Ask Dr. Z

Is there a specific NCCI edit in regards to billing 76937 with congenital cardiac procedures? If so can you direct me to where that can be located in NCCI? Medicare only references the adult non-congenital codes.

Would it be possible to code diagnostic and catheter selection during the same study? Example: The doc knows that he is performing an embolization for a known aneurysm in the right internal carotid artery. Before he starts this, he says he is doing a left diagnostic angio (left carotid artery and left vertebral). So, would this be coded 36224/36226-LT and 36217 (for right internal) and 61624 for embo? Or would these qualify for all cath placements (36217/36216 x 2)?

In follow-up to our previous question (Question ID: 13287) titled “Single chamber tv PM replaced w/dual chamber PM generator and L atrial lead,” can you clarify why CPT code 33214 would not be appropriate in this scenario? Is it related to the anomalous patient anatomy (arterial switch) and the new lead being placed in the LA instead of the RA? Code 33214 seems to describe exactly what was executed in our procedure. "Procedure: Patient with single chamber (LV lead) pacemaker, pacemaker generator removed, insertion of new lead to L atrium, and new dual lead pacemaker generator inserted. Existing ventricular lead retained and hooked up to new generator."

A patient has a nipride challenge via existing Swan who also has critical care billed. Is this challenge bundled with the critical care, or how is this billed?

Would unlisted code 37799 be appropriate for the following? "Patient referred for removal of tunneled central line. The catheter exit site involvement with tumor was prepped, and during the sterile prep the tumor started to be bleed superficially. Direct pressure did not ablate the bleeding, nor did cautery, nor injection with lido with epinephrine. 2000 units of thrombin was injected into the superficial tumor bleeding site, which resulted in cessation of bleeding. The catheter was not removed on this encounter."

When is it appropriate to bill code 50684?

Quite often, one of our cardiologists will do the diagnostic cath, and then the interventional cardiologist will step in right after to do the angioplasty/stent. For years, I have been applying the -59 modifier to the diagnostic cath, and I am now being told that this is incorrect since two separate docs are involved. Since they are from the same group, isn't this recognized as one and the same doctor and a -59 modifier will be needed on the diagnostic cath?

If a diagnostic angiogram of bilateral lower extremities is performed with catheter placement in the distal aorta (36200 and 75716), then followed by a contralateral revascularization, do we get to keep the 36200 for the diagnostic angiogram?

Our physician used an Atlas PTA balloon to treat DVT in the common iliac vein. Would you code this scenario as unlisted or 37187 (thrombectomy) since that was the intent of the venoplasty to tx DVT? 

When a CT is done that shows pelvic hemorrhage, but not the source, and the patient is sent to IR to have an embo but they do imaging to find the exact source, is this considered diagnostic and billable? Or would it be guiding shots since the hemorrhage was known?

When a patient gets an MRI-guided laser ablation of a prostate lesion, would you use 53899 or 55899 for the unlisted?

Should a cooling catheter be billed with code 36556 or an unlisted code?

How would you code a percutaneous AV graft ligation or collateral veins? I have three examples: Example #1) Two stab incisions were made at the site of the collateral once local anesthesia was infiltrated. Under direct ultrasound guidance, a Hawkins needle was passed deep to the collateral vessel from one incision out the next. Example #2) The collateral vein was identified with ultrasound, which demonstrated an early bifurcation. Under ultrasound guidance, a curved needle was used to guide 4-0 silk sutures around the larger branch, which was subsequently tied off. Example #3) Under ultrasound guidance, a Hawkins needle was advanced deep to the juxta-anastomic venous outflow segment, and a 0-0 silk suture was pulled through the soft tissues and out the skin. The Hawkins needle was then advanced superficial to the vein remaining deep to the skin, and the 3-0 silk suture was pulled in reverse through the soft tissues and out the skin. A surgical knot was tied down, reducing the diameter of the juxta-anastomotic venous segment to 5 mm.