Ask Dr. Z

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?

"A bilateral uterine artery embolization is performed for uterine fibroids. After the procedure is concluded, but prior to the patient leaving the OR, a superior hypogastric nerve block was performed after the embolization was completed. A 22 gauge 20 cm Chiba needle was advanced under fluoscopic guidance, and a solution of 20 mL of 0.5% bupivacaine and 40 mg of triamcinolone was injected." Is the nerve block injection billable since it was not performed prior to the intervention?

Does CPT code 77001-26 include imaging for the SVC if done from the same access? "Wire could not be advanced into the IVC, therefore contrast was injected through 4 French catheter, and superior venacavogram was done." This was done during a placement of a tunneled perm cath placement from the catheter access. My doctors insist the IVC or SVC should be separately reported. Please deny or confirm so I can get back to them.

When coding for a right face lymphatic malformation, how would the following be coded: 1st site: direct puncture from a posterolateral approach into a right preauricular macrocyst was accessed, 2nd site: direct puncture from a anteromedial approach into a separate and discreet anomalous macrocyst of the right cheek?

My physician carried out stenting of LM, LD, and LC. Stent in LC was crushed with stent from LM into LD. It was followed by multiple kissing balloon angioplasties. Can I code three separate stents 92928-LM, 92928-LD, and 92928-LC?

Will there be a CPT code down the road for drug-coated balloon for dialysis?

Physician removed dual chamber pacemaker device and capped of the the atrial lead and replaced with a single pacemaker device. We are tossed up on the codes 33227 or 33233 and 33212.

I am hoping for your feedback regarding pre-operative vein mapping for ERFA. Patients presents to general surgeon for initial visit with subsequent diagnostic Duplex performed by vascular specialty (i.e. 93970). Based on findings the patient is then scheduled for ERFA 1-3+ months later by the general surgeon with pre-procedure vein mapping performed by the vascular specialty. Question surrounds the allowance to bill for the vein mapping. Per Medicare one pre-procedure Doppler/Duplex is allowed. Would this refer to the diagnostic study initially performed? There is no specific vein mapping code allowance for ERFA nor do I believe the vein mapping supports billing for a Duplex (93970/71). We want to be sure to capture what is supported in this case while ensuring we are payer compliant. Your guidance surrounding appropriate billing for the pre-procedure vein mapping in this case scenario is much appreciated.

Could I get your advice on how to code an exchange of a Corpak tube? This is how the report reads: "The existing tube is removed completely, and the right nare is anesthetized. A new Corpak tube is then advanced through the nose into the stomach, then manipulated out of the stomach and into the jejunum. Position verified with injection of contrast. Successful fluoroscopically-guided placement of a new Corpak after unsuccessful attempts at declogging the existing tube."

Can you bill codes 33228 and 93286 together? If so, what would be the appropriate modifier?

We are an IR group contracted by the hospital and perform procedures in the hospital setting. If a physician does not append a CPT code that is eligible for a modifier -26, will this code get denied by insurance? For example, if a paracentesis is planned, but limited ultrasound shows no fluid and images were permanently stored, would we get reimbursed for code 76705, or would it need to be 76705-26? Is there a list of procedures that require modifier -26 for reimbursement?

A provider wants to bill a 92941 for a patient with an acute MI who was too unstable to go directly to the cath lab. The patient was stabilized and sent for a cath and intervention later. Would this be coded with a 92941?

The physician placed a VAD a few days before and left the patient's chest open. The patient came back in for surgery to have a mediastinal washout, a chest closure, and to tunnel the VAD cannulas into the upper abdominal wall. I cannot find a code for the tunneling of the cannulas, as that is usually included in the initial placement. What would you suggest?

I need clarification on billing IVUS when performed in the femoral and popliteal arteries. Would this still be considered one artery, or would you be able to bill separately? For interventions we were told these arteries are considered one for coding purposes, but I am finding conflicting information and need to confirm.

"Patient with an infected right common iliac artery contained aneurysm. The physician placed a left axillary bi-femoral bypass. He then entered the abdomen, clamped inferior to the inferior mesenteric artery, and identified the left common iliac. Placed clamps proximally and distally and removed stent. Oversewed the left external iliac and common iliac. Entered the aneurysm in the right common iliac and found pus within the arterial wall. Resected all purulent portions of the wall and debrided the retroperitoneum. Gained distal control with Fogarty catheter. Oversewed the right external iiac. Divided and resected the aorta going proximally, oversewed the lumbar arteries. He teed off the aorta just distal to the inferior mesenteric artery and performed two-layer closure." Would 35131 direct repair aneurysm and graft insertion iliac artery be correct? Since aneurysm was in the iliac artery I didn’t think 35102 would be correct. Can the left iliac stent removal be coded, or would that be included? What are your thoughts on this?

47383 vs. 0600T for CT-guided percutaneous liver ablation. "The patient was placed on the CT scanner in the supine position. Initial CT images of the upper abdomen were obtained. Automated exposure control was utilized. The skin overlying the liver was prepped and draped in the standard sterile fashion. Under CT guidance three IRE ablation probes were advanced to the lesion in the caudate lobe. Once the three probes were positioned appropriately sagittal reconstructions were performed and ablation parameters were calculated. Ablation was performed using standard protocol and reverse polarity. Probes were removed. Two IRE probes were then advanced to the peripheral right lobe lesion and ablation was performed in the same manner. Probe were removed and follow-up CT scan was obtained showing expected postablation changes with no significant hemorrhage. IRE ablation was utilized due to the otherwise inaccessible lesion in the caudate lobe. IMPRESSION: Impression: CT-guided liver mass ablation x 2."

Is IVUS chargeable without including vessel measurements?

We need updated guidance for coding the combination of stereotactic-guided vacuum-assisted core needle breast biopsy using tomosynthesis guidance.

Would you be able to clarify for us the billing requirements for intraoperative ultrasound when done prior to the incision for an AVF? If this is a reportable code, we're curious about the following... Is a hard-copy image mandated to be on file? How extensive do the findings need to be documented in the operative note? Or is this included or not billable with AVF 36821?

I am new to ASC coding. I am trying to bill C9600 with a POS 24 to Medicare. I am sending the claim via HCFA1500 to First Coast (my local MAC). But, I am getting a denial code CAS-109, stating that the claim needs to be sent to the right contractor. I am at a loss, because I did not think these codes needed to be sent to the DME contractor? I cannot find C-codes listed on CGS's Fee Schedule. Any suggestions?

What's the correct CPT code for outpatient middle meningeal embolization for management of chronic subdural hematoma?

Should the ramp study be coded with the unlisted code 33999?

What CPT should be reported for a 4D CT of the heart? Specifically looking at prosthetic valves.

Can we code this as 64647? "The patient was placed in the ultrasound procedure area and a preliminary ultrasound evaluation at the superficial right and left abdominal wall was performed. Superior, medial, and inferior segments of the right and left external oblique muscle, internal oblique muscle and transverse muscle were identified and marked on the skin. Areas previously marked were then prepped and draped under sterile fashion. Using a 25-gauge needle the skin was anesthetized with lidocaine. Using ultrasound guidance a 21-gauge needle was advanced and administration of Botox was done bilaterally involving the superior, medial and inferior segments of the external oblique muscle, internal oblique muscle and transverse muscles. A total of 300 units of Botox were used which were administered equality at the previously marked sites. The patient tolerated the procedure well without any immediate complications. IMPRESSION: Ultrasound-guided right and left external oblique muscle, internal oblique muscle and transverse muscle Botox injection, as described above."

What code for SFA reimplantation during Ileo-Profunda bypass? "The distal anastomosis to the profunda was then completed using a 6-0 Prolene in standard running fashion. Next an 11 blade was used to make a graftotomy on the lateral wall and a slight oblique fashion to accommodate the spatulated SFA. Next the SFA was reimplanted onto the anterior and medial aspect of the ileal profunda bypass using a 6-0 Prolene in a standard running fashion."

Patient has an SVT ablation, a secondary ablation for atrial flutter, followed by an AV node ablation for atrial fib prior to a dual chamber pacemaker implant. Can the AV node ablation be billed as an additional ablation with code 93655, or can it be billed as 93650?

"A midline incision was made to the sternum with a sternal saw. A high-flow aortic cannula was placed, a two-stage venous cannula was placed, and the patient was placed on full cardiopulmonary bypass. Following this the aorta was cross-clamped with patient given a single dose of antegrade cardioplegia. I ligated the left atrial appendage with a 45 mm AtriCure clip. Aorta was open, and aortic valve inspected. There was a mass very consistent with a fibroblastoma on the left coronary cusp. I excised this sharply with scissors and then debrided it with a 15 blade. Care was taken to preserve the aortic valve. Following this, the aorta was closed with a running Prolene suture. Following this I de-aired the ventricle for the next 10 minutes, and the cross-clamp was removed. Patient was easily weaned from cardiopulmonary bypass. Sternum was closed with sternal wires and the wounds closed with Vicryl sutures." Do we code for the mitral valve clip (33999 since it's an open procedure), or is this inclusive of the primary procedure 33120?

For Y-90 if injected in multiple vessels for HCC embo but one embo can you use 79445 more than once even though one embo site and 1 MUE? Is the 79445 based on one Y-90 embo or how many vesseks injected during the embo?

If patient is getting an open aortic valve replacement, CABG, aortic root endartectomy, and LAA AtripClip placement all at the same time, would the aortic root endartectomy be bundled into the valve replacement?

"During mapping, the pulmonary veins were noted to be silent from prior ablation. The pulmonary veins were isolated to the level of antrum using RE. A roof line and an infero-posterior line were created with radiofrequency ablation for the purpose of isolating the posterior wall of lt atrium. Electrograms were mapped to the Septum and floor of lt atrium, lt atrial lateral wall and anterior roof of the left atrium. RF was applied with elimination of these potentials. Left atrial appendage was ablated and coronary sinus was ablated/isolated. Isuprel was infused up to 20mcg/min. Following infusion, there was no evidence of reconnection between lt atrium and pulmonary veins. No arrhythmias were induced. Superior vena cava was silent. Conclusion: Successful ablation of lt atrium septum, coronary sinus, and lt atrial appendage." Should 93656, 93655, and 93657 be coded or only 93656 for ablation procedures?

We are having some confusion as to the billing of add-on code 93622. We are confused, as we have seen other documentation to the fact that there needs to be an additional catheter inserted. Our provider states that one catheter is used and positioned into the LV. There is documentation to support the pacing and recording. Can you please confirm he needs to document that an additional catheter was inserted into the LV in order to report the code?

Stenosis in the left external iliac is placed. Left femoral bypass graft is accessed, and a thrombolysis catheter is placed. Code 37221 includes the catheterization, and 37211 does not. Can 36247 be separately coded with a modifier for the catheter placement in the bypass graft for thrombolysis?

Do you have any information on the CMS new technology add-on payment (NTAP) code?

What CPT code would best descript a VSD closure that is not for a congenital VSD, but post MI?

Provider wants to perform an ultrasound guidance chemo injection of the lymph node of the neck. He will be using NBTX-R3. How would I code this case?

I have my provider billing a revision (36832) for aneurysmal resection with ulcerations. He notes that there was no penetration into the fistula wall. Would this support a revision? My gut is telling me no, but I want to be certain. "Patient had 2 aneurysmal areas on the fistula with ulcerations on top of the aneurysm. At this point in time elliptical incision was made and surrounding the area of the aneurysms. The aneurysms are resected. There is no penetration into the AV fistula wall for which reason the wounds were both closed in a double layered fashion with absorbable suture."

I have a peripheral angio where the right side was imaged completely, but the left side was only imaged from the common iliac to the SFA because the patient has an above-the-knee amputation on that side. Would you recommend adding a -52 modifier?

In 2014 question ID 6155, code 37241 is recommend for portal vein embolization, but in 2015, question ID 6336, code 37243 is recommended. I’m confused by what makes the questions different. Can you please confirm which is appropriate? Patient has hepatic cholangiocarcinoma. If portal vein embolization is being done prior to future hepatic resection but the report does not specifically state that it is done to shrink one side of the liver to cause hypertrophy of the opposite side of the liver, is it assumed that the embolization is done to shrink/kill (37243), or do we use 37241 if it only describes the procedure as embolization to prepare liver for planned hepatic resection?

Years ago, I seem to recall that we were advised that the ophthalmic artery was skull based, rather than a cerebral vessel. My question is if a physician selects out the internal carotid, and the only vessel he describes is the ophthalmic artery, would we still use 36224 or would we "down code it" to a 36222? Angio is actually done as an aftercare following up a coiling of an ophthalmic aneurysm. The following are the findings. "These images demonstrate stable complete occlusion (Raymond 1, 100%) of the left internal carotid artery ophthalmic segment aneurysm that was treated with primary coiling on 9/7/2017. The internal carotid artery and its branches are patent and preserved."

Will you please confirm if these are both examples of appropriate medical necessities to charge 93567? Assessment of a bioprosthetic aortic valve and/or assessment of aortic valve stenosis. 

When coding a TEVAR, is the Coda balloon also considered a balloon angioplasty?

Can you please advise if 73085 is billable for the following? "Under fluoroscopy guidance a 25 gauge hypodermic needle was inserted into the radiocapitellar articulation via a lateral approach. 4 mL of a mixture of gadoterate meglumine, Omnipaque-300, 1% lidocaine, and saline were injected into the elbow joint under fluoroscopic observation. Contrast was seen flowing away from the needle and into the the joint without extravasation. The needle was removed, and hemostasis was achieved with manual compression. Permanent fluoroscopic images were obtained and stored in PACS."

This question is similar to question 10455. Patient had an existing defibrillator with atrial, RV, and LV leads to start and presented for a multi-lead defibrillator generator exchange. Generator was exchanged and upon interrogation, RV lead showed significant electrical chatter, and was no longer functional. At this point the old RV lead was capped, and a new transvenous RV defibrillator lead was placed. How would this coding change since the device placed was a biventricular defibrillator? I don't believe that 33264 for multi-lead defib gen change can be coded with 33216 for transvenous lead placement. My guess is that we would code for 33241 for device removal, and also for 33249 for defibrillator insertion with placement of a new RV lead, but I am uncertain because the patient had a biventricular device. Please advise.

"A patient presents for CRT-D implant. A peripheral venogram is performed to confirm patency of the left subclavian vein and to guide venous access. The left subclavian vein is accessed with a micropuncture needle; however, the physician is unable to advance the J-wire due to a persistent vena cava, which is confirmed by additional IV contrast injection. The skin is then closed. Next, a right-sided peripheral venogram is performed to confirm patency of the subclavian vein and to guide venous access. The CRT-D implant is subsequently performed using the right-sided access." Are any CPT codes reportable for the left-sided venogram and aborted access?

When a chest port is removed and fluoroscopy is documented, "a spot film was obtained at the end of the procedure confirming complete removal of the port and catheter"... would CPT 77001 be coded along with the port removal CPT code? It looks as if it is just a confirmation film and not an actual fluoroscopic guidance procedure.

Patient has a nephroureteral catheter in on the right side and an access site on the left where her nephroureteral catheter was pulled out. We were consulted to insert a new nephroureteral catheter to the left (existing access site was open) and exchange the existing one on the right. The only code I can find is 50387 (50). Is this correct?

"In the left lower quadrant the catheter was placed into the peritoneum using ultrasound guidance. 1 L. of yellow fluid was drained, but then the catheter would not drain further despite further repositioning of the patient. The catheter was against the bowel. The catheter was then removed. The right lower quadrant was then prepped and draped. Under ultrasound guidance the catheter was advanced into the peritoneum. An additional 4 L. yellow fluid was removed. The catheter was then removed." Is it permissible to code 49083 twice?

I have an op report for a mitral valve replacement using the Tendyne delivery system. At this time, code 0484T is being used. Has there been an actual code established for this, or should 33999 be used? Also, the valve itself is included in the procedure, correct?

"The ATA was selected with a glide wire and crossing cath and selective arteriogram performed of the distal ATA and DPA showing focal nearly occlusive filling defect in the very distal ATA and another high grade stenosis at the ankle joint in the proximal DPA. The distal DPA was surprisingly good caliber making 2.5mm angioplasty viable. 200 mcg of nitroglycerine was slowly instilled into the ATA through a cath. The 014 wire was advanced through the crossing cath into the distal ATA across the ankle into the DPA into the first dorsolateral DPA branch on the dorsum of the foot. The .035 crossing cath was removed and the .014 crossing cath advanced over the wire into the DPA . The wire was replaced into the the DPA and lateral branch crossing cath removed and the 2.5mm balloon was advanced over the wire and angioplasty performed of the diseased distal ATA segment and stenosed proximal DPA segment into the mid DPA where it was of good caliber." Is this 34203 and 37228, or 37229?

"Patient has lead fractures of both the ventricular and atrial leads with lead malfunction. Both leads were disconnected from the pacemaker pulse generator and removed. RV was capped and RA lead was exchanged for a new one and positioned in the RA appendage, and then was connected to the RA port of the original pulse generator." Should I report codes 33235 and 33216 in this case, or should I report codes 33206 and 33235?