Ask Dr. Z

Ask Dr. Z Knowledge Base houses over 7,500 coding questions and answers dating back to 2013.

Ask Dr. Z Disclaimer

36222 vs. 362223

What is the difference between codes 36222 and 36223?

Contralateral venous sinus selection

We are looking to get clarification on the furthest selectivity principle and how it applies to contralateral venous sinuses when selection has been made by advancing straight through the torcula from one side to the other, rather than pulling back and entering the other side through the internal jugular. Our case example is this: Right femoral access, with selections in: right internal jugular, advancing to right sigmoid sinus, advancing to right transverse sinus, advancing through torcular herophili, advancing to left transverse sinus, advancing to left sigmoid sinus, advancing to left internal jugular (with angiography taken at each placement). Would code assignment be one unit of 36012 due to the furthest selectivity principle? Also for the angiography S&I, are we only able to code 75860 x 2?

Critical Care time after patient expires

Questioning if I can bill critical care. The patient encounter was created at 12:23 arrived in the ED department at 12:28 and there is no documentation stating that he was in contact with the EMT’s enroute to the hospital, so 12:28 would be the accurate start time and the family wanted CPR measures stopped at 12:52 and that was the time of death recorded in the nursing timeline. So this would only be 24 minutes of critical care time. The provider did not give me a start time or stop time or total time spent but a blanket statement of 30-74 minutes spent providing critical care (documentation template). The provider did receive lab results at 13:27, and the ET tube was removed at 13:49 and had a long discussion with the family, but at this point the resuscitation efforts were no longer being performed. This patient is Medicare, and the resources we found state that Medicare does not allow family discussions to be included in critical care after the patient has expired. Would I be correct in assigning the 99285 instead of 99291?

Biopsy and Localization

Office setting (global billing) with two physicians: Physician A performs breast biopsy 19083 at 1 pm and Physician B performs SAVI Scout localization 19285 at 2 pm. They both dictated reports and both insist that they can be billed separately because it was performed by two physicians and that per NCCI edits 19285 can be billed with 19083 if they add a -59 modifier since 19083 does not allow modifier -62. Thoughts?

TCAR/Silk Road w/ Cardiologist & CV surgeon

If the CV surgeon performs the exposure/close, and the cardiologist performs the remainder of the procedure for carotid stent, would 37215 for cardiologist and 37215-80 for surgeon be appropriate if documentation supports? SVS recommended this, and I believe Silk Road did as well. I would very much appreciate your opinion too please.

ECMO Management in a Global Period

If a surgeon performs a 90-day global procedure and places the patient on ECMO, what modifier should be appended to the ECMO daily management CPT codes for the surgeon if he/she is providing the ECMO management post op?

PET/CT 78431

When reporting code 78431 is it necessary to document the CT component on the report since the machine our health system uses is a PET/CT combo and the CT images are fused with the PET images? Is it necessary to state "PET CT nondiagnostic CT completed" for attenuation correction only?

Ultrasound and Flouro Guidance

I have been seeing a lot more reports stating two guidances and was wondering if you can use two guidances on procedures. Example is 32550 & 75989, the report states: "Under ultrasound guidance, an 18 gauge needle was placed into the left pleural cavity. A tract was tunneled from the lateral aspect of the left back to the access site using a tunneling device which was used to pull the Pleurx catheter through the tract. The needle was exchanged over a Rosen wire for serial dilators and a peel-away sheath. The catheter was placed through the peel-away sheath, which was removed. Fluoroscopic image demonstrated the catheter to be in good position." So I don't see anything in the CPT book stating you can't. Am I wrong on this?

Sotradecol and Optiray 320 can it be billed?

I checked and the cost of the coils has been factored into the embolization code 37242, which means the coils can't be billed. But where I need guidance is in an office (POS 11) my physician treated an AVM using both coils and Sotradecol. Report states: "On the back table we administered Sotradecol foam mixture consisting of 3 parts air to 2 parts 3% Sotradecol in 2 parts full-strength Optiray 320 contrast." This mixture along with coils were used to embolize a branch of the profunda and two branches off the SFA. I know the coils cannot be separately billed, but can the Sotradecol (J3490) and the Optiray 320 (Q9967) be also coded?

Biopsy Intercostal Mass

Would biopsy of left intercostal mass be reported with 20206?

Procedure attempted, equipment malfunctioned Heart Cath

Can you bill 93571-26 for an attempted left heart cath that was not completed because of equipment malfunction? Report states: "LAD: Mid LAD: 60% stenosis. Comments: heavy calcium, FFR attempted x 2, equipment malfunction. Mid LAD: Comments: Patent In-Stent. LCx: Normal."

Micra Leadless Pacemaker Insertion via Open heart incision

We have a cardiologist who is performing a Micra leadless pacemaker device insertion into the RV during another surgeon's open heart procedure (e.g., TV replacement). He is deploying the device through the catheter delivery system, but the tip of the catheter is being inserted via an open incision into the heart and the catheter is not being inserted into a vein access point. Can we still report this using code 33274?

Multiple right breast cyst aspirations with ultrasound guidance

LESION/LOCATION: Right 10:00-11:00, 5-8 cm from the nipple. TECHNIQUE: Ultrasound-guided needle aspiration. The skin was prepped in the usual fashion. 5 cc of 1% buffered lidocaine was used for local anesthesia in the skin and deeper tissues using ultrasound guidance. Preliminary ultrasound shows multiple benign cysts in the right upper outer quadrant. Using a single entry site, 5 of the benign cysts in the right upper outer quadrant were aspirated using an 18-gauge needle and ultrasound guidance, yielding a total of 7 cc of tan fluid. Aspirated cyst were seen to completely resolve on real-time ultrasound. The patient tolerated the procedure well and there were no complications." Do you recommend coding this as CPT 19000, 19001 x 4, 76942... or 19000, 76942? For CPT 19001, does it have to be a separate needle puncture into each cyst, or can it be one needle puncture and redirect the needle to adjacent cysts to drain each one?

Intervention in LAD and in a branch of LC

Lesions in both LAD and the 3rd obtuse marginal branch of the circumflex are treated with drug-eluting stents in the same encounter. What are the appropriate CPT codes to report in this case? Should we report 92928- LD and 92928-LC (C9600-LD and C9600-LC for Medicare) or 92928-LD with 92929-LC?

PAVF Using Ellipsys Device

What is the appropriate CPT for PAVF using an Ellipsys device? Should we use an unlisted code along with G2170 to report our physician's work? Our physician also performed brachial plexus nerve block immediately prior to the PAVF. Would this be bundled, or is it separately reportable?

Thyroid Microwave Ablation

Can we assign code 60699 for thyroid microwave ablation?

33249

Patient had a CRTD initially placed, then developed an infection and the PG and leads were removed. Once the infection was resolved at a later date a new CRTD system was implanted. Insurance is denying 33249, as patient no longer meets NYHA Class II, as during the time of having the CRTD he improved. Should this be coded as a 33249? Or is there a more appropriate coding scenario for a system removal and new system implant at a later date post infection?

ICD-10 QUESTION ON E11.51

For E11.51, what is considered "peripheral angiopathy"? Does this include varicose veins? DVT? Superficial thrombosis? Phlebitis?

IV Drug stimulation and Pacing after ablation

After pulmonary vein isolation is confirmed, and the physician then says isoproterenol was used to induce non-PV triggers and no other arrhythmias were induced, it is my understanding that if an IV drug stimulation is performed after an ablation that we cannot charge for the 93623. Is that correct?

Bone imaging whole body with SPECT/CT

How should bone imaging whole body with SPECT/CT be coded? Is it only code 78830, or 78306 for planar whole body and 78830 for SPECT/CT? Does SPECT/CT include bone imaging whole body, or can two codes be billed separately?

36012-Per Extremity?

If the provider catheterizes the right GSV and the right popliteal, is that one 36012 since same extremity or 36012, 36012-XS since both are separate second or higher order?

EP / Ablation PVI CTI

I am so confused with our new cardiologist’s documentation. Pre procedure patient had Px Afib. Post procedure diagnosis – Px Afib and CTI dependent macro reentrant RT atrial tachy (typical A. Flutter). Patient had comprehensive EP study with RA, LA, RV, LV pacing and recording. 3D mapping was done, as was ICE. “The pulmonary veins were examined with Pentaray and all were electrically active. Wide antral circumferential ablation was performed around the pulmonary veins. Bidirectional block confirmed. The patient went into nonsustaned AT. ECG consistent with typical atrial flutter. In the right atrium the CTI was mapped and ablation carried out from the tricuspid annulus to RA. Halfway through CTI ablation, patient went into AF, which thereafter organized into sustained typical atrial flutter. This was terminated during ablation with confirmed bidirectional CTI block.” Would you code 93656, 93655, 93613, 93662, and 93622? I thought they had to go into the pulmonary veins to ablate them – I do not see that here?

Cineflouroscopy for MBS

Cineradiography vs. cinefluoroscopy. Are these terms interchangeable? If cinefluoroscopy is done instead of traditional video recording, is it appropriate to use 74230?

EPS

"Patient brought into the EPS lab for presumptive type 1 atrial flutter. 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." The doc says in the name of the procedure that he was cardioverted via his implantable ICD, and that his ICD was working well. I was thinking of using the individual study codes, but since he used multipolar “electrodes” does this mean he’s doing this through the device? Could you please advise what CPT codes you would use?

93975 with 76856

I have a claim that is editing for NCCI of 93975 with 76856. I would put a -59 modifier on 76856. Is this correct and why or why not? "Reason for Exam: Lower ABD/Femal Reproductive Organs lower abdominal pain, RLQ or LLQ Exam: Transabdominal Pelvice Ultrasound with Doppler Technique: Transabdominal real-time Duplex scan was performed using B/Mode/gray scale imaging, color flow and spectral Doppler analysis to include bilateral Evaluation of arterial and venous flow. Findings: Uterus 8.0 x 3.9 x 2.8cm No myometrial mass to suggest Leiomyoma. Endometrium: 7 mm Ovaries: Right ovary 4.2 x 2.3 x 2.3cm. Normal arterial and venous flow. No focal lesions Left Ovary: 3.7 x 2.3 x 2.9 Normal arterial and venous flow. No focal lesions small amount of cul-de-sac fluid Normal uterus, Normal Ovaries without evidence of torsion. Trace amount of cul-de-sac fluid, nonspecific."

Catheter and Sheath Exchange Thrombolytic Therapy

"Patient returned to the OR a few hours after the initiation of catheter-directed thrombolysis. Patient had bleeding noted around access site. Patient needed up-sizing of the sheath to stop the bleeding, so the sheath was exchanged. The Angiodynamics Unifuse side hole catheter was also exchanged (replaced and repositioned over the existing wire). tPA was restarted." Can anything be billed for this?

Aortic valve replacement with mitral valve debridement

Our physician was doing an aortic valve replacement on a patient for severe aortic stenosis. During the procedure, the patient was found to have anterior mitral valve leaflet calcification, which was debrided. "Anterior mitral valve leaflet debridement: There was a band of calcium that was extending from the aortic annulus to the anterior mitral valve leaflet. This was debrided carefully without perforation of the anterior leaflet of the mitral valve." Please advise if an additional code should be used for the debridement of the mitral valve or if this would be included in the aortic valve replacement.

Appropriate 78830 Post Treatment SPECT/CT after Y-90

Yttrium-90 Thera-spheres was administrated and coded with 79445 and C2616. Post procedure SPECT/CT done and coded with 78830. There are NCCI edits with 79445/C2616 and 78830. Seems like 78830 is a diagnostic code/procedure and is being used to confirm success of the procedure and probably shouldn't be reported?

Ultrasound guidance for dialysis AVfistula intervention

Ultrasound guidance is used frequently for access to dialysis AV fistulas/grafts. Coding 76937 is allowed if all the elements of the code are documented and only "when the AV graft or fistula is documented as either immature or failing". Immaturity is usually well documented. When would the AV graft or fistula be imaged and have some type of intervention performed if it is not failing? Is thrombus, stenosis, etc. found during the fistulogram treated with angioplasty, stent, thrombectomy enough to consider it failing? Is there specific documentation needed, or can 76937 be coded if an intervention is performed?

Mechanical thrombectomy in two intracranial arteries

I have a provider that is documenting mechanical thrombectomy in both the right ICA and right MCA. Would you code 61645 x 2 or 61645 -22? This one is throwing us off since it is the same vascular family, so we're not sure how to code this properly.

is C9764 -C9767 to be used only for lower extremities lithrotripsy

Should codes C9764-C9767 be used for revascularization of other vessels: coronary, renal, upper extremities, etc.?

RFA of the Suprascapular Nerve

Would you code this as 64640 for a peripheral nerve, or 64999 unlisted? "Using intermittent fluoroscopy guidance, a 25 gauge, 3.5 inch needle with 10 mm active tip was slowly advanced through the skin and towards the suprascapular notch. Thereafter, sensory stimulation at 1V and 2Hz replicated the pain pattern. After negative air and heme aspiration, medication mixture was injected. RFA was undertaken at 42 degrees and 120 seconds. All needles were removed, and a sterile dressing was applied."

RHC and Biopsies

I work in a large academic hospital with a large volume of RHCs and biopsies. The OIG clarification this year seemed to say that if hemodynamics are fully reported that the RHC could be billed with modifier -59. My physician practice compliance officer says we can bill with the documentation our physicians are completing, and my hospital compliance officer says we are not and is completely removing the charge for the RHC. These RHCs = > 4.5 million in charges per year. What is your opinion?

AVG with Brachial Artery Angioplasty

"Using US, I was able to visualize the left upper extremity AVG. Exchange was then made for wire and micropuncture sheath 035 wire was advanced into the central venous system. Exchange was then made for 7 French sheath. I did the same maneuver with cannulization into the arterial system. Exchange was made for stiff Glidewire Bernstein catheter, which was navigated into the brachiocephalic trunk. Angiogram was then completed, which demonstrated stenosis within brachial artery. I then exchanged this for a 6 mm balloon angioplasty of the brachial artery was then completed which promoted excellent inflow. Given the findings change was then made for a Trerotola which was utilized to clean the arterial limb and subsequently the venous limb. Stiff Guidewire was then navigated into the venous limb where balloon angioplasty of the AV graft was then completed along the venous outflow system. Complete angiogram showed excellent flow." What all can I code here? Brachial angioplasty also?

TTE and TEE guidance for ASD closure, separate encounters, the same DOS

We had two distinctly separate echo studies. Patient had procedural TEE (93355) in the morning for ASD closure and the transthoracic echo later in the day. Both have orders, images, and final reports. Facility echo charges: 76376, 93325, 93321, 93308, 93355. There is an NCCI edit between 93355 and 93308, no modifier permitted. How should we report those two procedures? Is there an edit that bundles 93355 into an anesthesia service for the facility?

Abbreviations in Regards to Electrophysiology Procedures

Are abbreviations acceptable for documentation purposes? Mainly anatomy related abbreviations. A few examples: ARGP - anterior right ganglionated plexus, LIGP- left inferior ganglionated plexus, LA - left atrium, CS - coronary sinus, CTI - cavo-tricuspid isthmusm LSPV - left superior pulmonary vein, SVC - superior vena cava. Some electrophysiologists describe procedures in a very technical manner. Occasionally, anatomical structures are not clearly identified, such as the ARGP.

Professonal modifiers 52 and 53

What documentation requirements are there to use these two modifiers? For instance, for modifier -52 does the physician need to state what percentage of a procedure was performed if attempting to angioplasty a coronary and cannot pass the wire after multiple attempts and much time has passed? Are there specific documentation requirements for -53?

2021 changes

What changes will happen to 93621 and 93662 valuation in 2021?

Failed Bi-V Upgrade

Patient had a single lead defibrillator with RV in place and plans to upgrade to biventricular with addition of RA and LV leads. Provider made three attempts to place an LV lead, then a Bundle of His lead, and finally a traditional RA lead. Due to a previously placed dialysis catheter that extended to the mid-lower position of the RA, access was difficult and all lead attempts failed. The LV lead was never placed in the body (only the catheters and guidewires), but both the BOH and the traditional RA were placed in the body before failure. At the end of the procedure, all we succeeded in doing was replacing the generator. Do I just stick to billing what we were able to complete and bill 33262 for the generator change and use modifier -22 for the additional work (time and difficulty in trying to place the other leads)? Or I know you have said in previous questions that if the lead itself is placed within the body we can bill for a discontinued procedure so bill 33262, 33216-53 x 1 (for the RA/BOH lead attempts since they were for the same purpose). Thoughts?

Ruptured Femoral Pseudoaneurysm Repair

Our physician performed a ruptured femoral pseudoaneurysm repair (35142) and then entered the retroperitoneum to I&D a hematoma the size of a football. Would we additionally code 49060 (drainage retroperitoneum) or not since the pseudoaneurysm caused the hematoma?

Excision of Carotid Web

How do I code excision of a carotid web? Is it included in the endarectomy?

A-Fib Ablation and CTI Line

Patient arrived in A-fib and had PVI ablation. The note then says: "Entrance and exit block were proven by differential pacing maneuvers-local pulmonary vein capture was identified without any left atrial capture. We then performed right atrial flutter line and bidirectional block was confirmed measuring 180 ms in either direction." Would I add 93655?

E&M and IR

Can you provide any information on situations IR could possibly bill for 99446-99449 interprofessional telephone/internet/electronic health records assessment and management service by a consultative physician? My IR doctor wants us to look into billing these codes.

Repeat Afib Ablation

MD does a repeat afib ablation, and the pulmonary veins are already isolated from prior ablation. Additional linear ablation is done for afib. Do we bill 93656 and 93657?

35876 vs. 35556 and 35700 - redo bypass

"The patient has a history of bypass done elsewhere. Since that time he had thrombolysis successfully, but recently developed recurrent stenosis after the patient stopped anticoagulation himself. He is now brought in for a repeat redo bypass due to popliteal artery aneursyms. The surgeon performed a left femoral artery to posterior tibial artery bypass using nonreversed left upper extremity arm vein with a left femoral localized thromboendarterectomy." I am unsure if I should code 35876, or 35556 and 34700? Or am I way off base here?

Intracardiac Thrombectomy During PVI

For professional billing, what code would best be used to report intracardiac thrombectomy during a staged PVI? The MD found thrombus while performing ICE and aspirated it by using an AngioJet.

Is KX modifier used on 33206-33208 for gen replacement w/ lead

The NCD for the -KX modifier is regarding the initial placement of pacemakers and specifically states that the NCD does not address replacement of pacemaker generators, CPT codes 33227, 33228, 33229, and 33233. My understanding of this is that we do not use -KX modifier on those four CPT codes. My question is for 33206-33208 when the generator is replaced AND a lead is placed/replaced in the same setting. Technically, this is still a replacement, but it codes out to a new device CPT. Would the -KX modifier be required or omitted in this circumstance?

93458 (LHC) with endomyocardial biopsy 93505

We have been billing code 93454 with 93505 when doing coronary angiography with endomyocardial biopsy based documentation. Our physician has stated that a LHC (93458) is medically necessary on OHT patients, as an elevated LVEDP can be a clue for microvascular coronary disease or diastolic dysfunction that is not apparent on coronary angiography. When one physician lacked the documentation of the LVEDP, he stated, “The LHC is standard for transplant surveillance, as the LVEDP gives us very important information, as well as with our congenital patients it is important to look for gradients at the aortic anastomosis. The LHC is not a means of getting to the coronaries as we use a separate catheter to perform this. A LHC is standard of care for transplant patients in pediatrics for surveillance caths. I don’t think this needs to be documented separately in the note.” Are we correct in asking for documentation of LVEDP to support the medical necessity for billing the LHC with an endomyocardial biopsy? Or is the physician correct that we can bill the 93458 with 93505?

Correct code for Impella RP

What is correct CPT coding for insertion of an Impella RP device at the bifurcation of the pulmonary arteries using right femoral vein access?

Myocardial Biopsy with RHC

In your opinion, is this enough documentation to show a separate reason for performing a right heart catheterization with a heart biopsy? "INDICATIONS FOR PROCEDURE: This is a 69-year-old male who was recently diagnosed with acute heart failure with severe systolic dysfunction, and as part of his workup he received a cardiac MRI that revealed evidence of an acute myocarditis versus cardiac sarcoidosis. The patient is now referred for right heart catheterization and endomyocardial biopsy. PREOPERATIVE DIAGNOSES: 1) Heart failure with reduced ejection fraction. 2) Inflammatory versus infiltrating cardiomyopathy with an abnormal cardiac MRI. POSTOPERATIVE DIAGNOSES: 1) Hemodynamically well compensated heart failure with reduced ejection fraction. 2) Successful right ventricular endomyocardial biopsy."

Need to ask Dr.Z?

Don't see the answer you're looking for in the knowledge base? No problem. You can ask Dr. Z directly!
Ask Dr. Z a question now!