Ask Dr. Z

Would the ECMO portion be coded as 33946? "Using real-time US guidance, a 21 gauge micropuncture needle was first used to enter the right internal jugular vein. A 5 French sheath was placed. A second access higher up on the right internal jugular vein was placed with US guidance. Additionally two more access points were placed into the left internal jugular vein. One access point was used for a triple-lumen central line and handed off to anesthesia. Additional access was also gained with US guidance of the left common femoral vein. The right IJ access point was upsized to a 26 French Gore dry seal sheath. A flush catheter was then advanced through the sheath into the lower IVC. Next the left IJ access was upsized to a 17 French ECMO cannula. In conjunction with the perfusionist team and the manufacture representative, the patient was placed on venovenous bypass. After the conclusion of the RLE mechanical thrombectomy procedure, the patient was taken off the venovenous bypass, and all sheaths were removed and hemostasis achieved with pursestring sutures."

The physician gained access in the femoral vein and artery, did arterial and venous diagnostic angiograms of the stump, selected both the arterial and venous superior lateral geniculate arterial branch, and both the arterial and venous sides were embolized using coils and alcohol. I know it says you are only supposed to charge for one embolization code per site; however, I was wondering whether I should charge 37241 or 37242?

I have billed Noridian codes 33249, 33225, and 33233-51, but only 33233 has been paid. I am trying to figure out how I can find out what appropriate modifier I would need to bill these procedures. How can I find what modifier would be correct to use and have 33249 and 33225 paid? "Using blunt dissection and electrocautery, prepectoral fascua was exposed. The pocket was opened carefully, and pocket was revised to accommodate the size of new device generator. RV lead was introduced and advanced to RV apex. Repositioned due to micro dislodged, LV lead was inserted to the branch. New LV, RV lead connected to the device generator, old RV lead capped."

"Angiogram (DSA) of the entire left lower extremity and iliac arteries using a 4 French x 45 cm long Rim catheter advanced from the right common femoral artery up and over and down into the left SFA. Selective angiogram of the left posterior tibialis, peroneal, and anterior tibial using a 4 French x 150 cm long Navicross catheter advanced from the right common femoral artery up and over the left lower extremity." Please confirm use of the correct codes: 36247, 36248, 76937-26, 75710-26?

Please confirm that appropriate codes were used for the following procedure: lower extremity angiogram with run-off using right radial followed by intervention of right iliac artery with a stent using right common femoral artery access approach. Are 75625, 75716, and 37221 the only codes allowed, or can you add-on code for the additional access?

I have to code for a RHC and LHC, with LV gram and coronary angiogram. Ultrasound-guided access times 2 per the doctors notes. Would this be CPT 93460 alone?

Would you code 93724 during this congenital cath case? "The patient is a 35-year-old male status-post Senning and multiple RF ablation, who was brought to the cathlab for hemodynamic evaluation prior to his scheduled Valve-sparing aortic root replacement surgery. During his most recent RF ablation, he developed CHB and is now pacemaker dependent. Under monitored sedation he underwent complete hemodynamic evaluation, demonstrating mildly elevated RVEDP=14 mmHg with at least moderate RV systolic dysfunction. During his last angiogram in the SVC, he developed slow atrial flutter at rate=100 BPM. He received 6 mg Adenosine to verify his flutter, which was not helpful. Therefore, Dr. X from EP Service overdrive paced at 550 msec using his pacemaker. He converted easily back to A-sensing and V-paced rhythm=70 BPM." 

What does the total RVU in your coding references represent? It does not match the with RVUs that are listed under other lookup tools.

Does code 75630 need to include femoral arteries in its findings? Bilateral femoral arteries?

Per Coding Clinic for HCPCS, 2nd Quarter 2019, they recommend using 33999 for a dual chamber PM when (1) of the leads is placed in the bundle of His. I'm not sure I undertand their logic, as we have been reporting 33208 for this situation. Also, when a bundle of His lead is placed in a CRT-D, where the bundle of His lead is taking the place of the LV lead (33225), would you recommend an unlisted code for this third lead?

My question is regarding the use of code 34831 when the physician is repairing an aortic aneurysm 1-2 years post op endovascular aortic aneurysm repair. My physicians are stating that this is only to be reported during initial operative session. Please clarify timeframe for usage of this code.

We have a patient who had open heart surgery and also had a CRT device placed at the same time. An epicardial lead was placed on the right ventricle, left ventricle, and right atrium. So CPT code 33202 is being reported for the epicardial lead placement and also 33221 for insertion of pacemaker pulse generator with multiple leads. My question to you is would you also code for 33225 for the insertion of pacing electrode for left ventricular pacing at the time of insertion of the pulse generator? I am questioning code 33225 because all the guidance that is available on this code suggests that is transvenous only, and this was done epicardially during open heart surgery.

The patient came in for a staged complicated procedure of the LAD and LC. The physician states, "Given the patient's LV dysfunction and cardiomyopathy, we elected to put in an Impella device." A right heart cath was done. RH hemodynamics: RA pressure was 7, RV was 36/5 with a PA of 36/10, and a wedge of 11. Mix venous sat was 74%. Should there be an additional charge for the RHC, or is this procedure a standard of care prior to an insertion of a VAD except during an emergency?

Is it appropriate to charge for ultrasound-guided access for EP procedures such as ablations, EP studies, and insertion of pacemakers and ICDs, if all criteria is met for CPT code 76937?

Physician performed a left heart cath with a root injection. She states, "Root injection to access anomalous coronary arteries." Her recommendations were, "CTA of coronaries to define origin and course of left coronary arteries." Would you say no code for the injection, because it was necessary to complete the diagnostic heart cath?

If using the category III code for vertebral stent (0075T), can the angioplasty for that same artery be billed for, or is it inclusive like other stents?

Can code 76937 be reported with heart caths, coronary angiogram 93454 or RHC 93451?

How would you code for an NG tube placement done without the use of imaging guidance (no fluoro)?

When separate lesions are treated with intravascular lithotripsy, atherectomy, and stent insertion in both the popliteal and the superficial femoral, would the new HCPCS code C9767 be assigned twice? The code description does not specify a vessel or group of vessels (e.g., femoral/popliteal or tibial/peroneal), it simply states "within the same vessel".

I audit for a large cardiology practice with several physicians and APPs. In the hospital setting, when critical care is provided, I know split/shared visits are not allowed. However, I have recently been told that an APP is considered to be their own specialty in billing critical care. Also, I have been told that if an APP renders critical care and supports time of 30 minutes or more, they can bill 99291, and then if the cardiologist sees the patient later and critical care is supported, they too can bill 99291. Do you know if this true regarding APPs being their own specialty, as I cannot find this information anywhere?

In an office-based lab (place of service 11), when a device is given to the provider by the manufacturer at no cost, does a modifier need to be assigned to the procedure code? I considered modifier -FB, but instructions for assignment don't seem to include office (POS 11).

Would you say sinus arrest would be best coded as sick sinus syndrome I49.5?

This was performed by the radiologist in the hospital setting. Can the radiologist bill anything for the CT perfusion study? "Craniocaudad Z axis spiral acquisition performed during injection of Omnipaque. Automated arterial and venous inputs used to create maps of cerebral blood volume, flow, transit times, and Tmax parameters. Findings: Normal CT perfusion with no findings of ischemia or infarction. Contrast was then instilled and patient sent to CT scanner. Impression: Good distribution of contrast with normal appearance of imaged osseous structures. Uncomplicated fluoro-guided lumbar puncture for instillation of myelographic contrast."

For hospital coding, I understand that an echo with contrast is coded as C8929. However, there are some payers that do not recognize the C code. Can we code the 93306 + contrast charge even if the description for 93306 does not mention with contrast?

For the following, is it appropriate to bill 35656 and 34203 same leg? "At this time the patient's left leg was positioned, and a longitudinal incision was made on the medial distal thigh. Dissection was carried down through the subcutaneous tissue, and the popliteal space was entered. Moderate edema it was identified. The popliteal artery was ultimately dissected free, and vessel loops were placed. No definite pulse was noted in the artery. A longitudinal arteriotomy was created and minimal flow was noted, contrary to the patient's angiography of one week ago. Only a mild-to-moderate degree of plaque was actually appreciated; however, a #4 Fogarty catheter was passed distally into the leg in order to perform a thrombectomy. Only a small amount of plaque was retrieved and removed from the popliteal artery just below the arteriotomy, but no thrombus was ultimately identified after multiple passes of the Fogarty catheter. The arteriotomy was opened to approximately 15 mm to allow for a bypass. A tunneling device was used to tunnel a 6 mm Maquet woven graft to the left femoral area."

"A patient undergoes UAE for fibroids. The left uterine artery is selectively catheterized, and embolization is performed (36247, 37243). Following the procedure, the catheter is repositioned into the ipsilateral internal iliac artery. Selective angiography confirms agenesis of the right uterine artery, which had been seen on the initial pelvic angiography at the start of the case. The catheter is removed; no embolization is performed on the right side." Is it appropriate to add code 36245 for the catheterization of the right internal iliac artery, considering that it was not performed for embolization?

I was wondering if 33533-52 or S2205 would be appropriate for a MIDCAB procedure with no bypass and mini thorocotomy? This would be for pro-fee billing purposes.

Which code is supported in this documentation? 93656 or 93653? "DuoDeca catheter inserted via right femoral, then placed into coronary sinus for electrogram. The other 8 French sheath was upgraded to a RAMP sheath, and ablation catheter was placed via sheath. Biosense 4-mm tip contact force ablation catheter. Entrainment revealed this was right atrial flutter. Ablation then performed along the cava tricuspid isthmus in the 12 and 6 o'clock positions. Each site ablated between 10-30 seconds with attenuation of electrogram with splits. Atrial flutter was terminated in the IVC and the isthmus."

Would this be coded as 34701 or 37242? "Utilizing fluoro guidance, an 18 gauge trocar needle was advanced in a left translumbar approach into the AAA. Contrast injection under fluoro confirms positioning. The 18 gauge trocar needle was navigated into the AAA sac. Angiogram demonstrates appropriate catheter positioning within the AAA. Multiple detachable interlock coils were placed in the aneurysm sac at the level of the inferior mesenteric artery origin. Coil embolization of an abdominal aortic aneurysm excluded sac. Successful thrombin with microfibrillar collagen embolization of the aneurysm sac."

Wire into the SVC, transseptal needle inserted, LA access obtained in the LAA, and angiography performed. The MD tried three different devices but was unsuccessful in placing a Watchman device. What would be the procedure codes? 33340 with modifier -74?

If the doctor biopsies a presacral mass, would that be considered soft tissue and not bone?

Please help. "Patient scheduled and brought to cath lab, intubated, and placed under anesthesia. Prepped and draped in sterile fashion. TEE performed to obtain measurements for planned ASD device closure. See full TEE report by Dr. G for details. By TEE the ASD measured only 3.8 mm. A small left to right shunt was identified. There is no sign of enlargement. Doctors elected to discuss situation with patient's parents prior to proceeding with cardiac cath. Following extensive discussion with parents, decision made not to proceed with cardiac cath. Patient will be followed in clinic over time for the development of heart right enlargement to suggest significant shunting and indication for closure." The physician is asking, how can this case be billed, or are there other codes that may be used? Per physician, "Supplies were opened and NOT used (all wasted)." Please help - I suggested to the physician that only TEE (93315) may be reported, but I would like your take on this. 

Starting to get these procedures and had a report that I charged C9765 with, and it edited wanting me to charge for closure device. Since per the description for these new codes they include the lower extremity procedures angioplasty, stent, and atherectomy, would the closure device not still be inclusive to the new codes C9764-C9767?

I'm on the fence about coding a transcatheter tricuspid valve replacement (TTVR). Are one of the following category III codes appropriate, or should I use a cardiac unlisted (33999)? 0545T: Transcatheter tricuspid valve annulus reconstruction, with implantation of adjustable annulus reconstruction device, percutaneous approach. or 0569T: Transcatheter tricuspid valve repair, percutaneous approach; initial prosthesis

What is the correct "Y" code to use with ISR T82855A? Y811, Y831, or something else? We are going back and forth on this one.

If a stent was deployed from external iliac into the left proximal common femoral artery, do you bill 37221 or 37226?

We have a provider who sometimes performs cervical carotid stenting without embolic protection. The documentation does cover the factors for not using it - either that it was contraindicated in that patient for specified factors, or that it was not used as it was not "meaningful under the circumstances". Is there a scenario where it could ever be appropriate to code 37215-52 if the documentation indicates why it is contraindicated or not possible in that patient? Or is the only option 37216-GZ?

I am trying to understand the Coding Clinic 2nd Quarter 2019 page 12 with effective date of June 26, 2019. It states that we should assign CPT code 33999 unlisted procedure for a pacemaker insertion where one of the leads is inserted in the Bundle of HIS. I am wanting to make sure that we are compliant with our coding of this procedure. What is your suggestion for using this code?

"While attempting a PVI the physician encountered tortuous femoral veins requiring venography. An attempt was made to place a duodecapolar catheter via the left femoral vein. Catheter could not navigate through the tortuosity. A venogram of the left femoral vein was obtained, demonstrating significant tortuosity of left femoral vein. An angled guidewire navigated the tortuosity, and sheath was placed into the inferior vena cava and allowed placement of duodecapolar catheter into position in right atrium and coronary sinus. Through the right femoral vein a catheter was advanced to superior vena cava. Attempted to advance guidewire from right femoral vein to superior vena cava. Encountered great resistance at junction of right femoral vein and inferior vena cava. Guidewire advanced into superior vena cava. Dilator placed prior, also could not navigate this point. Venography demonstrated an apparent stenosis of the vein with significant collateralization. Cavotricuspid isthmus was eventually ablated." Is the venography billable? If so, what are the appropriate codes?

My question concerns coding 35666 and 37228/37224 together when the same vessels are involved. My physician placed an SFA femoral-posterior tibial bypass graft (35666) in the lower extremity due to atherosclerosis, and then following this procedure he did a balloon angioplasty in the superficial femoral artery (37224) and posterior tibial artery (37228) at the anastomosis to optimize inflow to the bypass graft. Would the balloon angioplasties be billable, or are they considered establishing inflow and outflow and are not billable?

I receive questions from radiologists asking if they can bill E&M in addition to diagnostic breast ultrasound exams they perform and meet with patients face-to-face, consult with the patients regarding findings, biopsy recommendations, risks and benefits of procedure, and pre-procedure clearance in order to cover the additional physician work. Also, these patients require a separate rad- path concordance report with recommendations. These are seen as a report addendum on the procedure performed. A concordance report is generated following review of the final pathology, and follow-up recommendations are given. Are there any billing opportunities for both of these scenarios? Can you provide guidelines if there are any for reference?

Selective catheterization of left common carotid artery was performed. Digital subtraction angiography of the intracranial left internal carotid circulation was performed in frontal, lateral, and oblique projections. Should this be coded as 36243 or 36244?

We have a cardiologist who wants to bill 76937 for the vascular access on his left heart caths (93458). This is how he is documenting it: "Realtime ultrasound guidance was used to achieve percutaneous vascular access of the mid right common femoral artery. The vessel was patent, and an image was obtained and placed in the permanent medical record." Is it appropriate to bill 76937 in this scenario?

Can you help us determine the correct CPT codes, especially for the ablation of the cavotricuspid isthmus? "Pre- and post-op diagnosis is atrial fibrillation. An 8 French ICE catheter was advanced to the right atrium and used to monitor throughout the case... Septum was punctured using a transseptal needle. A PentaRay catheter was inserted into the left atrium, and 3D anatomical and voltage mapping was obtained. Patient was noted to have significant areas of scar anterior posteriorly as well as partial scarring of the pulmonary veins. A Biosense Webster FJ ablation catheter was advanced to the left atrium. Sequential lesions were placed in antral fashion along the left and right veins. After circumferential ablations were completed, the PentaRay catheter was again replaced into the left atrium, and block into the veins was demonstrated. Ablation of cavotricuspid isthmus was undertaken at this time. Sequential lesions were placed from the tricuspid valve to the IVC. Block across the cavotricuspid was demonstrated after ablations were completed, and the block persisted for an appropriate waiting."

What are the documentation requirements for limited TEE with 93321 and 93325?

"Patient underwent implantable defibrillator generator change with the addition of a new atrial lead. New lead needed due to fracture in existing chronic lead. Generator was at elective replacement. Chronic right atrial lead was detached from the chronic generator and capped. Chronic right ventricle lead was detached, examined, and then attached to the new generator along with the new right atrial lead." Since code 33249 includes the replacement of an existing generator along with the insertion of a single or dual set of leads, and the original lead was not removed (only capped), would we need to code 33241 for the removal of the original generator as we would if we had removed a lead (along with 33244)? Or would 33249 suffice for the entire procedure?

Patient brought into the suite for an abdominal arch angiogram. The physician puts the cath into the arch and performs the angiogram. He documents he was satisfied. Then he writes I should note he attempted to cath LCC but could not because the catheter kept slipping out. The auditor coded 36222-LT/74. I suggested 36221. I am curious about provider's intent. The op-report states he went to shoot the arch. Do you give him credit for attempting the LCC even though that was not his intent? This comes up often in our hospital. The physician set out to do one thing, and while he is in there he attempts something else and does not succeed. When does intent kick in?

Can 38790 be reported multiple times for multiple lymph node injections for unilateral lymphangiography? Or can it only be reported once per side (38790 x 2 for 75807)?

"HeRO graft placed two weeks prior. Patient developed steal syndrome. The radial artery was occluded. The graft was doubly ligated with silk sutures and left in place. This wound closed. He re-opened outflow catheter and harvested it. He then tunneled a new 23 cm catheter through the counter incision, placed peel away sheath over the wire, removed the wire and inner dilator, and placed the catheter through the sheath." How would I code this?

If an IR provider provides fluoroscopic guidance ONLY for procedures (e.g. central line placement), can the IR provider bill for that? I know most codes require the primary procedure be billed as well, so we were thinking perhaps 76000 could be a possibility. Example: "CLINICAL: Hickman placement. TECHNIQUE: Multiple intraoperative fluoroscopic radiographs are provided for interpretation. COMPARISON: None available. FINDINGS/ IMPRESSION: Fluoroscopic guidance was provided for Dr. R with a single digital spot films obtained intraoperatively. This shows a right central venous catheter, which appears to been placed from a jugular access with the tip in the superior vena cava approximately 2 cm above the expected level of the cavoatrial junction."