Ask Dr. Z

Is there any way to report the new technology Viz LVO Stroke Software for reimbursement for physician billing? There is an ICD-10-PCS code, but is there either a HCPCS or CPT code for physicians to report?

Since 93356 reports with 93303, 93304, 93306, 93307, 93308, 93350, or 93351, can it also be reported with C8921, C8922, C8929, C8923, C8924, C8928, C8930? I am not seeing any information that it cannot, so I want to validate.

The doctor was able to get the Pipeline device in; however, it failed to open spontaneously. Would the doctor still get credit??

Our hospital recently began doing CTO (C9607). I have questions on how these claims should be coded to receive proper reimbursement. Can you please provide me with a source of information or some guidance?

"After informed consent was obtained, access to the left femoral artery was performed via modified Seldinger technique. A 5 French pigtail catheter was positioned in the infrarenal aorta for abdominal aortogram with runoff visualization to external iliac arteries. Catheter was then advanced to the right common femoral artery for selective right leg runoff to the left trifurcation. Catheter was then positioned in the left external iliac artery for selective right left leg runoff to the trifurcation." Should I report code 36247, or should I report 36140 and 36246?

Left vertebral artery DSA biplane, intracranial: left vertebral artery balloon angioplasty and stenting of the V4 segment for a medical refractory intracranial atherosclerotic disease. Can we use code 61635 for left vertebral artery balloon and stenting?

"Patient with history of AF and cardioversion came to the ED with cardiac palpitation; EKG was ordered for tachycardia. Medication did not resolve the condition, so the decision was made for cardioversion and was successfully converted back to normal sinus rhythm on a repeat EKG."  Is the first EKG considered a diagnostic, and is modifier -59 appropriate? If post EKG was performed to see if the heart rate return to its normal sinus rhythm, is this considered medically necessary or is this considered routine?

Can you bill code 37765 with 36471 for the same leg at the same encounter on the same day? I see instructions for 37765 with 36475-36482 but nothing about 37765 with 36470.

Can you clarify what the ICD-10 code should be for a physician who specifies "dual anti-platelet therapy" without specifics to which anti-platelet/anti-thrombotic drugs are in use? Based on my own reading I've always gone with Z79.02 and Z79.82; however, I've been recently advised that only Z79.02 would be appropriate.

If an ICY cooling catheter (CPT 36556) is placed outside the cath lab, does it require a chest x-ray to confirm tip termination end point?

My doctors are using a new navigation software to guide the needle for cryoablations. He utilized the 3D CT guidance for cryoablation of a renal mass. Can I report code 76377 for this? Would this be 50593, 76377? Or do I add the 77013 also? "Utilizing the 3D CT guidance... Images were transformed to an independent workstation for 3D rendering and image review under concurrent supervision."

A patient has a dual chamber pacemaker implanted. The device is currently programmed VVIR due to a damaged atrial lead. The patient is in the office having a pacemaker programming performed. Would we report 93280, because the CPT code description is for the "system" not the amount of functioning leads? Or is the appropriate code 93279 since only the one lead is functioning?

Cardiac catheterization: If a balloon was inflated three times at a high pressure inflation and ruptured all three times, does this qualify as a successful balloon angioplasty or does it require a -52/-53 modifier?

Based on the description of CPT code 33340 it states "with endocardial implant". I would assume that to mean the Watchman is included? Please clarify.

Please advise how you would report the following: "Exposure of the proximal 4-5 cm of the profunda femoral artery, which lay below the previously worked on common superficial femoral system. The profunda femoral artery was ligated just distal to the stenotic connection to the lateral branch and divided. The distal portion of the profunda fomoris artery was mobilized. The distal hood of the existing vein graft was opened longitudinally and had an excellent lumen. The end of the profunda femoral artery was spatulated and an anastomosis carried out to the vein graft with 7-0 prolene suture. Backbleeding and for bleeding were allowed to occur, and flow was restored into the profunda system."

If two separate structures and biopsied in the retroperitoneal space (adrenal mass and retroperitoneal lymph node), can code 49180 be submitted twice?

My question is regarding angiographies performed during hepatic embolizations. If the patient has a known tumor and no previous angiography was performed, and the tumor was located by a previous scan/MRI/biopsy, would the angiography be considered diagnostic, or would it be considered roadmapping to locate the tumor for completion of the intervention? In the reports we are seeing, the MD does not document that the angiography led to the decision for the intervention.

How would you code a deep vein arterialization procedure? The procedure is described as a bypass with the proximal anastomosis with an in situ vein, and there is not a distal anastomosis. Vein valves are lysed. This is to cause the distal vein from the anastomosis to become arterialized (fistula?). Would it be appropriate to report the bypass code 35587 alone or 35587-52 (for the single anastomosis) with add-on code 35686?

Patient previously treated with infrarenal aortic endograft and followed by TEVAR for ruptured thoracic aortic aneurysm. He now returns because aorta has degenerated between the thoracic endograft and the infrarenal aortic endograft to a max diameter of 7 cm thoracoabdominal aortic aneurysm. Patient is taken to surgery for FEVAR for repair of visceral aorta with stents into celiac, SMA left, and right renal (which is CPT 34844). Also thoracic aneurysm repaired with Zenith graft deployed with adequate overlap of existing thoracic graft and the new fenestrated endograft. What coding can the thoracic graft get? Technically it's a delayed distal extension of the TEVAR 33886 or proximal extension of FEVAR, which there is no coding as it's bundled into 34844. Or the other possibility is a new TEVAR of 33881 not covering the subclavian. He did treat two different problems, so I feel additional coding is warranted, but wanted expert advice on the correct way to go about it. There is no bundling issue with either scenario.

Patient had atherectomy in AT, angioplasty in dorsalis pedis, arch and lateral plantar. In this situation, would we code an additional 37232 for the angioplasty below the ankle along with the 37229 for the AT?

IVUS was done for a patient in the fem/pop, AT, and pedal loop. Would coding 37252, 37253 x 2 be correct? If not, what are the guidelines for coding IVUS below the ankle?

Our MD accessed the femoral vein instead of the femoral artery by accident. While he was in the vein he shot images and charged for it. Since this was not part of his original intent, would we allow those charges?

Is an iliac branched endograft billable when performed during a FEVAR? "A 4-vessel branch-fenestrated endovascular repair of thoracoabdominal aortic aneurysm (terminating in common iliacs) and bilateral internal iliac branch endoprosthesis for treatment of bilateral common iliac artery aneurysms."

Is new code 76145 for 2021 used for physician or hospital billing?

"1) Exploratory laparotomy. 2) Retrograde superior mesenteric artery recanalization, angioplasty, and stenting with 6 mm x 29 mm VBX stent graft. Yesterday, I performed a brachial artery attempt at mesenteric recanalization in an antegrade fashion, which was unsuccessful due to the dense calcification and occlusion of the origins of the vessels. Brought back for laparotomy and retrograde approach today. A longitudinal midline incision was made through skin and subcutaneous tissues. SMA was accessed retrograde with a micropuncture wire and needle, followed by a 4 French microcatheter. We were able to traverse the area of occlusion into the abdominal aorta. A 5 French sheath was then placed over the Glidewire into the SMA. We then were able to bring a 7 French sheath across the occlusion, then brought a 6 mm x 29 mm VBX stent graft and delivered it through the stent and pulled the stent back into the residual SMA."  Do I report code 37236 with modifier -22 or report an unlisted code?

Placement of Chimney for previous EVAR with endoleak by vascular surgeon. Per note: "Open left subclavian access, percutaneous right brachial access, percutaneous bilateral femoral access with only right side using larger than 12 French sheath. Selective cath and stent placements in right renal, SMA, and celiac arteries. Decision to continue with the extension of the infra-abdominal endograft and ends stenting of the aforementioned arteries. A 6 mm x 79 mm was placed in the right renal artery. A 6 mm x 59 mm stent was placed in the SMA. The right groin sheath was removed and the artery was dilated serially to 18 French size. A Medtronic Navion endograft was then placed over the Lunderquist wire and deployed into the abdominal aorta just below the celiac artery takeoff. The balloon-expandable stents in the right renal artery and SMA were then deployed. Abdominal aortogram showed inadequate overlap of prior endograft. Another Medtronic endograft was deployed." Provider wants to use code 33881. It seems this is in abdominal aorta and not thoracic; however, Navion device is used for TAAA. What are your thoughts?

If the documentation only documents the intravascular Doppler velocity pressure derived coronary flow reserve measurement for coronary vessel, do you bill 93454 with it?

How would I code a guided fiducial marker of the hepatic lesion? "Using aseptic technique, a 17 gauge fiducial deployment needle was advanced into the lesion under CT guidance. A total of two markers were placed in the lesion margins (superior and inferior)."

The clinic we do billing for hired a device company that monitors PPM and ICD devices. We are having concerns because the physician signs the notes late and we are trying to be compliant. The device company is telling us that even though the physician signs the notes late we are still able to bill it on the date the service was completed. For example, CPT codes 93297, G2066, and 93295 were all completed on 10/01/2020 and the doctor then reviews the notes and signs them on 10/12/2020. From my understanding the date the physician reviews the note and signs would be the DOS that we would bill on, can you clarify this? Also, they want us to bill the remote technical G2066/93299. Per, biometric telemonitoring state that "remote device evaluations" (93926 and 93299) require "general supervision" by a physician. Since it's a device company we are not supervising. Therefore, I am not sure whether we could bill the technical. Can you provide any guidance on this matter?

When a catheter is placed in the right gonadal vein that is directly off the IVC and diagnostic venography is done, what is the CPT code for the venography? Is 75831 permitted?

Our facility is considering coding 36410 when one of our nurses goes to do an US-guided IV for diagnostic (CT, MRI) procedures, or for cancer patients receiving therapy and a regular IV cannot be started. This is the same code we charge for midlines done by our IV nurses that are used for medicines being administered. Is this an allowable code for this? The CPT Codebook says by physician or other qualified healthcare professional. A similar question has been asked before but over a year ago. What is the newest recommendation?

The day following a dual chamber pacemaker implant, my provider drops a charge for the interrogation of the pacemaker, but the only documentation he provides is the following in his progress note:
Interrogation: P- 4.8 Imp- 513 A- 0.25 @ 0.4 R- 9.9 Imp- 627 V- 0.5 @ 0.4". Is this enough documentation to bill for an interrogation? My feeling is that it is not proper documentation to warrant a charge for the interrogation.

Would this support 35371 and 35372? I think 35355. "We performed a linear incision overlying the common femoral artery and dissected down onto the artery without difficulty. As expected, the external iliac, common femoral, and superficial femoral were densely calcified. We then proceeded to expose the deep femoral and dissected it down to the third collateral branch. In the process, we had to ligate the deep femoral vein to give additional distal exposure. We reached a soft spot on the deep femoral. All the side branches were looped. We prepared for clamp application on the external iliac and at this point we administered heparin, dose 100 units per kilogram. Clamps were applied. We made an arteriotomy beginning at the distal deep femoral and then running the arteriotomy onto the common femoral. We also extended the arteriotomy onto the superficial femoral. We performed aggressive endarterectomy of the distal external iliac, common femoral, and deep femoral."

We have had some issues with our Holter monitors that stop recording before 24 hours. Sometimes we only receive 4 hours of recording. Should we append a -52 modifier to 93226? This is for hospital outpatient dept.

We have physicians who indicate a patient has acute on chronic anemia (without a specification of anemia due to chronic disease/CKD/etc.). There's some debate on how to actually code it, though the consensus seems to be D64.89 for the other specified anemia. Can you verify D64.89 as a valid option, or would some other code be more appropriate?

It is my understanding that the provider should not bill for the nerve block performed immediately prior to the Ellipsys procedure. Is the nerve blocking ever reportable by the provider? I have a case in which the provider describes successful right brachial plexus nerve block immediately prior to the basilica vein banding procedure he performs. Reportable? Or bundled?

"Diagnosis: AAA with bilateral large renal accessory arteries emanating from the aneurysm and include extensive iliac occlusive disease, as well as ectasia of bilateral common iliac arteries. PROCEDURE: Aorto-bi-femoral bypass with 16 x 8 Dacron Hemashield graft and bilateral reimplantation of accessory renal arteries to the body of the Dacron graft." AAA that involves both visceral and iliac vessels? Do I report 35091 with 35697 X2 or 35102 with 35697 X2?

We have a dilemma. My doc inserted an LVAD 33979-52 left open "0" global days. Closed chest 21750 on a subsequent day with 90-day global. Now this bundles any E/M services they performed subsequently. We were wondering if appending a -58 to the 21750 would make a difference. Any directive is appreciated.

What do you use if the doctor replaces a midline? "INTERVENTION: The collateral venous network was unable to be successfully negotiated with a wire, and the decision was made to replace the patient's midline catheter. The catheter was cut to an appropriate length of 11 cm and advanced through the peel-away sheath into the vein. The tip was fluoroscopically positioned in the left axillary vein. The catheter was able to be aspirated and flushed easily. It was secured to the skin with a StatLock. IMPRESSION: Left upper extremity venogram demonstrating stenosis at the level of the upper arm with multiple venous collaterals. Technically successful exchange of left upper extremity midline over a wire under fluoroscopic guidance."

How would you code this? "Procedure done under US guidance. Posterior border of sternocleidomastoid muscle identified. Scalene muscle identified. Injection posterior to the sternocleidomastoid muscle identified. No paresthesia was noted. No blood was aspired. Good local spread. Trigeminal neuralgia is being treated."

"The pacemaker was explanted. Atrial and ventricular leads assessed. New subcutaneous pocket created. His mapping, recording, and pacing performed under fluoro. Three positions attempted. Final new lead position - His. Device connected to all three leads." His lead not stated for LV pacing. Diagnoses are chronic diastolic heart failure, new nonischemic cardiomyopathy from RV pacing, chronic atrial fib, complete heart block. LVEF is 40-44%. Would you consider 33225 for placement of His lead with 33229 as primary code? Position for His lead is HBP per registration.

Code 62273 states injection of blood or clot patch. Would you consider fibrin glue to be a "clot" patch?

When using a left radial approach to place a catheter in the left subclavian, would that be 36215 or 36216?

Would codes 37238, 36012, and 75820 be appropriate for the following? "The left internal jugular vein was catheterized. We used a Synchro 2 microwire, which we advanced past the stenosis in the superior sagittal sinus. The 3 Max catheter was tracked along this to the superior sagittal sinus. The wire was removed, and the system was flushed. Contrast injection was performed utilizing DSA in multiple views, which re-demonstrated the stenosis at the transverse sigmoid junction. it was decided to advance the 8 x 30 mm Precise stent over the wire, which passed easily. Once in place the stent was positioned in the optimal location based on the roadmap images and deployed under fluoroscopic visualization."

Please advise on correct coding for this procedure. Examination: FL enteroclysis tube perc. Clinical History: Image-guided postpyoloric corpak placement. Intra-Procedure Meds: Contrast agent omnipaque 300 50 ml bottle 50 milliliter. NASOGASTRIC Using fluoroscopic guidance a 10 French Corpak feeding tube was placed without difficulty. Result: Position was confirmed with a small injection of barium; the tip is in the third portion of the duodenum. The tube was then flushed with a small volume of water. Impression: Uneventful placement of Corpak feeding tube." Should this be coded with 43752 or 49440 or 74355?

May code 76932 be billed for use of "fluoroscopic guidance" of an endomyocardial biopsy? Or do you recommend another CPT code to capture the service? This is the documentation in the report: "Right ventricular endomyocardial biopsy was then carried out using a 7 French St. Jude bioptome under fluoroscopic guidance. A total of four biopsies were sent for analysis."

The provider placed a double lumen PICC in the right basilic vein. Would 36573 only be charged once regardless of how many lumens were inserted at the same site? "Using ultrasound guidance for vascular access, the RIGHT basilic vein was accessed, and a 0.018 inch wire placed through the needle under fluoroscopy. The needle was removed and exchanged for a peel-away sheath-dilator. The 0.018 inch wire was placed into the atrial-superior vena caval junction under fluoroscopy and the catheter cut to measure. The 5 French PICC line catheter was placed with the tip in the atrial-superior vena caval junction under fluoroscopy. Spot radiograph was obtained for documentation. The peel-away sheath was removed. Both lumens aspirated blood easily and then were flushed and locked with heparinized saline."

What CPT code is used for the aspiration of thrombus along 36902/76937? "The 70% stenosis at the edge of the stent, as well as the intrastent stenosis, were maximally dilated using an 8 mm x 8 cm Gladiator angioplasty balloon. Prolonged balloon inflation was performed. Repeat angiography demonstrates wide patency at the treatment site with minimal recoiling. A non-pulsatile thrill was palpated within the graft at this time. In order to allow easier access to the venous graft limb, it was decided to aspirate thrombus from the thrombosed pseudoaneurysm of venous graft limb. After administering local anesthesia to the overlying skin using 1% Xylocaine solution, an 18-gauge needle was advance into the pseudoaneurysm. Approximately 15 mL of liquified thrombus was aspirated. Hemostasis was achieved using manual compression. The sheath was then removed and hemostasis was achieved using manual compression. Liquified thrombus was aspirated from thrombosed venous limb pseudoaneurysm in order to make it easier to access stents within the venous limb during hemodialysis."

Is code 76498 still the correct code for a whole-body MR?

My physician does the following on a previous common femoral to peroneal bypass using saphenous vein. Due to the vein graft stenosis a previous covered stent was placed in the distal portion of the bypass graft. The patient presented with exposure of the covered stent. My physician performed the following procedures: Revised the proximal saphenous vein anastomosis with interposition of a cryosaphenous vein graft at the anastomosis to upper thigh saphenous graft due to intimal hyperplasia of the proximal several inches of the saphenous vein graft. Revised the distal saphenous vein anastomosis with removal of the penetrating stent and interposition of cryosaphenous vein graft at the anastomosis up to the distal thigh saphenous vein graft with removal via catheter of thrombus from the peroneal down to the level of the ankle. I considered codes 35881 or 35876. Would I code it twice? Would I code removal of the stent separately and if so what code would I use? Since the thrombus removal was down to the ankle, would I code separately for that?