ recorder was removed from the left parasternal border and a new LINQ was placed along the left sternal border 4th intercostal space, would this be considered a new location? And therefore the removal and placement of the LINQ recorder can be coded with 33286-XU and 33285? If the LINQ was placed in the same pocket only the insertion would be coded. Report details: "Old LINQ was removed, 3-0 polysorb suture was placed and dermabond applied (33286). New LINQ was placed along the LSB 4th ICS, and dermabond and steristrips applied (33285)."

After placing Nano knife probes "bracketing" a renal tumor, FNA and core biopsy of the tumor are done, then the IRE completed. Is the biopsy also reported?

Patient received an ICD upgrade from single to dual. Next day, they reopened the pocket and swapped the lead ports due to provider error. Facility side: can this be charged to patient, and if so would you say 33215? What would this procedure be considered? I don't think the patient should be billed for an provider/device rep error. Patient is outpatient as well, which would matter as far as charges.

What CPT code do you suggest for contrast injection of a nasogastric or NJ feeding tube? Some suggest 74241, and I have seen some suggest 49424/76080.

Should we follow the revascularization guidelines for lower extremity arteries when coding venous stent or angioplasties? Would an angioplasty in the femoral and popliteal veins be coded as a single angioplasty? Do you have any official guidelines supporting either way?

The physician documents that the patient has chest pain, and the angiogram shows stenosis in the coronary arteries. I would code diagnoses I25.10 and R07.9, but I am being told that it should be I25.119 since angina is chest pain caused by ischemic heart disease. Should the connection be made that the chest pain is angina due to the reduced blood flow to the heart, or does the provider have to make the connection by documenting angina to code I25.119?

Left femoral access, superficial femoral artery endarterectomy, then performed proximal vein anastomosis, brought the vein graft through the tunnel, then performed arteriotomy in the below the knee popliteal artery and performed endarterectomy of that as well. We also performed balloon thrombolectomy in the peroneal artery, and there was no clot noted. We then performed end vein graft to side popliteal artery anastomosis, again spatulating it and making the anastomosis approximately 15 mm. My question is, with this documentation can we bill codes 35556 and 34203? Is there enough information to support the embolectomy?

Two years after having an aortic valve replacement and replacement of the ascending aorta with a Hemashield graft, the patient developed two small pseudoaneurysms adjacent to the ascending aortic graft. The doctor closed them both percutaneously using ASD and VSD occluder devices. What CPT code would you recommend for these closures?

When coding catheter placements, does the dictation/radiologist have to say selectively catheterized or have the verbiage "select" to code it? Example: "The Mikaelsson catheter was used to select the celiac artery. The microcatheter was advanced into the right hepatic artery." Can "advanced in" be counted as a "select?" Does that meet the rules and guidelines? Any idea where I can find more information on this subject? 

After anesthesia was provided, but before the patient was prepped and draped, he began vomiting. Afib ablation was cancelled. Do we charge 93456-74 or 93619-74 or anesthesia bill only?

"Left subclavian was selected, and angiogram here revealed complete occlusion of the origin of the left vertebral artery. There was a somewhat prominent posterior deep cervical artery noted with origin stenosis and some reconstitution of the vertebral artery, as well as retrograde opacification of the occipital artery with filling of facial lingual and maxillary trunks. Wire was carefully manipulated through the origin, and catheter was advanced to slightly open the origin. Left common carotid: Wire was carefully manipulated through this plaque and preocclusive lesion to at least slightly improve the antegrade flow. This was now judged to be barely but adequate flow. OP Note: Mild mechanical clot/stenosis disruption by wire/catheter tip manipulation." FROM DR. Z BOOK: Is this 61645? This code is for revascularization by any method to treat thrombus/embolus/occlusion of cerebral arteries. 

If a radiologist gets a CT pre biopsy and then does the biopsy with ultrasound, but also does a CT after the biopsy, can we charge for 76380?

Is it ever okay to bill 92941 twice in one day? Examples: If the MD states co-culprit lesions for the STEMI? Or if the patient has two different STEMIs noted on the same day with different culprit lesions and different MDs intervening (different practices)?

Right M1 occlusion following four attempts at the mechanical thrombolysis. No reperfusion is obtained. Can we still bill 61645 with a modifier -52 or only the guidance?

Do you recommend codes 36573 and 37248 for the following? "The left arm was prepared and draped in sterile fashion. The brachial vein was shown to be patent by ultrasound. A spot image was stored. The vein was punctured under direct sonographic guidance and local anesthesia. A wire was advanced to the SVC. The tract was dilated. The wire did not pass centrally. Contrast was injected to confirm a stenosis at the level of the thoracic outlet. Ultimately, a catheter wire was associated across the stenosis. 4 mm balloon angioplasty was performed to facilitate passage of the PICC line. The catheter was measured and cut to length. A dual lumen PICC line was placed through a peel-away sheath. The final tip was confirmed to be in the lower superior vena cava with a spot fluoroscopic image. The catheter was secured, flushed with Heparin, and a sterile dressing was applied. FINDINGS: Central venous stenosis at the level of thoracic outlet protruding wire passage. Area treated with 4 mm balloon angioplasty to facilitate PICC line placement."

In reading some reports I noticed that 3D mapping was performed during an AV node ablation. The mapping wasn't billed separately, but there are no NCCI edits indicating this is bundled. Is there a specific reason this could not be billed separately?

We have a question regarding diagnostic angiographies performed after a "catheter-based" study was done, taking into account the CPT guidelines indicating when it is appropriate to bill for this angoigraphic study performed, etc., which we understand. At a recent seminar, the guest speaker indicated that a CTA was not a "catheter-based" study, so I guess we're looking for some clarification then as to exactly what's considered a "catheter-based" study.

In order to qualify for 36820, does the physician documentation need to indicate the vein was mobilized or tunneled? If the physician indicates the vein was "transposed", does that meet the criteria? We have a physician who documents forearm fistula as "vein was transposed", and I just want to make sure this is sufficient.

For tricuspid valve repair using the Pascal device, CLASP TR Trial, would unlisted code 33999 be used, or 0569T and 0570T?

Does the shockwave device have a HCPCS code, and is it still considered like angioplasty?

We had a consult tell us that we should be coding 76856 and 76830 for this exam. The docs are coding 76857/76830. They are using both Transab and Transvag. Can you clarify how both of these can be coded but neither are documented separately? This looks like 1 exam. "Indication: Post-Menopausal bleeding Method: Transabdominal and transvaginal ultrasound examinations. Uterus: Normal. Position: anteverted. Endometrium: fluid noted within with a focal echogenicity Endometrial thickness: 1.4mm Cervix: Normal Polyp (size/mean documented) Right Ovary: Normal, No adnexal masses (Size/Mean documented) Left Ovary: Normal, No adnexal masses (Size/Mean documented Cul de Sac Normal, no fluid within Impression: Endometrial polyp outlined by fluid."

Does a provider have to perform imaging on the entirety of both legs (to toes) to be able to bill 75716? For instance, the right leg is imaged from common iliac all the way to dorsalis pedis. The left leg is imaged from common iliac to common femoral. The provider wants to bill 75710, but I believe 75716 is more appropriate.

Would you report code 61626 or 61624 for embolization of a ”high cervical skull base right internal carotid artery aneurysm with a wide neck”? We were leaning towards 61626 since it’s skull based but were wondering since it affects cerebral circulation if we should go towards a cerebral embolization. "A pipeline flow diverting stent was deployed through the phenom microcatheter across the neck of the aneurysm. Completion angiograms were performed demonstrating no vascular pruning or parenchymal deficit intracranially."

Is endarterectomy of the distal iliac artery reportable with code 35566? "Incision was made on the left leg, the distal popliteal and TP Trunk that were dissected free. The saphenous vein had caliber 3 mm, dissected it below the popliteal and also incision was made from the knee toward the groin and the vein was removed. Next inguinal ligament was identified and the iliac artery, common femoral, superficial and profunda were isolated and dissected. Then the tibioperoneal trunk was crossclamped, thromboendarterectomy was done at the takeoff of the posterior tibial. The saphenous vein was reversed and cut to match the opening in the artery and end-to-side anastomosis was performed. The vein was brought via subfascial fashion towards the left groin where the common femoral, profunda superficial were fully exposed and crossclamped opened with a knife and Potts scissors. We did an endarterectomy of the area involving the distal iliac artery and also in the profunda and superficial, there was a big branch of the profunda that was open, the vein was divided and an end-to-side anastomosis was done between the artery and vein.

We have a provider who documented the indication for a pacemaker as non-reversible symptomatic bradycardia due to 2nd and/or 3rd degree AV block. There is no further documentation to support 2nd or 3rd degree block in the record. Would you code anything for this documentation or consider it 'working uncertain diagnosis' and only code the bradycardia? I realize this was taken verbatim off Noridian's nationally covered indications; however, I'm having trouble justifying dx coding with the AND/OR verbiage.

How would you code an excision of right external jugular vein aneurysm? Would you use unlisted code 37799?

"While radial artery line was being placed by the anesthesia team, the catheter broke off at its hub and was retained in the left radial artery. The left arm was prepped and drapped. A longitudinal incision was made and the radial artery exposed. Vascular tapes were placed proximally and distally. The arterial puncture site was closed with a 7-0 prolene. The retained catheter was palpable. A transverse arteriotomy was performed and the catheter removed. Tapes were secured and the radial artery repaired with interrupted 7-0 prolene sutures." I could not find an open code for fractured cath removal, only the percutaneous code 37197. He also closed the puncture site in addition to closure of the open procedure. I'm not sure exploration code 35860 would be appropriate either. Would it be unlisted 37799 (possibly based off of 37197 and an arterial repair code, and if valid arterial repair of the puncture site or would that be inclusive?), or is there a more appropriate code?

"FULL RESULT: Transverse, longitudinal and oblique ultrasonic sections of right neck was performed. Color Doppler evaluation also was performed. 1. Under antiseptic precaution and ultrasound guidance, 0.47 mCi of technician MAA particle in 0.2 cc was injected into the right mid thyroid nodules including 1.0 size size and 0.6 cm size. No complications were observed. Postbiopsy images show no evidence of bleeding. 2. Under antiseptic precaution and ultrasound guidance, 0.49 mCi of technician MAA particles also was injected into the right mid lateral neck level III 0.4 cm size nodule. Patient tolerated the procedure well. No complications were observed. Postbiopsy images reveal no evidence of bleeding.IMPRESSION: 1. Ultrasound-guided technician 99 MAA particles were injected into the RT mid thyroid bed two nodules. 2. 2. Ul-guided dictation 99 MAA particles was also injected in RT mid neck level III 6 mm nodule." Would you code 60699 & 76942-26? Would you code 60699x2?

Can 3D ICE be billed using codes 93662 and 76376 to indicate the 3D portion of the work?

I am a little confused on the use of a -50 modifier or -RT/LT modifiers for spine injections and cerebral angio add-on codes. Is it appropriate to code 64493-50, 64494-RT, 64494-LT, 64495-RT, 64495-LT for 3-level bilateral lumbar facet injections? How would you code bilateral external carotids: 36227-50 or 36227-RT, 36227-LT?

Patient recurrent in-stent restenosis, treated multiple times. Restenosis has returned; patient now presents for brachytherapy. Is this T82855A or T82855D?

What code can I use for billing percutaneous cement osteoplasty of pelvic bone?

We have a pain management group that says that they were told never to use chronic pain diagnoses for the follow-up visits for chronic pain medication management. They did not provide a source, and we have failed to find any guidance that confirms what they have been saying. Is there an guidance when we should or should not use the Dx codes from G89 category for the purpose of the follow-up visits for medication management for chronic pain?