Ask Dr. Z

The surgeon describes completing venoplasty in an arteriovenus fistula by direct access using IVUS as S&I. No angiogram/venogram was done. He used IVUS to diagnosis the stenosis in the AVF. Can I still use CPT code series 36901-36909?

When coding an EP study, and the left atrial roof line is mentioned after the PVI is performed, what else needs to be documented to be able to bill this code? This is an example i have come across: "...All four pulmonary veins were isolated with radiofrequency ablation followed by a left atrial roof, floor line, anterior mitral isthmus and a complex fractionated electrogram ablation. Pulmonary vein isolation was demonstrated with entrance and exit block and loss of pulmonary vein potential signals." Is this enough to bill, or does it need to be documented that an additional rhythm was detected? What exactly is the verbiage needed to compliantly bill this code?

Adenosine infusion to evaluate for dormant conduction and acute PV reconnection. Body of report: "Adenosine 18 mg IV was given, and there was no evidence of dormant conduction or acute PV reconnection for all PVs and posterior wall." Is this enough to report code 93623 since it sounds like he was looking for a dormant conduction as well as checking the efficacy of the PVI?

It is my understanding the measurements provided by the tech are part of the technical portion of an echo. My provider feels he does not have to provide an interpretation in his findings if the measurements are listed. Does he still get credit for a complete echo?

As of 2018 the CPT book states 61630 and 61635 are both column 1 codes and 61645 is a column 2 code and should not be billed with 61630 or 61635 in the same territory. This is opposite of your coding reference guidelines stating 61645 bundles 61630 and 61635 as well. Can you advise?

Is there a CPT code for removal of stent right subclavian, or do we just use foreign body removal?

Is code 93600 allowed with the 93650 per this documentation? If so, is the bundle of His allowed with all AV node ablation procedures? "The existing biventricular pacemaker was interrogated, revealing stable lead parameters. Reprogrammed to VVI 40 for the duration of the procedure. An 8 French sheath was placed in the right femoral vein. An 8 mm tip temp control ablation cath was advanced to the right atrium via the 8 French sheath. The ablation cath was advanced to the region of the His bundle, taking care to avoid the chronic pacing leads. The cath was then withdrawn posteriorly and inferiorly to the region of the compact AV node using a combination of intracardiac electrograms and fluoroscopy. Radiofrequency energy was then applied. During radiofrequency application, complete heart block was obtained. Following ablation, there was evidence of a stable junctional escape rhythm at 45 bpm. There remained no evidence of antegrade AV conduction after a 30-minute observation period. End of procedure. Pacemaker was interrogated, revealing stable lead parameters and reprogrammed."

Three separate lymph nodes were injected with 3-4 ml of lipiodol. Status post thoracic lung resection mediastinal nodal disection and subsequent chylothorax. Can this be coded as 49185?

With the creation of code 64625 for RF ablation of the nerves innervating the SI joint, does radiofrequency of the lateral sacral nerve fall within the reporting of this code? Can you explain the difference between the guidance for reporting the lateral sacral nerve ablation using code 64640 vs. the new code 64625?

If a patient has an outpatient cath performed one day but they stay in observation till the next day, what should be billed? In what instance should we bill a short stay summary, 99236?

Is the removal of the midline catheter included in the placement code 36410? So you don't report anything for the removal?

Can I bill an iliac angioplasty done during an Impella placement? I have found no guidance on this.

My doctor did an angioplasty of a pop-dorsalis pedis bypass graft. Would this be coded with 37228? Can you recommend anything that I could access/buy that would help me to understand which vessel I should be billing when there is intervention in a bpg?

Can you assist in coding this type of case? What about code 37241 or 49185 for the cystic malformation arm? I'm not sure where to start for the laser that was performed. "Under ultrasound guidance multiple lymphatic microcysts within the soft tissues of the right posterior elbow right mid arm and right medial elbow were cannulated with a 25-gauge needle followed by injection of bleomycin in a concentration of 1.5 units per mL. A total of 15 units of bleomycin was injected. Followed by surface laser treatment of multiple cutaneous lymphatic vesicles over the right arm and right chest wall and flank. Laser Parameters ND YAG laser (Venacure, Angiodynamics) 1470 nm: 2876J, 719 sec, 4 watts."

Encoder Pro is showing G0365 to have been deleted for 2020, but does not give a cross reference code. What is to be used for this now?

Would you recommend codes 93653 and 93655 for this procedure? "We measured baseline intervals. We then performed atrial extrastimulus testing as well as incremental pacing. There was dual AV nodal physiology with induction of short RP less than 70 millisecond tachycardia. His refractory PVCs did not pull in the a. his refractory PACs delayed the next his ruling out junctional tachycardia. Ventricular overdrive pacing resulted in VA treat response ruling out atrial tachycardia. We then used a irrigated force catheter to perform right slow pathway modification with powers of 25 w. There were good junctional beats with 1-1 retrograde conduction. We then repeated programmed electrical stimulation with doubles from the high right atrium and from the coronary sinus with and without Isuprel up to 0.04 mcg per kg per minute. There was single jump without any echoes. In the process of programmed electrical stimulation we induced typical atrial flutter. Entrainment confirmed that it was caval tricuspid isthmus dependent flutter. Ablation was performed across the caval tricuspid isthmus that terminated the flutter."

I have a cardiac clinic patient coming in 7 day TAVR procedure follow-up. In the clinic note, MD states in assessment/plan as first listed diagnosis is "severe aortic value stenosis". Would we use Z48.812 for first listed diagnosis? In your answer for question 10857 it was stated to use Z09, but we are thinking Z48.812 is more specific to a cardiac procedure. Can you please elaborate on your answer "Do not report code I35.0, Nonrheumatic aortic (valve) stenosis, as this condition is no longer present"? Is aortic stenosis with the new aortic valve only coded as a complication because the new value completely resolves this condition?

Is new add-on code 93356 appropriate for facility coding?

When a midline catheter is placed with ultrasound guidance, can we report code 76937 with 36140?

I code for a hospital outpatient facility. When a physician performs needle biopsies of cervical lymph nodes on both the right side and left side of the neck, can we bill 38505 twice?

How would we code this? As a delayed extension even though it’s a main body graft that is being placed? "The patient had an endovascular repair of the abdominal aortic aneurysm in 2013. The aneurysm has started to increase in size due to the main body of the graft having disassociated from the proximal fixation prosthesis. Procedure performed: Graft disassociation producing significant enlargement of the aneurysm sac. This was treated using placement and realigning of the previously placed graft with an endovascular bifurcated tent graft and bridging prosthesis from Endologix. The main body proximal prosthesis and bridging graft were deployed and post dilated with a Reliant balloon. Following placement of the endograft within the previously placed endograft, imaging was performed showing no evidence for type 1, type 2, type 3, or type 4 endoleak."

Should code 92941 be used for NSTEMI?

Could you explain the coding for this case? "Bilateral groin incisions performed. The very large lymphoceles were drained. It was clear. It was not infectious. The patient then had fulguration with argon beam coagulator performed of the entire base. Excess skin was excised and again the argon beam coagulator was used to completely fulgurate the base of the lymphocele on both groins and again excessive skin was removed and talc was placed in both wounds and the wounds were closed tightly with PDS #1 in both groins and then 2-0 PDS was use to close the subcutaneous tightly. Skin was closed with interrupted 0 Prolene vertical mattress sutures with good approximation of skin edges."

If a cardioversion was performed for SVT during a CABG, should code 92961 or anything be reported? "Normal sinus rhythm developed spontaneously, then quickly converted to SVT. We performed cardioversion at 10 joules and the rythm was corrected to NSR. We placed ventricular pacing wires, with no pacing needed. The patient was then easily weaned from cardiopulmonary bypass. No pressors were required. Protamine was then administered to reverse the heparin. The cannulas were removed and cannulation sites over-sewn."

We are doing overreads for an outside company for MRI and CTs. The description for 76140 says consult on "x-ray" performed elsewhere. Does the word "x-ray" encompass all radiological modalities? Is there a place or link that I can find this information? My hospital is wanting to report the MRI/CT CPT codes with -77/-76 modifier. I think we should stick with 76140, but I can't find anything about the modalities.

Does the following statement suffice for reporting 34839? Case: A modular fenestrated endovascular aneurysm graft, including two visceral artery endoprosthesis for right and left renal arteries was placed (34846). The physician stated in the operative report: “Planning for 3-vessel fenesterated EVAR with modular Cook device (I spent 120 minutes planning the EVAR fenestration).”

We have several doctors who have been billing inter-operative cholangiogram (74300-26) with laparoscopic cholecystectomy (47563). They note in the report that it was performed along with their findings. We have been receiving some denials. Are there specific requirements for the physician to bill both 47563 and 74300-26? 

When coding Varithena procedures, the difference between 36465/36466 and 36470/36471 is the CPT descriptor of truncal veins, correct? If the documentation does not state truncal or saphenous vein, can you still code 36465/36466? Operative note just states "Area treated: left calf," (this is Varithena treatment post ablation) Or, since it is post GSV or SSV ablation, can we assume truncal vein since it is following ablation therapy?

I have found the codes for 2020 genicular nerve block (64454) and the 2020 genicular nerve destruction by neurolytic agent (64624). I am not finding the coding for 2020 genicular nerve RFA. Would you use the new code for destruction 64624 even though the description does not state by RFA?

Can ECMO management CPT codes 33948 and 33949 be utilized as a split/shared service? When reviewing documentation for ECMO services, I am finding the physicians documentation supports management of ECMO circuit. However, the physicians are not including, in their attestation, the diagnosis as to why the patient was hooked up on ECMO circuit. If the diagnosis is documented in the NP's progress note for the same date of service, is it allowable to combine both providers documentation and bill for the ECMO management service? Also, are there specific documentation requirements for ECMO managament, and, if so please elaborate as to what this would consist of?

I just wanted to get clarification on how to code the below scenario. I read the guidelines about disc/paravertebral biopsy/aspiration in the new 2020 book, which have changed slightly from last year. I'm still a little confused about how to code a paraspinal lesion aspiration and biopsy. You state that if they do a paraspinal aspiration and adjacent vertebral body biopsy, that the biopsy is included. What if it's a core biopsy of the same lesion? Is this also included in 62267? Or do we code this as 20206?

If the surgeon places a stent in the right iliac via right common femoral access and then performs an atherectomy on the left popliteal via left popliteal access, can a separate catheter placement for the left popliteal be billed? Or would it be bundled with the popliteal intervention?

A patient presents for dialysis Permacath placement. The physician states, “I will also assess his veins for hopeful AV fistula creation in the near future.” After the Permacath insertion is completed, the physician states, “I inspected his arms with B-mode ultrasound and the basilic and cephalic veins in both arms were not adequate for AV fistula creation.” This is the only documentation we have for the ultrasound procedure; there is also no saved ultrasound image in the record. Is this procedure codeable? If so, how?

Do you know why there are PTP edits for A9503 with 78306 and 78830? Is anyone looking to get them reversed?

What documentation should I look for to know that the left atrium was "recorded" in addition to the pacing that was documented? If we don't see the word "recorded", do we need to query?

Can code 36620 be billed with 33340?

Can the BASILICA procedure be billed separately from TAVR?

I'm not sure how to code this. Patient has an internal iliac aneurysm. From the right common femoral artery, MD does a coil embolization of the left internal iliac and places a stent graft across the left common and external iliacs. Should we report codes 37242, 37236, 36246?

"Patient had enlarging hematoma in the right groin post angio. Incision was made in the right groin, and dissection was carried down to expose and gain control of the femoral artery, which was bleeding actively. Interrupted prolene sutures were utilized to control the bleeding. It was noted the patient did not have retroperitoneal hematoma. After further dissection on to the external iliac artery, patient was noted to have a large abdominal wall hematoma. The external oblique muscle was opened up, and a large hematoma was evacuated. There was old clotted and non-clotted blood. Patient appeared to have had a small tract from the active bleeding area of the artery posterior to the muscle into the abdominal wall. Upon completion of the drainage, the area was irrigated thoroughly with irrigator solution and antibiotics. Wound was then closed in a double-layer fashion with absorbable sutures." I have 35226 for the femoral repair, but I am stumped on how to report the hematoma drainage. Any guidance would be greatly appreciated.

Can we report 36905 (balloon angioplasty, peripheral dialysis segment, including all imaging, radiological supervision) with 76937 (US guidance for vascular access requiring US)? We were previously told that 76937 is included.

Code 37242 is on the intense device-to-procedure edits; however, during this particular case Trufill was used to close the Triple AAA leak, which HIM coded 37242. This product does not have a HCPCS assigned, and it may be considered off label used in the method it was during this case. A response from MAC indicated -CG modifier may need to be applied on certain device-dependent procedure when placement of a device was not completed. I'm very confused by this response and not sure a modifier is needed. Is this a possible miscoding issue?

A resident is involved with an IR procedure that involves moderate sedation, and the physician states the following: "I was personally responsible for the administration of moderate sedation during the procedure performed." Would modifier -GC be appended to 99152 and 99153 since it doesn't state the resident was involved in that part of the procedure?

In regards to "catheter placement", can selective catheter placement CPTs (ex: 36245) be coded if a sheath (e.g., Raabe) is utilized as a catheter and selective injection performed?

We have a patient who presented with plan for EP study with PVC ablation. The patient had no PVC on arrival, so they infused Isuprel. This was taken up to 2 mcg/min and then 4 and 8. No PVCs were seen, so the procedure was aborted. Since the Isuprel is an add-on code and needs the parent code, what do you recommend we bill in this instance? Would you use 93619-73 and 93623 or something else?

If a unilateral rib x-ray is performed with three views, but not with a PA chest x-ray, is 71100 the correct code to report?

When coronary shockwave lithotripsy(IVL) is performed and stent was done of the same artery, how do you recommend this be captured? Coding Clinic HCPCS for 4th q 2019 says to use unlisted 93799 and the stent code, 92928.

Some of our providers are doing an EKG (93005 for technical portion) on the same day as a Holter hookup (93225 for technical portion). When I run that through 3M, I get an edit that allows for a modifier if performed on the same day if appropriate. However, I cannot find any documentation of what would be the appropriate circumstances in which to bill both services on the same date.

BCBS is requiring us to use anatomical modifiers for cath placements for angiography. My team cannot come to an agreement on which modifier to use. If access is on the right side and catheter is placed on a vessel on the left side, which is the correct modifier to use, RT or LT. We are evenly split on this half of us say it should be the access side and the other half saying it should be the side of the vessel that was catheterized. Can you clarify this for us?

Can you please help me understand the new LCD for vertebral/kyphoplasty? Am I understanding correctly that the patient has to be seen by a neurologist prior to the procedure being done? And did they remove all the previous ICD-10-CM codes? The new policy I'm looking at only shows: M80.08XA - Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture; M80.08XS - Age-related osteoporosis with current pathological fracture, vertebra(e), sequela; M80.88XA - Other osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture; M80.88XS - Other osteoporosis with current pathological fracture, vertebra(e), sequela I'm really confused by this. I need to understand it better before I let my IR know about these changes. I think they took place.

There was a VT ablation done on a patient by one of our EP providers. This provider had one of our interventionalists place an Impella device during this ablation for ventricular support. Upon completion of the ablation the Impella was turned off and removed, and patient was sent to ICU. I have not see this device used for this purpose before. I am wondering what your thoughts were on this.