Ask Dr. Z

"Right hip: 1. Right articular branch of femoral nerve anesthetic ultrasound and fluoroscopy block. 2. Right superior articular branch of obturator nerve anesthetic ultrasound and fluoroscopy block. 3. Right inferior articular branch of obturator nerve anesthetic ultrasound and fluoroscopy block. Using ultrasound and fluoroscopic guidance a 22g 150 mm spinal needle was advanced to the anteromedial aspect of the extraarticular portion of the hip joint where the articular branch of the femoral nerve traverses until a bony endpoint is felt. Attempted aspiration yielded no blood. 1 cc of 2% lidocaine was injected through the needle. The needle was then withdrawn. Using ultrasound and fluoroscopic guidance the needle was advanced to the incisura of the acetabulum where the articular branch of the obturator nerve traverses until a bony endpoint was met. Attempted aspiration yielded no blood. Radiographs were made. 1 cc 2% lidocaine was injected through..." Since the obturator nerve is a separate nerve, can CPT 64450 be reported twice?

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.

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?

The Coding Clinic for HCPCS I used as the reference is the latest guidance on this subject and advised us not to use CPT 96450, as Spinraza is not a chemotherapeutic agent and advised us to use CPT 62322/62323. There is also under National Government Services a description about how to use Spinraza and should be billed using CPT code 96450. Chemotherapy administration, into CNS (intrathecal) requiring and including spinal puncture. I am very confused about what code to use 62322/62323 or 96450. Please advise. 

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?

If a cervical carotid stenosis is treated with angioplasty (Medicare) (37246-GZ), and an ipsilateral MCA is treated with thrombectomy (61645), are these okay to bill together, with -XS on 61645 per NCCI edits? I am finding that 61645 bundles intracranial angioplasty but not finding anything for cervical carotid. 

If an IABP is inserted and removed on the same day, we know that you can bill 33967 and 33968 (CPT Assistant, November 2011, page 8). However, can you code the removal if it is done the next day? I am assuming that would require a separate report?

When doing a percutaneous gastrostomy tube insertion (49440) and the doctor does a barium enema (74270) in order to highlight the colon, can we charge for the barium enema portion also?

"Vessel catheterized: Segment 2 hepatic artery gives rise to a subsegmental vessel that is the minor supply to large tumor spanning segments 2 and 3. Vessel catheterized: Subsegmental branch of the segment 2 hepatic artery." Would the codes be 36247 and 36248?

Is a genitofemoral nerve injection (steroid/anesthesia mix) best captured with 64450 or 64447?

I would like to know if code 64520 can be billed multiple times. For example: "Under direct CT guidance, two 22 gauge needles were advanced into the bilateral L2-L3 and L4-5 paravertebral space hip joint capsule. This was followed by injection of a mixture of 7 cc 1% MPF lidocaine and 1 cc Kenalog mg/ml into each needle, respectively at each level bilaterally."

Conscious sedation, patient is having two exams, same setting. The MD performs the first exam and leaves the room while we prep for the second exam (patient did not leave the room but still in the department). Then MD performs the second exam. Do we do the sedation as one setting (99152 / 99153 - time appropriate) or restart with 99152 for the second exam?

Patient has an outpatient scheduled cath. A diagnostic cardiologist performs the cath, and per results patient needs an intervention. Patient remains on the table, and an interventional cardiologist is called into the room to perform the intervention. The cardiologists are in the same practice, but one is diagnostic and the other interventional. Can the interventional cardiologist charge a Consult/E&M visit on the same day because he was called in to perform the intervention? I have a physician who is insisting he can charge a consult or E&M visit when he is called in to perform the intervention on a scheduled outpatient cath. He does create a visit note.

An inpatient patient had a subclavian venogram performed a few days prior to a CRT-D upgrade. Patient was brought to the cath lab, and a venogram was done to assess for subclavian patency several days before the upgrade was performed. Would this be reported? Typically it is included in the procedure, but unsure if this can be captured if done prior.

We have a patient with an existing PFO. Watchman procedure was performed through the existing PFO. No transseptal puncture was needed due to the existing PFO. PFO closure was also done, and both were planned at the beginning of the procedure. Is it okay to bill 33340 and 93580 in this case?

I understand when they insert a tunneled peritoneal catheter and drain ascites using the tunneled catheter it is included in 49418. However, in our case same setting first drained fluid from a needle like regular paracentesis. Then needle was removed and a tunneling device was used, and a tunneled catheter was placed for long term. In this case can we code both 49083/49418?

I have a physician who reports that "additional radiofrequency energy was delivered across the left atrial roof and floor to achieve posterior wall electrical isolation". He does not state that atrial fibrillation continued, so we can't report 93657 for this. I was wondering if we can report 93655. The MD does not state the "discrete mechanism of arrhythmia". Can we assume that there was another discrete mechanism if he performed those additional ablations?

What specific wording in the documentation do you look for in 93312, 93320, 93325 to code and bill out all three CPT codes? I was told in the past that if the documentation says "atrial appendage free from thrombus" and/or mention of velocity, pulse wave, continuous wave, that if any of this is documented to report code 93320 valve regurgitation and/or stenosis documented code 93325. Please clarify.

I am having trouble with Medicare accepting CPT code 33361 (TAVR). I keep getting a denial stating: "Missing/Incomplete Investigational Device Exemption Number or Clinical Trial Number". I have the clinical trial number attached to the CPT code along with modifiers -62/-Q0. Please help!

What codes can we report when all three procedures are done together? "PREOP DX: Left neurogenic thoracic outlet syndrome. SURGICAL PROCEDURES: 1) Left transaxillary first rib resection. 2) Left anterior scalene and partial middle scalene resection. 3) Decompressive neurolysis of the left brachial plexus. 4) Placement of AmnioFix amniotic membrane around the T1 nerve root. 5) Free run EMG and somatosensory evoked potential, left upper extremity monitoring." Can you bill 21615, 21700, and 64713 together? There is an NCCI edit between codes 64713 and 21615, but the physician feels more work is done than to report only one code. There is no NCCI edit with 21700 and 21615, but should these codes be billed together? What do you suggest coding on these cases? "FINDINGS: There was a thick band anterior scalene muscle, which was released. The T1 nerve root posteriorly was also compressed by the middle scalene, which was in part resected. The first rib was successfully removed with freeing of the space around the lower trunks of brachial plexus."

What codes would I use for this procedure? "An oblique incision was cephalad to the skin crease in the right groin and carried down the subcutaneous tissue with electrocautery. Dissection was deepened to the level of the common femoral vein. The vein was exposed, including the area where the wire attached to the Cardizem and device was present. There was some bleeding around the access site. The vein was clamped proximal to the device and distally. Device was now completely retrieved. The defect in the common femoral vein was repaired using interrupted 5-0 Prolene sutures. Hemostasis in the field was completed. There was good hemostasis at the suture line and in the field. Irrigation was performed. The subcutaneous tissue was closed using a 3-0 Vicryl in a running fashion, and the skin was closed using a 4-0 monocryl subcuticular suture. Dermabond and a dressing were applied to the wound."

Diagnostic coronary angio codes (93454-93461) and injection procedure codes (93563-93564) should not be used with percutaneous coronary revascularization services (92920-92944), when they are used to report: 1 contrast injections, angio, roadmapping, and/or fluor guidance for the coronary intervention 2 vessel measurement for the coronary intervention 3 post-coronary angiop/ stent/ atherectomy angio, as this work is captured in the percutaneous coronary revascularization services codes (92920-92944). Diagnostic coronary angio performed at the time of a coronary interventional procedure may be separately reported only if the following circumstances apply: 1 No prior catheter-based coronary angio study is available, a full diagnostic study is performed, and a decision to intervene is based on the diagnostic angio 2 A prior study is available, but as documented in the medical record: 1 The patient's condition with respect to the clinical indication has changed since the prior study 2 There is inadequate visualization of the anatomy/pathology.

The Society of Vascular Ultrasound protocol for a mesenteric Doppler directs to the use of codes 93975 and 93976; however, the protocol does not call for venous outflow imaging. We are currently using 93978, as the aorta is part of the study. Would this be correct?

Patient presented with chest pain, had a CT chest with contrast, and was to have a CTA; however, calcium score was too high to perform the study. Can the CTA be billed with a -52 modifier, or should this be billed as 71270 CT with and without or 75571 just the cardiac scoring?

Dialysis intervention codes for angioplasties 36902 - 36908... I heard that these procedures were going to be reduced significantly. Is this true, and if so where and how can I find out how this is going to impact practices such as ours?

Patient has a heart cath one day and then patient is brought back on a different date of service, but during the same hospital stay, to have iFR of the LM to further assess severity of LM stenosis. Can iFR be charged because it is during the same hospital stay, but different date of service? Or do we still use the unlisted code?

If RA/RV pacing and recording are not mentioned in the documentation during an ablation for afib/VT/SVT (93656, 93654, 93653), is it necessary to append the modifier -74 (hospital side) to show the full EP study was not performed? Does the reason for the MD not performing the RA/RV pacing and recording have to be documented?

I have not been able to find any guidance on whether the new Shockwave codes (C9764-C9767) can be billed in the same territory as 37220-37235. The codes currently do not have any NCCI edits, so it would seem they can be reported together without resulting in claim errors. However, I noticed the new codes are assigned to the same APC payment as their 37220-37235 counterparts, which would seem to result in double-billing. For example, should Shockwave lithotripsy and CSI atherectomy of the SFA territory be billed as C9766 and 37225, or only C9766 since the description includes atherectomy and the APC payment is the same, even though the codes do not edit?

For physician billing, can the nephrologist bill for a hospital E/M visit or any service when they see a patient after their outpatient, elective dialysis catheter exchange procedure (when performed by IR MD)? The patient is ESRD and carries Medicare.

H&P documentation often states cardiomyopathy and heart failure. Should both be coded, or does HF supersede the cardiomyopathy? Would it depend on the type of cardiomyopathy?

If a patient has a stent placed in the left subclavian artery and the access is from the left radial artery, would you bill 36215 for catheter placement?

Provider documents that a 7 French balloon tip Swan-Ganz catheter was advanced into the wedge position where the appropriate pressures, cardiac outputs, and saturations were recorded. He then documents that a 6 French pigtail catheter was advanced into the left ventricle, and simultaneous right and left heart pressures were recorded. Pullback pressures were then recorded in the left and right heart pigtail catheter. In addiiton to the findings for the left heart cath, the report also documents findings for resting right heart pressure, mean right arterial pressure, Fick cardiac output, theromdilution cardiac output, pulmonary vascular resistance. Does this documentation support reporting left and right heart cath? I am not sure if the provider needs to actually state that a catheter was placed in the right heart, or if these findings are enough to support that the catheter was in the right heart.

Percutaneous creation of AVF. Are we able to bill 37241 + 36215 + 36901 + 76397 + 75820 + 75710 since it is now FDA approved, or do we have to stick to 37799?

We know that it is expected for all images to be saved for ultrasound procedures. We know that in order to bill CPT 76937 we need physician to state that images are saved/recorded. Should the same be stated in operative report if 76942 is billed?

Physician performs aortoiliac bypass with FP bypass graft and extends graft into both external and internal iliac arteries. He wants to bill x2 for 35537 for each of the arteries. Is this correct? Fee schedule MUE is 1. Please advise.

Physician performed right L3-4 MBRF, L5 dorsal rami RF, and S1-3 dorsal rami RF. I get codes 64635-RT and 64625-RT. There is an NCCI edit when reporting these codes. What would be the correct codes for these procedures?

Is this simple 51705 (75984) or complex 51710 (75984)? "Fluoroscopically-guided exchange of suprapubic catheter. Procedure and Findings: The procedure was performed in the VIR suite following informed consent. A time-out was performed, and the correct procedure site was initialed by the radiologist. Preprocedure antibiotics were not indicated. With the patient in the supine position, the lower abdomen and the existing tube were prepped and draped in the usual sterile fashion. All elements of maximal sterile barrier technique were followed including: cap, mask, sterile gown, sterile gloves, a large sterile sheet, hand hygiene, and 2% chlorhexidine for cutaneous antisepsis (or acceptable alternative antiseptics). The position of the tube was assessed with fluoroscopy and contrast injection. The tip of the tube was in the urinary bladder. The retention balloon was deflated. The catheter was removed. The new 16 French suprapubic catheter was advanced through the existing tract into the urinary bladder lumen under direct fluoroscopic guidance. There was immediate return of the urine."

In reference to Q&A ID 2726 from 2011, what would be considered a separate technical study for an MRI and MRA when performed at the same encounter? Whether it is a stroke protocal or provider just orders an MRI & MRA of head, can you elaborate on what would be seen as separate and distinct in a technical study when these are performed at the same encounter to justify both CPTs with a modifier? The radiologist provides a report for the MRI and a separate report for the MRA. The clinical indications from the ordering provider are often the same diagnosis.

We had a patient with pain due to the position of the generator and leads. The physician repositioned the AICD generator and cleaned up some scarring around the leads. How would you code that? No lead replacement.

If provider replaces ICD generator, multiple lead, as well as capped and replaced transvenous electrode (RV), why is 33216 not allowed to be used with 33264?

Could you please take a look at the following and instruct us what CPT codes you would use based on the documentation? "Right atrial electrocardiography. Entrainment mapping of the cavotricuspid isthmus. Intracardiac cardioversion via his implantable cardioverter defibrillator (ICD).  Right and left inguinal areas were anesthetized with 1% local lidocaine. Hemostatic introducer sheaths were placed percutaneously in the right and left femoral veins using modified Seldinger technique. Multipolar recording and ablating electrodes were advanced from the femoral veins to the right atrium. Entrainment mapping from the cavotricuspid isthmus produced classic entrainment with a change in the atrial activation and a long post pacing interval. With that finding, it was felt to represent a non-cavotricuspid isthmus of dependent atrial flutter. I elected to cardiovert him and will plan to try to suppress his arrhythmia with antiarrhythmic drug."

Physician planned an RFA of dual AV node physiology for SVT. Comprehensive EPS was performed, with recording of the high atrium, His bundle region, RV apex, and coronary sinus. Standard pacing protocols done. After the RF lesions were placed, the patient developed complete heart block. They waited 30 minutes and AV nodal conduction did not return, so "the atrial and ventricular pacing catheters and their sheaths were secured into place with a silk suture." The statement in the quotes is what is confusing to us. Were those the EPS pacing catheters being used as pacemaker leads? Nowhere in the description does it state that a temporary pacemaker had been placed. Or were the pacing leads he is referring to just be a temporary dual transvenous pacer and he just failed to tell us that he placed earlier? The physician does state that a "temporary dual chamber pacemaker placement" in his procedure list. The discussion does state that "there is a back-up dual chamber transvenous pacing system in place should the patient become unstable." Should we report 33211-59?

Previously we have been advised at my facility that the -51 modifier should not be used with cpt 93451. Our current code validation software indicates the -51 is not applicable to 93451 as either a professional or facility code; however, it's not listed in Appendix E or with the universal symbol in the AMA CPT guide. Can we get clarification on whether -51 is a valid modifier for 93451, and if not why is it not a valid modifier for this code?

There were three clips placed in a MitraClip. I plan to submit codes 33418 and 33419 x 2. I can't find clear confirmation that 33419 can be billed more than once. Can you bill 33419 twice?

What CPT codes are used for CT cystogram? Would this be charged with codes for CT pelvis (CPT 72193 or 73194) or cystography min three views (CPT 74430)? Is code 51600 reported separately for the contrast administration?

CRT-D generator replaced only and existing RV and LV leads reconnected. (No RA lead existing or implanted) –Would we code this as a dual lead or multiple lead replacement? We are finding conflicting advice--CPT Assistant, December 2013 states whenever a LV lead is implanted, it is a multiple lead system. A dual lead system refers to Right sided only pacing system (RA and RV). A 2017 webinar from another coding resource states BiV device does not always mean a “multiple” device is implanted. The example given: “A patient with chronic A Fib may not have a lead in the RA, but leads in the RV and LV. This case would qualify as a BiV device, but coded as a dual and not multi since only 2 chabers are paced, not 3” --- 2020 CPT guidelines state, “If only a pulse generator is inserted or replaced without any RA and/or RV lead(s) inserted or replaced, report the appropriate code for only pulse generator insertion or replacement based on the number of final existing lead(s) (33262, 33263, 33264).”

Patient has an Indiana pouch with stoma plus nephrolithiasis. Pouch was accessed by way of stoma using angiographic cath under fluoroscopy, and contrast and saline were used to distend the pouch. Under US guidance, direct percutaneous access into Indiana pouch with tract dilation and placement of drainage catheter into the most dependent portion of the pouch was performed for planned stone removal in future." How will this be coded? 51102 for suprapubic cath placement? Please advise and explain.

What is the code for drainage of bilateral pleural effusion, open approach, when performed in conjunction with an aortic valve replacement procedure? "Procedure Description: Drainage of bilateral pleural efusions secondary to congestive heart failure and placement of Blake drains. Details of procedure as follows: A primary median sternotomy incision was performed. Massive bilateral pleural effusions were drained in excess of a liter from each pleural space."

Is the procedure reported open or percutaneous? "A micropuncture needle was used to access the AVF close to the arterial anastomosis. A microcath/dilator was inserted. Venogram: high grade 80% stenosis at the level of a subclavian SVC stent; multiple in stent stenoses at the axillary v. A glide wire was passed into the atrium using a kmp catheter, replaced with a super stiff wire, upsized to a 6 introducer. At one point we could not pass the balloon cath centrally because of resistance to pushing it in so a more proximal cannulation was done with a micropuncture needle, which was up sized to a 6 introducer, and a 6, 8, and 10 mm diameter 4 cm long charger balloon dilatation cath were used to dilate the lesion to profile. The 100 balloon burst on a calcific plaque and got hung up pulling it out, so xylocaine was infiltrate, the fistula was dissected out to control it proximally and distally, and the balloon cath was removed. The opening was closed with 5-0 prolene. The wound was closed with vicryl and Monocryl and a single nylon for hemostasis. The cath was removed after a 3-0 nylon suture and swizzle stick was place."

Is the stent billable with 35301, and which stent code would you use? "Longitudinal arteriotomy was made from the common carotid beyond the plaque in the ICA. An endarterectomy was performed using a Freer elevator of the common carotid, carotid bulb, internal carotid artery. The endpoint tapered nicely. Eversion endarterectomy of the ECA was performed. Please note that a clamp was placed proximal to the carotid bulb to avoid any potential embolization. We transitioned to endovascular mode. An 8 French sheath was secured to the skin. A Glidewire and angled vertebral catheter were now advanced crossing the common carotid artery ostial lesion into the aortic arch. The catheter in the arch aortogram was performed, showing intraluminal placement and a focal stenosis involving the proximal common carotid artery. A retrograde angiogram was performed through the sheath. We used the subclavian stent as a landmark in conjunction with the calcification of the aortic wall. 7 x 9 Gore VBX balloon expandable stent, deployed."