Ask Dr. Z

After the ASD/PFO has been repaired and there is no residual left, should I code the echo as congenital (93303) or non-congenital (93306)?

How to code cutdowns. What does the word cutdown mean? Femoral artery cutdown? Carotid artery cutdown? Brachial artery cutdown? Is the repair included in the cutdown?

We are reporting unlisted code 93799 for a BASILICA procedure performed during TAVR in addition to 33361; however, we're unable to come up with a comparison. What CPT code might be used a reasonable comparison for the BASILICA procedure?

For the following dictation, what can be coded? Would it be coded as 64640 x 4 (for the levels) or 64640 x 12 (for the 12 sites)? “Procedure: Fluoroscopically-guided radiofrequency ablation at right sacral ala and lateral branches at S1, S2, and S3 (12 sites). Detail: Following informed consent, and with the patient under general anesthesia, she was prepped and draped in usual sterile fashion. The skin and subcutaneous tissue were anesthetized. Following this I used a 22 gauge angulated 150 mm exposed tip needle at each level, correctly placing them under fluoroscopic guidance at right sacral ala and lateral branches at S1, S2, S3. After stimulating at each level without evidence of motor signs, I performed radiofrequency ablation at each site, heating the affected nerves to 80 degrees centigrade for 90 seconds. A total of 12 sites were heated and treated. I removed the needles and applied sterile dressings.”

How would you code for an ICE catheter used for guidance during a TIPS procedure?

How and why would code 0205T be used? The description states intravascular catheter-based coronary vessel or graft spectroscopy during diagnostic evaluation &/or therapeutic intervention.

Patient had a PVC ablation performed from the endocardial regions instead of epicardial. Is there a difference in reporting?

I know that there is no longer a CPT for revision, so I was wondering what would be the best way to code this procedure. "Incision made over device and device removed. Leads disconnected from device, and pocket revision performed to free the previously placed leads. Leads were then reconnected to generator, irrigation of pocket performed, and generator placed back in pocket. Pocket closed and patient sent to recovery in good condition." Would this be billed as 33215 or unlisted CPT?

Patient had a post-operative coronary sinus dissection that propagated to the posterior LA and IAS causing a large hematoma that was obstructing flow. The procedure performed was percutaneous drainage of a coronary sinus/left atrial hematoma and placement of a 35 mm Amplatzer Cribriform Occluder device in the left atrium, through the hematoma, and into the right atrium. I’m going to use unlisted code 93799 comparable to 93580 for the acquired ASD occlusion repair. However, would the percutaneous drainage of the atrial hematoma be inherent to the placement of the atrial occlude device, or can I bill it separately? If I can bill for the hematoma drainage separately, would it be an unlisted code?

For 2020, is unlisted code 37799 the correct code to use for cooling cath?

I review coding for a pediatric cardiology group. The cardiologists frequently bill complete congenital echoes even when there is no congenital finding (for example, syncope or a functional murmur). Is there a difference between the two "complete" echoes with regard to the structures viewed and measurements? In one conversation, one of the doctors did seem to feel the complete congenital echo was more work than a complete non-congenital echo and wished to bill the 93303/93320/93325 instead of 93306.

How would you code this procedure? Would you use 35045 or unlisted code 37799 where no graft or patch graft performed? "Patient was brought to the operating theater and placed in a supine position. The patient's right arm was prepped and draped in the usual sterile fashion. Once timeout was completed, we created a longitudinal skin incision overlying the pseudoaneurysm with a 15 blade. We dissected through subcutaneous tissue with electrocautery. We identified the pseudoaneurysm and dissected it out circumferentially. We dissected out proximal and distal radial artery and applied vessel loops for proximal and distal control. We then systemically heparinized the patient. We obtained proximal and distal control and then created a vertical arteriotomy with an 11 blade. Carried this cephalad and caudal with potts scissors. We retrieved some old thrombus from the sac and were able to identify small bleed from the artery where the sheath had been placed. We oversewed this with several 6-0 prolene sutures and a pledgete suture."

I have three providers who think that they can bill out modifier -62 for each on a TAVR procedure. PLEASE, correct me if I am wrong, but a -62 modifier is only for two providers of different specialties. Only two providers can bill out for the procedure with a -62 modifier with supporting documentation. Not 3 or 4 providers. Is this right?

The patient has a right ventricular lead, which was retained. The old generator was replaced with a Quadra Allure MP™ CRT-P, and the left ventricular lead was inserted. Would code 33229 be reported, or is 33214 more appropriate since only the right and left ventricular leads were utilized?

One of the physicians I code for only states a bone marrow biopsy and aspiration was done, but doesn't provide a description of how the procedure was performed. Could you please provide an example of the documentation needed to support the assignment of 38222? 

Could you please clarify the changes in how codes 64561 and 64581 are used since the stipulation of temporary vs. permanent has been removed? Code 64561 is now described as including guidance and is percutaneous, and can be either temporary or permanent placement of electrode. Code 64581 is described as using an open approach, and it also can be temporary or permanent. My surgeons normally use a percutaneous approach to place a permanent tined lead through the S3 foramen, create a pocket and tunnel, attach an extension to the lead, and send the patient home for a trial period before they call the patient back for placement of the InterStim generator (64590). This sounds like 64561 to me because of the percutaneous approach and use of fluoro guidance. The type of lead and the fact that it is permanent seem irrelevant. They want to code 64581 because they are placing a permanent tined lead, and they have always used 64581 for stage 1.

Patient with wide complex tachycardia has a diagnostic EPS with 3D mapping, programmed stimulation of the left ventricle, and ICE revealing a right to left shunt. A Swan-Ganz is placed and O2 saturations and QP/QS are calculated, but no pressures reported. Swan is removed at end of procedure. Reporting 93620, 93613, 93622, 93623, 93662, but ????? the O2 sats and QP/QS as this is not 93451?

"A right brachiocephalic stent was placed via a right femoral approach. A selective catheter was placed in the right brachiocephalic with images. The catheter was then advanced through the right bracheocephalic, subclavian, and axillary in the right brachial artery. Images of the right brachiocephalic were obtained. The bilateral common carotids, bilateral subclavian, bilateral vertebral, and the right axillary were all read." Are 37218, 32222-59, and 36226-59 the codes to use for this procedure?

Would it be appropriate to report code 93657 for CFAE ablation in absence of atrial fibrillation after PVI ablation (per CPT Assistant 9/1/2019 Frequently Asked Question: Surgery: Cardiovascular)? CPT Assistant's answer would be in contradiction with the description of the code, which states the code is for the treatment of atrial fibrillation remaining.

Encounter 1: the surgeon did percutaneous insertion (over 6 years in age) into the common femoral artery and femoral vein. The next day (Encounter 2) they do groin cutdown and expose both artery and vein. They decannulate both vessels and perform patch repair on both vessels. Do I code 33952 (percutaneous) for the first encounter and 33984 (open) for the removal and repair of the femoral blood vessels? 

Can you explain if the G2066 is to be reported in addition to the 93297 / 93298 codes - wouldn't this be double-dipping on the technical portion if 93299 was deleted and CPT Changes is saying this was deleted and the 93297/93298 will reflect the practice expenses? Is this new HCPCS code a "tracking" code and no reimbursement is expected?

I've seen both 37241 and 20615 as answers for sclero of an ABC. How would you code these?....#1Care taken to avoid inferior epigastric and femora vessels. direct injxn. doxycycline foam sclero into rt. pubic rami and acetabulum ABC w/guidance-3 sites....#2 - Prev.angiog.com.iliac art. showed no abnl.tumor vascularity. Image guided sclero of lg. aneurysmal bone cyst rt. ilium-4 sites. Which code? How many sites coded?

Can art line insertion be charged with any procedure that uses anesthesia? EP, TAVR, cath lab? It seems it was mentioned in your most recent seminar; however, I cannot find notes regarding the comment. 

How would I code a CRT placement with capped atrial port? "An RV single-coil ICD lead was delivered and deployed, as well as LV lead, both leads anchored to the floor of the pocket. Pulse generator was brought to the field and the atrial port was plugged." Code 33249 is correct for dual leads. How do we account for LV lead, 33225?

We're looking to find out when it is appropriate to bill 27592 vs. 27590 for an AKA, first operation. "Standard anterior-posterior fishmouth type incision was made justt above the knee. This was carried through skin, sub-q tissue, and through crural fascia muscle layer. All muscular tissue was transected using electorocautery surround the femur. We then identified the popliteal arter and ven and ligated artery and vein with silk sutures. We then ligated distally as well and transected them. Next, we completed our posterior circumferential transection of muscles and tendons around the femur. Finally the sciatic nerve was ligated high in the field and then cut high in the filed and allowed to retract back. I then made another cut anteriorly on the femur with the oscillating saw to create a bevel to avoid any compression. A rasp was used to file down the edge of the femur so it was not sharp. I then irrigated and achieved full hemostatis. I buried the popliteal artery and vein stumps. We then closed in layers."

Since 93299 has been deleted from CPT, if the patient does not have Medicare so G2066 does not apply, what CPT code should be reported on a claim?

With the pericardiocentesis code updates for 2020, could you please provide guidance regarding the use of 33016 and 33017? What is the difference between a drainage tube that we may see with 33016 and an indwelling catheter we see with 33017? What should we look for when trying to determine the difference? The old code, 33010, was used when drainage access was done percutaneously. Code 33016 doesn't use specific language to that effect, but is that still the same? Similarly for 33017, with the old code there needed to be an incision made, but now the code description states that this is done percutaneously; does that mean an incision is no longer required?

Pediatric patient with dextrocardia, double inlet left ventricle, pulmonary atresia, and MAPCAs receives two stents, one in left and one in right aortopulmonary collateral. Do you agree with unlisted code 37799, or are cardiovascular system unlisted codes 39999/93799 more appropriate?

Repeat mesenteric exam. No bleeding source identified again. tPA challenge done. What code is used for the tPA injection, if any?

The physician removed a massive 5 cm wide fistula that was not infected. He also repaired the brachial artery. Code 35903 is for removal of an infected fistula. Is there a more appropriate code for this? We are trying to avoid using an unlisted code.

One of the changes made this year is to break CPT 74220 into two codes, to distinguish between single contrast exams and double contrast exams. Code 74220 has been retained, but redefined as "single contrast". Code 74221 has been added as a new code for "double contrast" exams. The example given for 74221 is an exam in which both barium and a solution of sodium bicarbonate crystals in water are administered. Scenario 1: Does the definition of 74221 apply only to studies in which both barium and an effervescent agent are administered, or does it also apply to studies in which any two contrast agents are used? Scenario 2: How would we code the occasional study in which water-soluble contrast, barium, and an effervescent agent all are administered? The definition of 74221 is specifically "double contrast". Would we have to report such a study with unlisted code 76499?

We had a STEMI come thru ER and emergently taken to cath lab. Patient was appropriately statused as IP by hospitalist and received a drug-eluting stent for a 100% occluded RC. Six hous post stent a different MD came behind and downgraded to OP status. How can we bill the case? Can we bill C9606 with -CA modifier?

The patient had a diagnostic angiogram of the ICA followed by neuroembolization of the anterior and middle cerebral arteries. I wanted to code for the catheter placement into the anterior and middle cerebrals with 36218 x 2. However, 36224 is not a base code for 36218. Please advise what to charge, if anything, for the catheter placements after 36224.

The Watchman procedures that we have billed since 10/01/19 for diagnosis I48.19 are not on the NCD 20.34. They are requesting that we change it to I48.1. As you know an additional 5th digit is now required for this code due to coding update 10/01/19. The NCD has not been updated to reflect this change according to our MAC, which is CGS. Is the only way to get this paid is do an appeal? Do you have any information or suggestions on how to handle this issue? At this time we have 6 claims that are not paying.

Our vascular surgeon documented fem to posterior tibial bypass done with synthetic graft and saphenous vein graft. This was due to saphenous vein not being sufficient length to accomplish the bypass, so he elected to perform a composite Gore-Tex and saphenous vein graft. End-to-side anastomosis done with the synthetic graft to the femoral, posterior tibial anastamosis was accomplished by means of an end-to-side anastomosis with the saphenous vein and end-to-end anastomosis was accomplished from the saphenous vein to the distal Gore-Tex graft. Would I use an unlisted for this procedure?

Excision of left brachial artery pseudoaneurysm/reverse saphenous vein interposition graft left brachial artery with excision of excess skin. I was thinking 35011/15839. Despite no edit being in place for 35525, it does not look right being billed as 35011/35525/15839. May I please have your advice?

I have a physician who did an ICD generator change and is wanting to bill 76000 for fluoro of lead. Report says: "Fluoroscopy of the ICD pocket, entire lead length from pocket to RA and RV was performed in AP, RAO and LAO. No externalization of the leads was noted." He then went on to exchange the generator, doing nothing to the leads. His indication is: "Fluoroscopy of leads to assess for conductor externalization." Would this be billable? He is a new EP to the practice and none of our other EPs have done this before, so we just want to be sure.

"Left IJ vein accessed and venography performed. Occlusion found and unable to surpass occlusion. Subclavian vein was accessed instead. After multiple attempts, they switched to a cutdown and open exposure of the subclavian vein in order to place the dual vortex catheter. Catheter finally was placed in the atriocaval junction under fluoro. Subclavian vein sutured and repaired." How should this be coded? Is open exposure of the subclavian vein bundled with 36558? My codes are 37799 (catheter placement in IJ), 75860, 36558, and 77001.

Is the use of tPA a requirement when performing percutaneous transluminal mechanical thrombectomies? 

I reported code 34703, but I'm not sure if that's correct. The note lists "unibody graft" for AAA. "An oblique incision was made on the right side, dissecting down to the site of the fem-fem graft through the previous scar. Once the external iliac arteries encircled with a loop, a micropuncture was used to access the vessel, and catheters were placed up into the aorta. There was noted to be plaque at the aortic bifurcation and the aorta. An angiogram was performed that showed where the renals were with a good neck. The patient was then heparinized. A 32 x 14 x 102 graft was deployed and brought up from the right side with some degree of difficulty. The device was released at the level of the renal arteries, which are approximately at the same level, and the top caps were released with good apposition here. Next, an angiogram was performed for the distal portion, and a 16 x 16 x 124 limb extension point was brought down to the hypogastric artery."

The rep is performing the interrogation, sending the information the provider, and the provider holds the claim until the 91st day. These codes are per 90 days, so can the patient have the remote services performed prior to the 90 days, and is it appropriate to hold them until the 91st day to bill? This would seem to be a stretch of the rules for these codes. Please provide clarification on remote coding and the correct dates for both the 93295 and 96.

We billed out 93880 but received a denial because the patient had one at another physician office. The MUE lists 1 and 3. Is there only 1 per day, or can we appeal with report? Could possible modifier -XP and/or -77 be used in this case?

I have a physician who is doing the Ellipsys placement. Prior to the procedure he is performing a supraclavicular nerve block. Is this a separately billable procedure, or is it considered part of the per fistula placement?

Does this documentation support 93657? "Isolation of all four pulmonary veins was performed. While isolating the right pulmonary vein, phrenic nerve integrity was verified via pacing, the phrenic nerve utilizing the quadripolar catheter above the pulmonary veins. Following the last cryo-application, the cryo-balloon was removed, and a post-ablation voltage map was then created. There was evidence of a gap in the right superior pulmonary vein. The balloon was then prepped again and advanced in the right superior pulmonary vein. An additional application of cryotherapy was made. Following this, the balloon was exchanged for the PentaRay catheter again. Post-ablation voltage mapping showed all veins were isolated."

I could use your help with this case ICD case. The first epicardial LV has failed, and the pocket was open to utilize the second LV lead. The generator was not changed; only the second epicardial lead was accessed/connected and the previous lead was capped. Here is part of the actual report: "The previously capped second epicardial LV lead was seen on the floor of the pocket, dissected out from the chronic scar tissue. The cap was then removed from the lead. The currently used LV lead was then disconnected from the chronic header, and the previously capped LV lead was connected to the header. Adequate sensing, impedance, and capture thresholds were confirmed through the second epicardial LV lead. The previously utilized but fractured epicardial lead was then capped and placed in the pocket. The device and leads were inserted in the pocket with care to ensure that the leads were beneath the device. The pocket was irrigated with antibiotic-containing solution." Would I report code 33999 for this scenario?

When is it appropriate to report/code a right heart cath with heart biopsy when performed in the same setting for a patient post heart transplant? Is having any additional diagnosis, like pulmonary hypertension, sufficient to support coding the RHC? Is an additional diagnosis sufficient, or is there additional language required in the body of the note to support coding both RHC and biopsy?

Do you agree with codes 20550/76942 for this procedure? Instillation of steroids/local anesthetic mixture into laminectomy defect at L4 and L5 with ultrasonographic guidance.

Please explain the difference between codes 37246 and 61630 for intracranial angioplasty.

For physician billing, are any additional codes appropriate when a carotid stent is placed using flow reversal? My understanding is that code 37215 includes the work of establishing flow reversal and closure, but some physicians want to bill codes 36556 and 35201 in addition to 37215. Here's an example of the documentation: "Right femoral vein access was gained using micropuncture under ultrasound guidance. An 8 French venous sheath was placed. Next a supraclavicular incision was made over the area of sternocleidomastoid muscle. Common carotid was dissected. Micropuncture was used to access common carotid artery. Silk road sheath was then inserted and secured with 2.0 silk suture. Flow reversal then connected. A 7 x 30 mm silk road carotid stent was then deployed. Postprocedure angiogram showed no residual stenosis. Wires and sheath were removed, and arteriotomy was repaired primarily with 6.0 Prolene stitches. Common carotid was unclamped. Total of 8.5 mins of flow reversal. Wound was irrigated, and hemostasis was controlled. Platysma was closed with 3 0 Vicryl in running fashion."

How would you code the following? It has been suggested to use codes 64640 and 77013, as these are not true paravertebral facet joints. Looking for clarification or suggestions. "The region of the medial branches at the L5/S1, S1, S2, and S3 levels were identified under CT. The overlying skin was then numbed using 1% lidocaine. Under CT guidance needles were advanced adjacent to these nerve sites. The ablation needles were placed, and motor testing was performed at four sites. No motor activity was appreciated. The sites were then numbed with Marcaine, and ablation of the L5/S1 facet as well as the S1-S2 and S3 sites along the SI joint was performed. Needles were removed, and sterile dressings were applied. IMPRESSION: Successful SI joint ablation."