Ask Dr. Z

The left V lead was advanced and positioned into a previously selected coronary vein. A second sheath was advanced over the remaining wire through which the His catheter was advanced to the His cloud. A new generator was brought into the field and connected to the leads. Device(s) Explanted: LV Lead: Pulse Generator: Device Information: Generator: His Lead: RV Lead: CS Lead: The RV lead was not replaced. Should this be charged to 33234 or 33229 for the LV lead and unlisted for the bundle of his lead?

I have an attempted TCAR procedure in which after insertion of flow reversal and CCA exposure the attempted wire crossing dissected the plaque causing an obstruction. The physician thought it was a thrombus and attempted aspiration with no thrombus return. He ended up doing a standard endarterectomy using the flow reversal system and a separate incision. My question is, since he did a separate incision would I be able to code the TCAR with a -53 modifier since he still utilized the flow reversal? I would think since this is part of a clinical study it would need to be reviewed. Also, would the intraoperative arteriography be codable? The sheath was able to be advanced to the ECA. I would greatly appreciate your coding advice for this scenario.

We are having issues while trying to bill the new 2020 codes for vascular mapping. We've been billing 93986 (unilateral) or 93985 (bilateral). There is no issue here. -- The code book tells you that you can code 75820 (unilateral) or 75822 (bilateral) along with code 36005. There is no bundling issue in our software, but the claims keep getting rejected, because it states that 36005 bundles into 75820 and 75822. We've even tried to append modifier -59 (as well as the laterality modifiers) to code 36005, but nothing seems to be working. Can you provide guidance on how to bill successfully, as a physician, for vascular mapping?

For 93000, many times the "official" interpretation is not done on the same date of service. If that reading is done on a different date from the technical component, can we still bill the global 93000? This is for services performed in place of service 11; we own the equipment, we employ all providers.

"Under US guidance using an 18 gauge needle, 5 cc of pus was aspirated. The aerobic culture showed isolated Eschericha Coli susceptible to all antibiotics." Is this coded with 10005 or 10160?

Our patient was brought to the cath lab for stroke management after an attempted carotid endarterectomy that resulted in a post-op complete occlusion of the cervical carotid. We placed a cervical carotid stent without distal protection and restored full flow to the distal vessels. No thrombectomy was required. Would you use code 37216 for this procedure?

Would the following report be coded as 55874 and 55876, or just 55874? "Local anesthesia was provided. Using transrectal ultrasound, fiducial markers were placed. The prerectal space was then accessed. A small amount of saline was injected to confirm position and free flow away from the needle tip. After carefully confirming the needle tip position at the mid gland, with careful attention to midline position, the SpaceOAR was delivered. The probe was removed, and the perineum was dressed appropriately. IMPRESSION: Successful delivery of prostatic fiducials and SpaceOAR in preparation for prostatic radiation therapy."

We are seeking clarification on the correct coding of two scenarios: LV lead removal and multiple lead removal. After extensive research, we are finding conflicting guidelines from multiple reputable coding resources. For LV lead removal, some say the LV lead removal is included in the appropriate removal code, whereas others say report unlisted for LV lead removal. For multiple lead removal (more than two leads), we found three different coding suggestions: 1) append modifier -22 when more than two leads are removed to capture the additional work; 2) report unlisted for multiple lead removal, as the current CPT codes do not capture multiple lead removal; and 3) report the appropriate removal code even if more than two leads are removed, as these codes cover all leads. These two scenarios overlap in some cases, which adds an extra layer of confusion (e.g. RA, RV, and LV lead removal). Please provide your expert opinion and rationale.

Patient indicating pacemaker pocket pain returned to the procedure room in the hospital during 90-day global period. The provider documentation states pocket incision was opened and pacemaker removed from the pocket. The provider then states: "It was noted that one of the lead collar's wings was pointing up, and this wing was removed." The pacemaker was reinserted in pocket. The pacemaker was not detached from the leads, and the leads were not removed or revised per the report. I have been unable to find a CPT code to bill this. Should unlisted code 33999 be billed, and can this be billed in the global period?

Please help with code for laryngoscopic visualization, Medicare guidelines notwithstanding... "FINDINGS: Using a 25g butterfly and Alligator 170mls of Doxycycline (17mls) placed in multiple sites in the posterior pharynx and peri epiglottis under laryngoscopic visualization until distension was achieved. At no site was blood aspirated prior to Doxycycline injection. Images were obtained under laryngoscopy only.   IMPRESSION: Successful laryngoscopically guided injection of Doxycycline into the peripharyngeal vallecula and tongue base LM."

Per Ask Dr. Z #3769 from 2012 & #5073 from 2013, an unlisted code was suggested for repositioning a port. Would same be suggested in 2020 for the following? Recently created port pocket incision was reincised, and suture material removed. Port reservoir was identified and anchored with 2 sutures of 2-0 PDS plus on a blunt needle. The port was then accessed with a noncoring needle, aspirated and flushed. The port was flushed with 100 units/mL heparinized saline solution. The port pocket was closed with sutures of 4-0 Monocryl and Dermabond. The port was deaccesed. The patient tolerated the procedure well and without immediate complications. Port reservoir was noted to be flipped such that the base was anterior. Fluoroscopy confirms the suspicion. On opening the port pocket, the reservoir was able to be righted without difficulty. After anchoring the reservoir with sutures, it was easily accessed. Blood was able to be freely aspirated; the port flushed easily. How will this currently be coded?

How should fibrin stripping be coded when done via the same access as central line replacement?

On page 597, instructions 6 & 7, in your IR coding book definition is stated without imaging guidance ( fluoro). But on 596 in the chart procedure description code 62272 lists WITH fluoro and CT guidance. To me this is a discrepancy. If not I need to get clarification.

According to the NCCI edits codes 34717 and 34709 are bundled and are not able to be unbundled. If the extension (34709) was into the external iliac on the left and the endovascular repair of the iliac artery (34717) was on the right, how should this be reported? CPT instructs us to not use 34717 and 34709 for the same side; however, we are having issues when this is opposite sides as well. Please advise on how you would report the extension into the left external iliac artery.

"Diagnostic catheters placed in the crista terminalis and CS. Sheaths placed in right and left femoral veins. 3D map of the left atrium. ICE provided. During RF ablation of left pulmonary veins, atypical atrial flutter was initiated, which was mapped extensively. This was found to be re-entry in the left PV. This terminated with LPV ablation. Post ablation both exit and entrance of confirmed in all veins. Re-confirmed at 30 minutes post isolation." Can I charge 93656 and 93655 for the different arrhythmia? Or because of the PVI is this considered part of 93656?

We are looking for guidance regarding the Penumbra Cat Rx mechanical aspiration catheter and whether this would be supported with CPT 92973 or if it is considered an aspiration catheter. Any insight you can share would be greatly appreciated.

My doctor performed sclerotherapy of the perforator vein using Sortradecol. He says he takes the vial and dilutes the 3% to 1.5% and then shakes it vigorously to make the foam to inject. Is this considered compounded (36470) or non-compounded (36465)? Are all foam therapies considered compounded?

When the documentation does not specifically state "origin" or "insertion", may we still use code 20551? "The patient was placed in the supine position, and the skin over the right anterior iliopsoas tendon area was prepped and draped in usual sterile fashion using chlorhexidine. Non-buffered 1% lidocaine was infused in the superficial and deep soft tissues for local anesthetic. A 22-guage 3.5" needle was advanced deep to the psoas tendon under direct ultrasound guidance. A total of  5 ml of a mixture containing 4 ml of 0.5% ropivacaine and 40 mg Kenalog was then injected. The needle was removed and the skin was bandaged. Ultrasound images were archived. There were no immediate complications."

Is 35883 or 35876 be more appropriate? Maybe 35883, 34203, 35371 for this case? "We began by opening up the left groin incision and removing the previous sutures. We then gained control of the CFA, profunda, SFA, and the bypass graft. We opened up the proximal portion of the graft. We identified acute thrombus within the lumen of the bypass graft. We also ID what appeared to be an obstructing flap in the LT CFA. We, at this point, decided to make an incision over the entire CFA and performed revision bypass angioplasty. We extended it proximally towards the inguinal ligament. We then confirmed there was a large flap within the lumen itself that was causing the obstruction. Endarterectomy of the entire CFA was performed. When then took a 0.8 x 8 mm bovine pericardial patch graft and performed patch angioplasty. We then reopened the distal incision above the knee, ID the distal graft, and gained control of the pop. A graftotomy was made and using a Fogarty catheter thrombus was removed from the entire graft and the SFA and then distally to the tibial vessels."

The patient with pleural effusion had left-sided thoracentesis done. Impression: Successful US-guided diagnostic and therapeutic left pleural drainage catheter placement. My question is that the drainage catheter was removed after two hours before the patient was discharged. Should this be 32555 or 32557?

I'm wondering if there have been any up dates this year to whether or not it is allowable to bill an unlisted code (33999 or 93799) with TAVR for Sentinel embolic protection device.

Patient has aneurysm of mesenteric artery. Physician performs diagnostic angiography, then treats the aneurysm with endovascular placement of stent. Code 37236 should be used for revasc for vessels other than lower extremity for occlusive disease. Since the patient has an aneurysm and not occlusive disease, what would be the appropriate CPT code for endovascular stenting of the mesenteric artery for aneurysm?

I'm having trouble trying to locate a CPT code that accurately captures this procedure. "A needle was used to attempt access of the lymphatic malformation in the left neck. Despite ultrasound images documenting needle position within a small cystic cavity inferior to the mandible, no fluid could be aspirated. A small amount of contrast agent was injected, which did not conform to the expected shape of the cavity. Therefore, no embolization was performed." Code 10160 seems like a possibility since he is accessing a cystic space of a lymphatic malformation, but I'm just not sure. And 36000 maybe for the injection of contrast?

How should we code a CT-guided lung nodule microcoil localization and indocyaninegreen (ICG) injection?

The people I work for will only listen to you. Would you code this as 64561 or 64581 for placement of an InterStim quadripolar lead? "Needle introduced 2 cm above sciatic notch and 2 cm lateral to sacral midline, feeling for foramenal margins. S3 foramen identified and penetrated. Depth of needle confirmed, adjusted with fluoro. Needle position confirmed by observation of bellows and plantar flexion. Needle stylet removed and directional guide placed, confirmed with fluoro. Needle removed. Incision made peripheral to directional guide thru fascia. Lead introducer sheath with dilator placed over directional guide into foramen ensuring radiopaque marker of introducer did not extend beyond anterior edge of sacrum. Dilator unlocked and removed with directional guide. Lead placed through introducer sheath to first white line. Position checked with fluoro. Lead further introduced until 3 electrodes visible below sacrum. Electrodes tested by observation of bellows and plantar flexion. Introducer sheath retracted under fluoro, deploying tines into perisacral tissue."

Could you please provide additional guidance for correct coding of endarterectomies of lower extremities? We have reviewed the previous responses, but we are not able to articulate to our providers in a way they understand why we would code only 35371 instead of each individual artery. What constitutes significant length into the SFA or profunda or iliac? Consistently, we are asked to code each artery separately, and we need talking points or references to assist us with the conversation with our providers and support when we could code additional arteries due to a complex case. We could send documentation examples, but they would max out the 1075 character limit.

How do you code a patch angioplasty of the common femoral artery onto the superficial femoral and the profunda femoris artey? Is patch angioplasty the same as PTA?

Is 93655 supported for the following? "Biosense CARTO3 3D right superior and inferior pulmonary veins were isolated in pair. Vertical alignment of the temperature probe with the ablation catheter was assured using fluoroscopy. Ablation was terminated when esophageal temperature increased to >0.2 degrees C. Additional lesions were applied if capture was obtained. Subsequently, cavotricuspid isthmus ablation was performed. Bidirectional block was confirmed. Adenosine was administered for both right and left veins; left vein was reconnected at roof after further ablation, and isolation was confirmed. Pacing and recording from coronary sinus was performed; no arrhythmia could be induced. Procedure was concluded."

"Dissection was deepened to the level of the common femoral artery. The common, superficial, and deep femoral arteries were isolated. Second incision in similar fashion overlying the left femoral artery. Exposure and control of the arteries. Tunneling between two incisions in a subcutaneous plane just superficial to the rectus sheath using a curved Kelly-wick tunneler. A 7 mm propaten graft was tunneld between the two incisions. Old graft was disconnected, and the thrombus was removed. The left limb of the graft was spatulated and anastomosed to the stump of the old graft using a 5-0 prolene in a running fashion. Now right femoral artery. Arteriotomy was made. Old graft was transected above the anastomosis. The thrombus was removed. The graft was cut to length, spatulated, and anastomosed to the artery using the same suture. Flushing maneuvers were performed and flow was established. There was good hemostasis at the suture lines. The femoral pulses were palpable bilaterally." What CPT codes should be reported? 35661 and 35875? How about the composite graft of old with new?

Operation: Right femoral cutdown, placement of right femoral conduit with 8 mm Dragon graft and right common femoral vein dissection with placement of a circumferential pursestring for venous cannula access. CPT code for: Graft not bypass femoral artery for conduit during heart surgery like repair of aortic dissection in this case, CABG with CPB? Is this billable? 

Without specific documentation, like "color Doppler", does the below documentation of the measurements meet duplex criteria for CPT 93990? "LT ARM AVF  ** FINDINGS **: Inflow Artery: 1.66 M/s Anastomosis: 2.26 M/s Prox Fistula: Depth/Diameter: 4.7/5.6 Mm Velocity: 3.70 M/s Mid Fistula: Depth/Diameter: 8.3/6.6mm Velocity: 221 Distal Fistula: Depth/Diameter: 10.0/5.9 Mm Velocity: 1.95 M/s Anastomosis: not a graft outflow Vein: 1.65 M/s  ** IMPRESSION **: Upper Extremity Hemodialysis fistula imaged for Vascular Surgeon.   Patent LEFT upper extremity first stage brachiobasilic AV fistula without stenosis."

If a diagnostic abdominal angiogram and bilateral runoff is performed (two cath positions) (36200, 75716), and then the physician decides to do an intervention of the contralateral leg, do we need to drop the 36200 for the diagnostic exam, or do we still bill that with a -59 modifier?

In your book, it states that 93975 is to be used when one or more organs are evaluated. A Q&A on your site quotes ACR as stating that when an organ is bilateral, both must be evaluated and documented in order to code a complete. An ACR Q&A also states that CPT code 93975 can be used whether single or multiple organs are studied. It is a complete procedure in that all major vessels supplying blood flow to the organ are evaluated. If the study is only a partial eval, then the limited code 93976 is billed. Unable to find this documentation on ACR’s website regarding the bilateral organ requirement, is there a reference to that source? How would we code the following scenarios? If a patient has had an ovary removed, or the report states one ovary is not seen, but the other ovary was seen and arterial/venous flow documented, can we code a complete? If one ovary was unseen due and the reason is documented, can we code a complete? Does duplex follow the same rules as a complete US in that if the reason for non-visualization is documented, then a complete can still be coded?

Is there any way to get an example document of what I should be looking for in order to code 77300 - basic radiation dosimetry?

I'm looking for some clarification on billing for 3D CT. My understanding is that a written request from the referring physician for the study is needed in freestanding and independent diagnostic centers. So in the hospital setting, is a written request still required? My physicians are hospital based and perform these studies during a SIRS mapping and chemo embolizations. The documentation is correct, so can we bill for this?

My cardiologists frequently will place a temporary Impella at the time of a cath procedure and remove it at the end of the procedure. Can you tell me if this should be coded with 33990 or 92970? Can you also let me know what the difference is between these codes and when we would use one or the other? 

I am looking for some clarification on coding this. Would it be 64635 (L2-L3), 64636 x 3 (L3-L4, L4-L5, L5-sacral ala) or 64635, 64636 x 2, 64640? They all say medial nerve in the header and the procedure report. "The target for the L2, L3, and L4 medial branch nerves was the junction of the transverse process and the superior articulating process of the L3, L4 and L5 levels respectively. The target for the L5 medial branch nerve or the L5 dorsal ramus nerve was the junction of the superior articulating process and the sacral ala. An appropriate skin entry site was identified after adjusting the fluoroscope to facilitate approaching the medial branch nerve target from a lateral and causal direction. The skin and subcutaneous tissues were the anesthetized. Through this numb and clean area of skin a 16 gauge 10 cm RFA probe with 10MM active tip was advanced under intermittent fluoroscopy until contact with the target was made."

For physician services, is ultrasound guidance (76937) billable in addition to PFO closure (93580) by the same MD when used only as guidance?

"The skin over the left popliteal fossa region was incised in a lazy "S" configuration, the wound was deepened with cautery, and the tibial nerve identified and preserved with a vessel loop. The bypass graft was located, and skeletonized proximally and distally. The area of concern over the medial femoral condyle was exposed. It appeared to compress over slip of muscle and become this with leg in full extension. The area beneath this, acting as a fulcrum, was the popliteus muscle, which was then divided with cautery. It arose from between the gastrocs and traveled to the medial condyle. Then, the adject medial head of the gastroc was divided with cautery near the bypass, to fully decompress this region, and allow the graft more room. Repeat extension showed no bypass compression, and Doppler insonation of the PT did not change with this maneuver as well. This completed the decompression. All areas were made hemostatic." Would this be an exploration, decompression fasciotomy, revision, or something else?

Since CPT 2020 added 64625 with note not to report in conjunction with 64635, we are not sure how to code sacroiliac joint denervation with radiofrequency lesioning of the L5 dorsal ramus and lateral branches of S1, S2, S3, S4 (using Simplicity III). Dx: bilateral sacrococcygeal spondylosis w/o myelopathy. "Procedure:...C-arm visualizing lateral inferior boarder of sacrum just lateral to S4 foramen... The needle contact the scrum bone the advanced lateral to S4 & other foremen but medial to the sij in cephalad direction. .. Simplicity III electrode inserted at entry point where spinal needle was placed...probe advanced maintaining contact with sacrum...Lesioning was carried out in the Simplicity III Program protocol at 80 degrees centigrade for 5 min. L5 Dorsal ramus RF: C-arm repositions... L5-S1 vertebra body squared. S1 superior articular process ID-ed. two 10 rf needle advanced to border of superior articular process and sacral ala. Motor stim done to 2 hz w/no motor recruitment...steroid injected. site lesioned 90 sec at 80 degree centigrade."

The CPT code description of 93657 states that additional Afib must be identified after the PVI in order to code. If the patient has a history of Afib (not manifested during the procedures) but additional ablation was given for "triggers" or potential areas of concern, is that enough to bill 93657? Or does the Afib have to manifest either spontaneous or induced?

When a midline cath insertion is done with ultrasound guidance, we code 36410/76937. We keep getting an edit stating that 36410 is for "incidental only" procedures. Any recommendations?

My provider performed a Watchman procedure. The device was deployed, and completion TEE revealed leakage around the device and the decision was made to remove it. It was recaptured and removed. Can we still bill 33340 since it was deployed initially?

Does the following documentation support 93567 when performed with a heart catheterization procedure? "A French pigtail diagnostic catheter was inserted over the diagnostic Versacore wire advanced into the aorta. Diagnostic wire removed from the body. Pigtail catheter introduced into left ventricle. A pressure was recorded. Left ventriculography was performed using 36 ml of contrast. Post left ventricular pressure followed by the measurement of the gradient across the aortic valve using the pullback technique." (In the findings, the pressure measurements are recorded.) Contrast was not injected, nor were there any aorta images obtained, but they did obtain pressure measurements.

Would you use code 37718 for the following operative note? "Exparel in combination with quarter percent Marcaine was then infiltrated into the soft tissues and the skin overlying the phlebitic small saphenous vein. A total of four transverse incisions approximately 1 cm in length were then created and the dissection carried down to expose the vein. Using both blunt and sharp dissection the vein was excised. Segments and thrombus were passed off the field as specimen."

Would the following be coded with 74018 or 74019? Is the scout billable? "A single AP abdomen scout was performed. Gastrostomy tube was injected with contrast. A second AP abdomen was obtained. No fluoroscopy was used."

In your 2017 and 2018 Diagnostic Radiology Coding Reference books, the instruction was that if an axial and appendicular imaging were performed, to only report the axial CPT 77080. In the 2019 and 2020 books, the instruction has changed to "If axial and appendicular imaging are both performed, report both procedures, appending modifier -59 or -XS to the appendicular skeleton code." When did that guideline change and do you have resources that support that change? Did the RVUs change, as it was my understanding that the RVU for 77081 was included in 77080 if both were performed. Also, the wording in the NCCI manuals has not changed for these edits. Previous examples cited from the Clinical Examples in Radiology published by the AMA and ACR state that they are not to be coded together, but I have not seen any update on that since 2011 or 2012 guidelines. Can you provide more information on this change please? 

If a baseline TEE is performed on the same day but before a TAVR or Watchman procedure, is this a billable service for the physician who is involved with the intervention?

Patient has AAA and has stenosis of femoral and iliac arteries. Documentation states the patient had bilateral external iliac artery angioplasty to facilitate advancement of aortic main body. Would that be included in the aneurysm repair, or can I bill the angioplasty separately? There is documentation that the patient could need femoral endarterectomy in the attending note prior to surgery.

Should a contained ruptured aneurysm be coded as a ruptured aneurysm (i.e., use 34702 instead of 34701)?