Ask Dr. Z

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?

"Patient found to have popliteal aneurysm with embolization. Incision made in left thigh and GSV harvested. The above-knee popliteal artery was then isolated just above the aneurysm through an incision just above the knee. A 0 Ethibond tie was passed around the pop artery where the aneurysm began. The below-knee pop artery was then isolated. The tibial veins were taken down to allow access to the anterior tibial artery and TP trunk. The pop artery was ligated with Ethibond ties proximally and distally. The prox pop artery below abductor canal was clamped, and arteriotomy was made. The GSV was then sewn in place with 6-0 prolene. A #4 #3 Fogarty cath was passed down the anterior tibial artery and down the peroneal. The thrombus debris was removed." Would this procedure be coded with code 35151 only for the aneurysm repair? We just wanted to make sure the thrombectomy could not be coded separately.

We have a patient with a history of malfunctioning GJ tube. The note of our provider states, "Fluoroscopic images were acquired and submitted for the interpretation by Dr. X during a GJ tube revision. Findings: Images demonstrate an endoscope passing through the gastrotomy into the jejunum. On the final image a gastrojejunostomy tube is seen with tip terminating at the duodenojejunal junction, confirmed by water-soluble contrast was administered in total. Impression: Gastric jejunostomy terminates at the duodenojejunal junction." My coder is wanting to use CPT code 74018 and I-10 code Z04.9. Any suggestions?

Would you use 37226 or 37236 to report an endovascular repair of a popliteal aneurysm with a Gore Viabahn covered stent?

"Patient presents for removal of infected peritoneal dialysis catheter and creation of right axillary to right basilic vein AV graft. The next day patient returned to OR for removal of AV graft with patch repair due to arterial steal right hand. A new AV graft using PTFE from right subclavian artery to right basilic was performed." Would codes 36830-78 and 37799 be the correct codes for the return to the OR?

This case is a lower extremity stent on common iliac , external iliac and common femoral bilaterally. Dr. Z book says for lower extremity to use codes 37721-37235, but these codes are for artery and we are doing veins.

I'm not seeing any NCCI edits with C9765 (lithotripsy, balloon right superficial femoral), 37221 (iliac), and 37224 (femoral angioplasty). So would it be appropriate to charge these together when provided during the same session?

My physician performed a debridement through muscle (11043) with a wound vac placement (97605). I don't see an NCCI edit for these two codes, but I'm wondering if it is best practice to bill these together, or if the wound vac placement is meant to be included in the reimbursement of the debridement.

The patient had open aneurysm repair (33859), and at the same time for atrial fibrillation had pulmonary vein isolation and left atrial appendage exclusion. I ended up coding the last two procedures as 33999, as I do not see codes for doing these as open. Do you agree?

My physician wants to bill 35371, 35372, and 35566. Please see the below portion of the operative note discussing the endarterectomies. My question is, can I bill for the extraction endarterectomy of the PFA along with the bypass? My thinking is that an endarterectomy is an endarterectomy, regardless if it was extraction or not. Also, are not the CFA, SFA, and PFA all contiguous? My proposed coding to the surgeon is 35566 and 35700. "A standard endarterectomy of both the external iliac, common femoral, and profunda femoris artery was performed. A cleavage plane was created, and the artery was pushed gently away from the plaque with a Freer elevator. An Extraction endarterectomy of the profunda femoris artery was performed." He then states, "...at this juncture, I redirected my attention to the profunda femoris artery, which is separated from the patch as a separate inflow." He then performs a profunda femoris to anterior tibial bypass. Is my coding correct, or am I missing something?

The op note states patient is getting first stage of a two-stage brachiobasilic vein transposition AV fistula. On the first encounter/procedure would you bill 36819 even though the transposition has not occurred yet? Or 36821? I know on the second encounter (stage 2) I would bill 36832. I feel like with billing 36821 then later 36832 the provider never gets "credit" for doing the transposition.

Would this be 35523 and 35523-52? Or just one 35523? "The great saphenous vein was prepared, situated in a reversed fashion, and spatulated. An end-to-end brachial artery-GSV anastomosis, an end-to-side radial-GSV anastomosis, and end-to-side ulnar-GSV anastomosis were created, with 6-0 prolene sutures created in sequential fashion. Care was taken not to narrow the lumen." The code description for 35523 states "brachial - ulnar, or -radial" instead of "and/or", so can we code two with one being a reduced service since it didn't have a different incision site and technically only ONE anastomosis was done for the brachial-ulnar artery bypass, as the brachial anastomosis would be included in the first 35523 for the brachial-radial?

History of bilateral fem-pop bypass in the past, now has claudication. Patient was scheduled to have fem-pop bypass. Incision was made above the crease and carried through skin into the subcutaneous tissue. Hemostasis maintained. There was heavy fibrosis and scar tissue around the previous double fem-pop bypass. Difficulties identifying the femoral artery because of body habitus. It was difficult to dissect through the artery and also to avoid going into the abdominal cavity. The risks of inability to control any bleeding show any vessel inadvertently nicked was too much. At this point case was aborted. Wound was closed in layers. Is 35703 correct?

How we report 93454 and 92928-LC ? Should we add modifier -59 to 93454?

Patient had a pericardiocentesis, and the drain was left in place. The next day the provider went to pull the drain and it would not release. Fluoroscopy was used to assist in finding the problem. The following was documented: "I was unable to remove his pericardial drain. I took him to cath lab and under flouro attempted to remove drain. It was not able to be removed initially, as it appeared there was a fulcrum effect with the drain near his skin. We inserted a wire, straightened the catheter, and it was easily removed. There were no complications. The area was cleaned, and a dressing was placed." Would it be appropriate to bill for the fluoro in this case?

Would you bill 73592 with modifier -52 for an infant where only the tib/fib were viewed? Or 73590?

Patient presents for Angiovac tricuspid valve vegetation debulking via IJ approach. ICE is used prior to Angiovac extraction to confirm location of vegetation. VV ECMO (percutaneous) is also performed, with US guided vascular access used for cannula insertion. My coding compliance department has rejected my request for set up of 93799 for stand-alone ICE use without an applicable base, and instructed me to use 36013 in past request. So my plan is to code 33999, 76937 x 2, 33946, 33952, and 36013-XS. Do you agree with this coding plan?

Can the subclavian vein or artery catheterization codes be reported with the heart cath codes from the same access site?

Do we need to have a statement included in our Cath/EP structured reports regarding storage of permanent images? This has been requested as an add by some coding staff.

Would the RFA of the coccygeal nerve be coded as 64999 as part of the ganglia sympathetic nerves or 64625? Does the coccygeal nerve innervate the SI joint? "A 22 gauge curved RF needle was advanced under intermittent biplanar fluoroscopic guidance until the needle tip made bony contact on the left aspect of the coccyx. The needle was then 'walked off' 2 mm. A radiofrequency ablation lesion at 42C was then made over 240 seconds. The needle was then retracted advanced to make bony contact on the right aspect of the coccyx. This was confirmed with AP fluoroscopy."

The thromboendarterectomy codes indicate for the arteries only, and there appear to be no specific codes for the veins. How would you code for a venous endarterectomy with patch graft (femoral vein)? Part of operative note: "The vein was incised with a 15 blade. A Freer elevator was used to mobilize the stent circumferentially. On the medial side, there was an easy endarterectomy plane; however, on the medial side, the vein was extremely friable and began to fall apart. With this transected, the stent, used the pliers to remove part of the stent in a piecemeal fashion. The majority of the stent was removed, and some of it was left on the lateral side proximally. We then cut a bovine pericardial vein patch to size and sewed it to the artery using a running 6-0 Prolene suture."

How do we charge for TTE done in place of guiding TEE during TAVR? Patient body habitus was small, and MD chose to use TTE during entire case.

My providers are performing percutaneous RVADs utilizing the ProTek Duo. Would we utilize the LVAD codes, as the descriptor DOES NOT indicate left ventricle or use an unlisted code? The procedure note is as follows: "The existing PA catheter was removed. A new 0.035" PA catheter was advanced to the right PA. The 0.035 PA catheter was exchanged for a Lundequist wire. The existing sheath was removed, and the venotomy was dilated up to a 26 French dilator. Anticoagulation was initiated. The 29 French Protek Duo cannula was advanced to the main PA, and this cannula was clamped. The inflow and outflow were then attached to the TandemLife RVAD system via wet-wet connections. Once the system was confirmed to be free of air, the clamps were removed and RVAD was initiated at 3 L/min."

In the case of your question 12015, if the patient came in for EP ablation treatment for atrial flutter and they induced atrial fibrillation during the procedure and MD noted it in the conclusion, wouldn't you code atrial fibrillation as an ICD-10 code, for this case? I have been told this would not be coded because it was only induced by the procedure. 

What are the appropriate Echocardiogram that should be billed for the following ICD-10 codes?Q21.1 (PFO) & Q23.1 (Bicuspid Aortic Valve) Should we bill CPT non-congenital Echocardiograms (93306-93308) or Congenital Echocardiograms (93303-93304)? The only documentation we were able to find is AMA CPT Assistant, May 2015, Volume 25, Issue 5, pages 10-11. Which states : Congenital echo codes should not be used when complex congenital heart disease is suspected but not found on echocardiographic evaluation or for “simple” congenital anomalies such as patent foramen ovale (PFO) or bicuspid aortic valve. Our Cardiologists disagree about Bicuspid Aortic Valve (Q23.1). They state we SHOULD bill congenital for Bicuspid Aortic Valve because it is by definition a congenital heart defect and will be followed by cardiology with serial echocardiograms over time even if they are asymptomatic. As for PFO (Q21.1) some of the Cardiologist considered it by definition a "congenital" heart defect, while other state we should not bill congenital for a PFO, it is a variant

What are the diagnosis codes for an AAA repair? Would I use I71.4 and Z95.828? My thoughts are that the AAA is still being monitored annually, but the Z code indicates the repair. Would this be correct?

Patient underwent a right common VEIN to left common VEIN bypass with PTFE and a fistula creation with 6 mm graft right common femoral artery to the fem-fem vein bypass graft. Since this is a vein to vein bypass, is this an unlisted procedure (37799), as I was under the assumption that the bypass codes (35501-35671) are only used for artery bypasses. It's comparable to 35661. The fistula creation I was thinking 35686, but it is an add-on code, and neither 35661 or 37799 is an allowed primary code. What would be your advice on which codes to use?

We code facility and pro-fee. Patient had a port-a-cath placed two days prior. Primary physician (Team 1) went back in to inspect for hematoma and remove gel foam. She dissected "down the cavity" and evacuated a small, old hematoma, removed the gel foam, and examined the entire cavity, trimmed the port catheter, resecured it, and closed the incision. During this operative session our vascular surgeon (Team 2) was called in to examine the wound cavity, but he didn’t do anything. “Upon opening of the wound, there was a little bleeding from the surrounding muscle, but no signs of vessel injury or a hematoma. Pressure was placed on the wound without any expression of hematoma. There were several pieces of gel foam seen in the cavity, which could have been the cause of surrounding inflammation. The wound cavity was examined by vascular surgery, and no significant sources of bleeding or hematoma were noted. The primary team tested the port-a-cath to verify it was patent and functioning well. Team 1 closed the wound." Would this be 36597-62? 36576-62? 37799?

Can you report code 36224 with this procedure since no actual embolectomy was done? Patient first had a CTA of head that showed left M1 MCA occlusion, then was taken to IR lab. Report reads as," Right CFA access with catheter into left CCA. Angiogram done of cerebral vessels. There was difficulty advancing wires due to tortuous vessels. Wire was advanced into left ICA, and a Neuron Max sheath was advanced over wire into left CCA. With a different catheter we eventually got into the left cavernous ICA and angiogram done. I was unable to advance embolectomy catheter, and then the sheath prolapsed into the aorta. No further attempts were made. ProGlide device for closure." Findings of the left carotid and cerebral vessels are described, and report states, "No embolectomy was performed." Since patient has KNOWN MCA occlusion from CTA and embolectomy not done, I am not sure what to code here. Can we report code 36224 even with CTA being done before angio? Or do you code 61645-74, or just cath placement 36217 (pt has Bovine arch)?

Say we have right femoral access and catheter was placed contralateral to the left common iliac, diagnostic imaging of the left leg was performed from the common iliac and the physician decides to perform an atherectomy and stent of the iliac... when using the 0238T code, do we also report the catheter placement and diagnostic imaging? CPT guidance on these atheterectomy codes says they do not include selectively catheterizing the vessel. So would we report 0238T, 36245, 75710? Any guidance is appreciated.

We have a patient who presented with a fractured RV defibrillator lead. The physician ended up changing out the generator and lead (the lead she needed was not available so changed generator and leads). HP - original device placed for ischemic cardiomyopathy with EF of 35% and EF has now recovered to near normal 50-55% with optimal medical management. We have to bill the original insertion codes, so it doesn't look like this patient will meet medical necessity for the device based on the documentation. Are you in agreement? Is it appropriate to code a history of chronic CHF now controlled with improved EF due to device as a secondary diagnosis if documented by the physician (if this is even a thing)?

Is the following enough to justify billing 33883 along with 33881? Does being placed second alone qualify it as a proximal extension? It seems if they were placed in the opposite order it would all be included. "We placed a Gore TAG graft 37 x 15 with proximal extension cuff of 37 x 22. We post dilated with a Tri-Lobe balloon."

Is a cutdown procedure to basilic vein separately reportable following fistulogram and angioplasty? What code is appropriate? "... Subsequently, wire access was obtained into the basilic vein outflow region. This was confirmed with digital imaging and roadmapping techniques. Subsequently, cutdown was performed after initial mapping with ultrasound and fluoroscopy. The catheter was performed at the level of the basilic vein. Blunt dissection techniques were utilized. Once the vein was identified, dissection was performed underlying the basilic vein, which was subsequently banded with a 4-0 Prolene suture. Pressure was held at an adjacent branch component of this vein. Following this, digital images were obtained. The cutdown site was then closed with subcutaneous stitches and skin sutures. Subsequently, banding procedure was performed as described, which resulted in significant diminishment of flow into the basilic vein with direction of flow increasing into the cephalic outflow location."

How do you code acute MI with mechanical thrombectomy using Penumbra? The note states, "The clot was removed mechanically. The catheter used was a 140CM INDIGO CATH RX KIT. Dramatic improvement of thrombus burden with two passes of Penumbra catheter. Intracoronary IIb IIIa inhibitor administered."

Is selective cath placement bundled in code 37226?

Patient had a flow diverter placed for brain aneurysm. After placement of flow diverter, an endoleak was seen. Balloon angioplasty was indicated. Can we pick up any CPT codes for the endoleak?

Can 93655 be billed twice? Physician found it necessary to perform ablation twice.

When performing a TIPS with intravascular ultrasound guidance via a transfemoral approach, can you also code for IVUS at the time of TIPS? Or is the IVUS code considered to be bundled within the TIPS code? If the code is not bundled, then do you have to have an ultrasound image stored to PACS to be able to bill for the IVUS?

I know that 93655 has an MUE of 2. My provider is wanting 93655 billed x 3 following PVI with RFA for A-fib. Would these arrhythmias qualify for billing 93655 x 3? 1) A-flutter-CTI. 2) Roof dependent flutter. 3) Mitral flutter.

"Patient had a typical aortic-bi-iliac endograft placed (34705) and then angiogram showed Type 1 endoleak. Then six EndoAnchors were deployed ( 34712). Repeat angio still showed Type I endoleak. At this point, he marked the renal artery and deployed a 34 x 34 x 52 cuff creating them 2 to 3 mm above the prior graft and deployed the top cap with the suprarenal stents. Repeat angio showed partial encroachement on the left renal artery. This was stented with 7 mm x 27 mm balloon-expandable stent." (Are these two procedures coded with 34709 for cuff and 37236 for renal stent?)

Could you please clarify the documentation requirements for device checks? We have a service that gathers the data, and our technicians download pertinent information into report format. Do the doctors have to add a review/summary, or can they just sign off on the technician's report? Would the requirements be the same for the remote and in-office checks?

If urology is asking IR for assistance with percutaneous nephrolithotomy, what has to be documented for code 50437? Would "accustick transitional dilator" be enough? Or does it have to say balloon and a large size sheath was used to use this code? Not much guidance out there.

When charging for magnetic resonance elastography with CPT 76391, should this be charged in addition to an MRI of the abdomen, or is this the only CPT that can be charged when MRE is performed?

Our cardiologists almost always sign/authenticate their TEE reports on the same date of service, but recently we have had a couple come through where the TEE report was signed on another date. We are submitting 93312-26, 93320-26, 93325-26, and 99152. We are questioning what DATE we should be using when the TEE is not signed on the same date of service. We know in the case of an echo 93306 or other study, we use the date it was read/signed, but because there is the actual hands-on of the placing the probe and administration of conscious sedation, we are thinking we should go with the actual date it was performed. 

Would this be coded with an unlisted code (19499) since a mammogram localization was performed with tomosynthesis? "The breast was placed in an open grid craniocaudal projection. The lesion was identified on digital breast tomosynthesis. A Cassi placement device was placed. A tangential view with digital breast tomosynthesis confirmed the marker to be well positioned for biopsy."

If an outpatient is scheduled for a biopsy or drainage procedure based upon previous imaging, and the radiologist decides that the mass or pocket of fluid isn't big enough to intervene, would we bill with the procedure code for the biopsy/drainage with a modifier -52, or bill a limited diagnostic procedure in which the radiologist dictates that we were unable to perform the procedure (aka only billing what was actually performed)?

Medicare denied our claim for missing modifier. I couldn't find it anywhere. When 78472 performed in a provider office setting, we billed it as global. Do we have to bill the charge separately as -TC and -26 for this 2020?

I am trying to code an atrial flutter ablation where a pericardial effusion developed during the procedure, and the EP doctor brought in an interventionalist who performed a pericardiocentesis. The EP doctor signed the report, which did describe the pericardiocentesis part of the procedure, and the interventionalist didn't create a separate report. What is the correct way to bill this? Does the interventionalist need to create a separate report for the pericardiocentesis, or can the entire procedure be billed under the EP doctor?

For a TEE procedure, is there a charge code for procedure room use/time? We do the TEEs in the cath lab (pre-intra-post), but Cardiology gets to bill for the TEE procedure because it is their machine and the US tech, yet the cath lab supplies everything else.