Ask Dr. Z

"A 4 French pigtail catheter was placed in the main pulmonary artery, and hemodynamics were recorded. The catheter was secured in place, and thrombolysis was initiated." Would it be correct to report codes 36013 and 37211, or should it be 37211 and 93451?

"Following sterile preparation of the left lower neck, ultrasound imaging was performed to identify the left common carotid and left thyroid lobe. The pre-existing nasogastric tube was removed over a wire, and a 14 mm x 4 cm balloon was positioned in the low cervical esophagus. The balloon was inflated to nominal diameter and ultrasound utilized to direct a 21 gauge needle between the left common carotid and the left thyroid lobe into the balloon in the esophagus. The wire was coiled within the balloon lumen and advanced down the esophagus into the stomach. Over an Amplatz superstiff wire a 10.2 French 60 cm multipurpose drain was placed from the left cervical transesophageal approach into the gastric lumen. The catheter was sutured in place and attached to an external bag. No immediate procedural complications." Would I code this unlisted with 43999 and add 76000 for the fluoro and 76536 for the ultrasound?

Patient has left thigh pain with fatty infiltrate of vastus lateralis muscle, here for direct puncture sclerosis, treating like a vascular malformation. "Sequentially accessed different points w/in malformation w/21 gauge needle injecting contrast to determine anatomy of lesion. Sotradecol foam injected to spread w/in lesion. Skin cleaned & dressed. Then RT CFA accessed, wire passed centrally, 5 F4 C2 cath passed over wire to select LT ICA anterior division (36247) w/imaging (75736-LT), Cath then pulled back &selected LT CFA (36248) w/ imaging (75710-LT) which showed no abnormal vascularity. Final was LT vastus lateralis focal fatty infiltration being treated as a vascular malforamtion. No evidence of AV malformation." This sounds like a direct puncture varicose vein sclerosis, but there was no vascular findings or location treated. How will this procedure be coded?

Right buccal/alveolar ridge mass concerning for malignancy. After verbal consent, a 3 mm punch was used for biopsy of the right oral mass and sent in formalin to pathology. CPT 41899, 40808 or 11104 ? Thank you!

Is it appropriate to bill G2017 for the Ellipsys procedure for physician billing? I see it is a status C indicator, inpatient only. Are there any other restrictions to billing this CPT we should know about? Should we expect that the HCPCS will be reimbursed?

What documentation do you need to support 93463?

Intracerebral vasospasm infusion codes 61650 and 61651 have minimal infusion time duration 10 minutes. Should it be total time, or time in each vascular territory when we have more than one territory treated?

Utilizing standard sterile technique and real-time sonographic guidance, approximately 1 cc of serosanguineous nonpurulent fluid was aspirated from the medial collection in the olecranon bursa followed by 1.5 cm from the lateral collection utilizing to difference syringes. Two separate laboratory specimens were sent, one labeled medial and the other lateral. Can we code this with 20605 and 10160?

Thank you for your newsletter for July 1, 2020 HCPCS code updates. Does the "shockwave" balloon qualify as the new C976(4) lithotripsy PTA endovascular procedure code? I have been coding the 3xxx revascularization procedure codes as appropriate prior to this release. Would you recommend utilizing the new C976X codes instead? 

What is the CPT code for retrograde access of the right radial artery with selective catheterization of the infrarenal abdominal aorta?

Please suggest CPT code for non-tunneled centrally inserted venous catheter performed three times per day. Can we code 36555, 36555-59, 36555-59?

Can you tell me if we can code anything for the pacing and/or mapping done to place a His bundle lead at time of new dual pacemaker implant? "The guide wire was advanced in the RVOT, and the sheath was positioned to stay just behind the tricuspid valve in RAO position. Then a Medtronic 3830-69 cm lead was advanced into the sheath. The lead was connected to the PSA cable/mapping system in a unipolar fashion. Unipolar mapping of His bundle signals was then performed, and a location was found where excellent His signal was noted with HV of around 48 ms. The lead was tested both in unipolar and bipolar fashion. Then the sheath was removed by splitting. The lead was secured to the pectoral muscle using two 0-Ethibond sutures. Non-selective pacing was achieved, but pacing threshold was 1.25 V @ 1ms. As such, non-selective pacing site was finally chosen for pacing site was finally chosen for pacing. Ventricular threshold of < 1 V @ 0.4 ms was achieved." My understanding is the His pacing lead is including in the dual pacemaker implant 33208. Can you advise?

Can both drug-eluting and bare metal stents placed in the same artery at the same session be coded together?

Four years ago you were asked this question: If we are doing a procedure and cause a dissection that needs to be treated with a stent, can stent device and/or pro fee for placement be charged? Is there a CMS or ACR directive on billing an iatrogenic procedure caused during a procedure? Answer: Currently we would code for the dissection treatment. If you don’t fix it, you may need to send to surgery to fix. This type of iatrogenic injury is uncommon but does occur. The first time we have seen guidance to not charge for this type of issue is with code 61650 (for intracranial vasospasm infusion) where, in the code description, it states NOT to use for iatrogenically-induced vasospasm treatment. I have not seen any further guidance on other procedures like the one you mention here being limited….yet. -Dr. Z

Asking the question again in 2020, has your opinion changed or stayed the same? Has there been any CMS or other guidance on this since 2016?

Our surgeon was called in to OR for patient undergoing spinal fusion of L2-3 when significant venous bleeding was noted. He extended the incision medially and laterally, and irrigated and identified a lumbar branch coming off the IVC that had been partially transected and was bleeding. He oversewed with 4-0 Prolene on either side of the tear and placed a medium clip on either side as well. Would this be coded as 37799? Do you have a suggestion for comparison code? Maybe 37619, although the work seems more extensive for this code.

Is it okay for facility to code a low level E&M for drain removal or Schon/Quinton cath removal when done by an RN if cosigned by the radiologist? Also, our facility is wondering if we can code the post-op thoracentesis x-ray done. I am aware the professional billing cannot code the post-op x-ray, but what about FACILITY?

I have a case that had an Impella removal and hemostasis was not achievable, so he performed balloon tamponade with stent placement. I know the balloon tamponade is typically included with closure. However, I am not certain with the stent.

For the following should we report 35876 alone or with 35883? "I passed a 4 Fogarty catheter distally through the graft to thrombectomize the graft. I also was able to pass a 3 Fogarty catheter distally in its entirety into the tibial level vessels. Thrombectomy was performed until there was no residual thrombus removed. I did extend out onto the graft, and in this area, there was what appeared to be extensive intimal hyperplasia, which was all resected sharply. A Freer elevator was used to perform a thromboendarterectomy of the laminated thrombus and some pseudo-intima. A 3 Fogarty catheter was passed into the profunda femoral artery to thrombectomize this vessel. There was some moderate stenosis of the region of the distal anastomosis, therefore a Glidewire was placed, and then a 4 mm balloon was then utilized to perform angioplasty in this region with a satisfactory result. A bovine pericardial patch that had been brought out onto the field and prepared was then used for patch closure from the proximal portion of the graft and onto the common femoral artery with a 5-0 Prolene suture in a running continuous fashion."

Is this reportable as AVF ligation or revision? "Post-op complication of AVF revision (aneurysm resection and angioplasty). Post-op diagnosis: Wound hematoma, ANASTOMOTIC BREAKDOWN. Clinical Indications: Bleeding fistula wound. Description of procedure: Prevail prep was used, and the right arm was isolated as a sterile field. The previous incision was opened by removing the staples and cutting the vicryl sutures. Blood immediately exploded out of the incision, and clot and blood were evacuated from the wound and control was obtained first by arterial pressure and then rapidly both the venous and arterial sides were controlled with vascular clamps. The arterial side was doubly ligated with silk and over sewn with a 4-0 prolene. The venous side was doubly ligated with silk. The wound was irrigated with the pulse irrigator and closed with nylon and staples. Findings: Completely disrupted anastomosis."

If angioplasty is performed the venous anastomosis, would this be considered the central dialysis segment? Or peripheral?

Would we charge 36215 and 75710 or just 75710 for a left subclavian artery angiogram when the access is the left radial artery to abdominal aorta for iliac artery angiogram then to left subclavian for angiogram?

Can you tell me what the code is for injection of anesthetic/steroid into pseudoarticulation of L5 transverse process and sacrum? "OP: Next the articulation between right L5 transverse process and the sacrum/ilium was identified using fluoroscopy. After administering local anesthetic lidocaine 1% 2 ml, a 22 gauge spinal needle was inserted into the region of the presumed articulation using oblique and lateral imaging. 1 ml of contrast confirmed location and desired spread. A combination of 3.0 ml of Bupivicaine 0.50% and 40 mg of Kenalog was injected in this region."

Patient has fem to fem bypass with graft and atherectomy of popliteal artery and SFA. Is the atherectomy coded separately?

Fluoro-guided left hip steroid injection along with left greater trochanteric bursa injection at same encounter. The greater trochanter is part of the femur, but not considered part of the hip joint. But I am uneasy. I notice in your book you state that 20610 includes trochanteric bursa. I guess my question is, since there are two injections, can we charge 20610 twice in this instance? Or do you mean that the trochanteric bursa is included in the original hip injection charge?

"Patient has a brachiobasilic AVF iatrogenic injury with pseudoaneurysm. A skin incision was created in mid arm. The pseudoaneurysm cavity was entered, and hematoma was evacuated. AVF is not repairable at original site of anastomosis and taken down completely. Minor side branches were suture ligated. The disrupted segment of the brachial artery was resected. Brachial was repaired by end-to-end anastomosis. The aneurysm cavity was thoroughly irrigated, and hematoma was evacuated. It was deemed that a new brachiobasilic anastomosis can be created proximal to the brachial artery primary repair site. A new brachiobasilic anastomosis was created." Do you agree with reporting code 36832?

Patient had an old ILR removed and a new ILR implanted in the same pocket. Do I charge for a new insertion (33285) and removal (33286)?

Is it okay to use 33999 for a TVR, or is 0545T more appropriate? I was recently told 0545T should be used more for a repair (e.g., tricuspid clip).

When coding an EKG, and the signed interpretation is: "Abnormal EKG - Sinus bradycardia, Inferior infarct, age indeterminate". Lateral leads are also involved. The signed order is for chest pain. What would be the appropriate dx code(s)?

Per CPT definition, code 64493 is for injection of facet joint or nerves innervating that joint. We performed this procedure for: "Lumbar pain post spinal fusion. Request for a therapeutic CT-guided facet (peri-instrument) injection around the fusion hardware at the right L5-S1 level". Our physician's technique is stated as: "Under intermittent imaging guidance, the needle was inserted into the peri-instrument soft tissues. Needle tip location was then confirmed by visualization of the needle tip around the fusion hardware. Steroid and anesthetic medications were then injected. Impression: CT-guided right L5-S1 facet (peri-instrument) steroid injection was performed." Because the report states the needle is inserted into the soft tissue and not the joint, how would this be coded? Some are coding this 64493, others are coding unlisted 64999.

In order to code for 36556, 36558, 36561, all exchanges, and replacement CVC lines... question- if guidance is not utilized for placement, and the doctor is unsure of the location of the catheter tip at the time of placement, would we still code the CVC codes listed above, or is there another code that would be better used for this type of procedure? You have stated that tip location is required; however, you've been vague on your responses on the appropriate use of CVC without definitive documentation to support this.

I have a case where patient already had the pacemaker inserted previously and was coming back for an AV node ablation. They performed pre-op and post-op reprogramming of the pacemaker during the same session as the AV node ablation. Can I report the perioperative device programming, and, if so what would my codes be?

Does repositioning of a CVC require suture removal, etc.? We have a report where there was only a pressure injection done and that moved the catheter into position. Is this reported with 36597 alone, or should a -52 modifier be appended? "Patient was brought to the interventional suite and placed on the table in the supine position. Pre-procedure fluoroscopy demonstrated the tip of the catheter to be curled in the azygos vein. Pressure injection of saline was made, which repositioned the catheter in the superior vena cava."

The CV surgeon makes an incision over the xiphoid process and down through the pericardium. The patient has chronic atrial fibrillation, and he created a standard box lesion set using a total of 50 radiofrequency burns in two overlapping rows. This is not a percutaneous intervention. Can you please recommend how we should code this?

Left heart catherization done for further evaluation of coronary anatomy and possible intervention. Catheter engaged in left and right coronary system, crossed aortic valve, left ventricular pressures obtained, left ventriculogram, and attempt to engage left internal mammary artery but unable. Would this be coded with 93459 even though unable to engage the mammary artery but that was the intention or would it be coded with 93458?

Would this be coded with an unlisted code, 32999? "Initial chest radiograph demonstrated a large right-sided pneumothorax. Evaluation of the surgically placed tube demonstrated a large fibrous clot along the exit of the tube into a Heimlich valve. It appears that the Heimlich valve function was compromised due to the clot, and this may have led to the large pneumothorax. Utilizing forceps the thrombus was removed. Initially after access of the most distal aspect of the chest tube with a 16-gauge Angiocath system, the pneumothorax was evacuated by hand with 50 mL syringes followed by placement of a new Heimlich valve. This was connected to Pleur-evac suction, and CT imaging demonstrated complete evacuation of the previously seen pneumothorax. A second 0-0 silk suture was used as pursestring fashion for the exit of the chest tube in order to minimize any continued subcutaneous emphysematous change extending inward with inspiration."

Can you help me code this procedure? Is 35661, 33990-XU correct? "Using modified Seldinger technique, a 6 French sheath was advanced into the right femoral artery, and an 8 French sheath was advanced in the left femoral artery. Two Perclose sutures were deployed. We then advanced a 14 French sheath into the left femoral artery. We crossed the aortic valve using a pigtail catheter and exchanged this out over a 0.018 wire. We advanced an Impella CP and turned the pump on. We then placed the reposition sheath and then took out the tear away 14 French sheath. We then took another abdominal aortogram. We then performed an abdominal aortogram from the right femoral artery using a pigtail catheter, which demonstrated very sluggish flow in the SFA, which would likely recommend that this SFA would be occluded soon. For this reason, we again did antegrade access with a 6 French sheath in the left superficial femoral artery. We then connected the right femoral artery sheath via male to male connector to the left femoral artery antegrade sheath and turned the circuit on."

Biventricular ICD implanted but they couldn't get the LV lead in. They finally gave up and the patient had an ICD with an RA and RV lead implanted. They attempted the LV, but "All branches of the CS were attempted but TH below 5 were not attainable." So they gave up on the lead. Later they decided to go back in and implant a His lead in the RV. So this is a return to the OR to put this lead in. My understanding is we can't bill the LV codes for it because it is a His lead, but what can we bill? Can we use 33216 if there is already an RA and RV? Is it an unlisted procedure?

If during a TAVR procedure, a balloon valvuloplasty is done and shock wave lithotripsy is performed prior to valvuloplasty, would you consider this as being inclusive and not separately billable?

Dynamic fluoro. Should this be billed as 76000 or x-ray? This is global. "TECHNIQUE: Dynamic fluoroscopy of the left thumb/wrist was performed with flexion and extension of the thumb and abduction and abduction. COMPARISON: None. FINDINGS: There is widening of the interspace between the first metacarpal base and second metacarpal base as well as widening of the first metacarpal base interspace relative to the trapezoid with abduction of the thumb. The interspace changes from approximately 3 mm in adduction to 5 mm in abduction. Mild DRUJ and radiolunate osteoarthritis. No significant instability in flexion or extension of the thumb. IMPRESSION: Widening of the first/second metacarpal base interspace with abduction of the thumb in the setting of prior first CMC arthroplasty."

I know that Z01.818 is sometimes used for mapping encounters, like mapping prior to creation of a dialysis fistula. I code for a hospital cath lab where the IVR doctors perform cath placements into the liver and inject MAA radioactive albumin into a hepatic artery. After patient leaves the cath lab a Y-90 simulation study is performed (77290). Then sometime later the actual Y-90 treatment is performed. Should I be using Z01.818 as the primary DX code for these MAA injection encounters, with the HCC code C22.0 as secondary?

Are there any updates to coding for Accucinch and Cerclage? Is it appropriate to report Accucinch with 0544T? Cerclage with 0345T? Any guidance is appreciated.

What code would you recommend for a transcaval Impella placement? Is this an unlisted code, or could we report code 33991 with a reduced services modifier?

What conditions constitute urinary pathology to qualify billing a complete ultrasound? Are kidney conditions part of the urinary tract pathology (e.g., AKI , renal failure)? Both kidneys and bladder are mentioned in the exam.

The doctor accessed patient's RCFA. Catheter selects right L1 lumbar arteriogram followed by embo with micro coils. Right renal, then right adrenal selected, arteriogram followed by embo with micro coils. Right hepatic selected, microcatheter redirected into posterior division branch of the anterior segment, arteriogram followed by embo with micro coils. How many embolizations are billable? Are these three separate surgical fields?

Would we use code 35646 with -22 modifier or code 35654? Procedure will be thoracotomy and sew the proximal 8 mm graft onto aorta with a side biter. It is a bifrucated graft. It is then tunneled out of chest wall and vascular surgeon does the fem-fem distal anastomoses.

For the following would code 60600, 38720, or 38500 be appropriate? "Next, the jugular vein was dissected out. We then dissected out the common carotid artery, and a vessel loop was placed around it. A couple of lymph nodes were removed in the area and sent for pathology. Next, we dissected along the lateral margin of the external and internal carotid, and vessel loops were placed around both. The carotid body tumor was primarily posteriorly, very vascular, and densely adherent to the carotid. A very tedious dissection was performed, resecting the mass in its entirety and using small clips on all the feeder vessels. The mass was then sent for pathology."

What code would you use for a diagnostic internal jugular vein ultrasound?

Does the 2020 code 64451 (nerves innervating the sacroiliac joint) replace 27096 when the injection states "into the SI joint", or is the code used in place of billing the S1,S2,S3 as peripheral (64450)?

"Patient is status post stage II Glenn shunt and closure of the Sano conduit. There was anastomotic obstruction at the Glenn anastomosis. 018 guidewire was positioned in the RPA and balloon angioplasty of the SVC/Glenn anastomosis was done using 10-2 Tyshak 2 balloon." Would this angioplasty be captured with 92997 (pulmonary artery angioplasty)?

The patient presents with persistent atrial fib. After pulmonary vein isolation and ablation in the RSPV, LSPV, and LIPV (93656), the documentation then reports spatiotemporal dispersion and ablation. Would this ST dispersion be reported with 93657? "SPATIOTEMPORAL (ST) DISPERSION. SP dispersion was defined as areas where 3 or more pentaray bipoles had signals that spanned most of the Afib cycle length. 2 areas of ST dispersion were identified. 1- Along the posterior wall floor below the RIPV 2- Anterior to the RIPV. ABLATION: Areas with ST dispersion: 40W power was used to ablate in the two areas but no change in AFib cycle length was noted."