Ask Dr. Z

Is there a code for test occlusion, 37246? "A 5 Fr Berman was advanced via the RFV to RA to the RV to the AAO and an angiogram was performed. The Berman was advanced into the right innominate artery and the balloon was inflated at the mouth of the BT shunt. The oxygen levels dropped significantly to the low 60's. An ABG was obtained and the FIO2 was increased to 50%. The balloon was inflated at the mouth of the shunt for a few minutes time and the pulse oximetry numbers dropped from the high 70's to the low 60's. The PA pressure and aortic pressure were measured with temporary occlusion. Given the hypoxia the decision not to occlude the BT shunt.Findings: Widely patent Glenn shunt and pulmonary arteries, acceptable PA presures and SVC pressure, large veno-venous collateral decompressing the Glenn via extensive paravertebral network which eventually reaches the IVC, patent BTS with good flow to both branch pulmonary arteries, mild pulmonary venous desaturation, widely patent Norwood and aortic arch and no AP collaterals."

The ordering physician requested an ultrasound of kidneys and post volume residual of the bladder. Is 51798 allowed to be charged along with 76770? They are both performed on the same encounter and documented accurately in the same report.

We could use your advice on how the following would be coded. We are unsure if the physician is describing an LVAD insertion or an ECMO cannula insertion. "Procedures performed: Placement of transseptal vent placement by right femoral venous approach. The patient is in cardiogenic shock, on ECMO, and brought for placement of transseptal vent to vent to the left ventricle. The right femoral vein was punctured, and a 0.032 inch wire was advanced into the right atrium. An SL 1 sheath was advanced over the wire into the right atrium. A BR K needle was advanced through the SL 1 sheath, and transseptal puncture was performed under transesophageal echocardiographic guidance. Following this, the SL1 sheath was removed over a 0.035 inch Boston stiff 03 5 inch guidewire. The septum was dilated, followed by placement of the transseptal cannula into the left atrium, position confirmed withTEE. Then the Y connector was connected to the ECMO circuit."

My doctors have started performing percutaneous AV fistula creations with the new Ellipsys device. The patient was brought back a month later after this creation, and a percutaneous angioplasty was performed of the fistula for stenosis, but in addition to this they did ligation of the basilica vein to increase the flow. Can I bill 37606, or do you advise revision 36832 with the angioplasty 36902?

If you were to stent the distal LAD with a drug-eluting stent (C9600-LD) and then perforated the proximal LAD while removing the balloon and had to place a stent in the proximal LAD to cover the hemorrhage, would you be able to charge 37244 along with C9600-LD?

If our general cardiologist performs the diagnostic LHC and moderate sedation, and documentation supports, we use 99152 for the moderate sedation portion. Immediately after the diagnostic, the interventionalist does a PCI with moderate sedation. If documentation supports, can we report code 99152 for the interventionalist also? The MUE is two, but I heard the interventionalist's is getting denied. Thoughts?

Would you use 93580 in this case? "Transseptal puncture with left atrial access,elective left atrial and left atrial appendage angiography. the left atrial appendage was taking a 90-degree bend and this segment was not covered by the AtriClip at all.Via TEE measured the residual hole at the mouth of the left atrial appendage and this measured to be 5 mm. The residual lobe of the left atrial appendage measured 13 mm on the inside. We decided to close this hole with a 5 mm Amplatzer septal occluder, which will have a 13 mm disk on one side and a 15 mm disk on the other side. Multiple measurements were taken to ascertain this following which, a 5 mm Amplatzer septal occluder device was advanced through the channel sheath into the left atrial appendage and 1 disk was released. We then pulled the guide catheter out of the left atrial appendage and deployed the second disk successfully sandwiching the hole and completely excluding it." Is there anything to code the transseptal or LA angio since the add-on codes wont work here?

Is there a specific CPT code for a timed esophagram study?

Can you report 93793 when the RN does all of the work and the provider just reviews/ signs?

How would a flipped Gore endograft contralateral limb for iliac aneurysm be coded? It doesn't appear to meet the criteria for 34718 since it isn't a branched endograft; should it be 34707? "Coil embolization of the right internal iliac artery aneurysm with 12 mm Amplatzer plug and RUBI coils (5 mm pod, 4 mm x 20 coil, 3 mm pod) in internal iliac artery branches with interpretations. Common iliac-to-external iliac Gore endograft (16 x 23 x 10-flipped) with interpretations."

Please let me know if I am coding this correctly. Upgrade duel chamber to biventricular pacer/generator with pinned LV port on generator (33229). Cardiologist was unable to advance LV lead so venogram was done and lt. subclavian vein is occluded around leads. So a new access into the rt subclavian vein with new pocket created on the right with attempt of LV(CS) lead but still unsuccessful LV lead placement. The right attempt pocket area is closed and the old left pocket reused. (33225-74). He also attempted to put in a new RV lead but due to Lt. subclavian Vein occlusion and tortuous vessels the RV lead was not exchanged (33215-74-XS). They plan on trying at a later date to place the LV lead.

Just wondering what are your thoughts now on venous manometry done during cerebral angiogram. I checked previous FAQs, but the response was from way back. Case background: "Patient has history of papiledema and vision loss concerning for IIH vs. cerebral venous stenosis. Via right CFA, bilateral ICA catheterized angiogram was done, right CFV was accessed, and cath was advanced to left jugular bulb then to left sigmoid sinus, the torcula, and up the superior sagital sinus at the level of vertex. Venous manometry was then performed." I got the ICA code, for the venous I got 36012. For venous manometry do I use unlisted code or do not code it at all? 

What is the correct coding for the vascular surgeon, vein repair only? "I was called to the OR for intraop. consult by Dr. X. He was performing enblock resection of pancreatic mass of the distal pancreas, mass is too close to the porta vessels and the celiac axis. The Portal v. was controlled; Splenic v. was ligated both proximally and distally and divided. Because of all the desmoplastic reaction, while dividing the Splenic v. off of the Portal v. confluence we noted a defect about 2.5 cm in length, manual compression we had control of the vein; I dissected the proximal and distal ends of the Portal v. and the SMV inflow to the vein. The defect was dissected and isolated, repaired with a 4-0 prolene suture in double layer running fashion with excellent hemostasis and good venous filling post repair. Our dissection was continued laterally to skeletonize the Common Hepatic a. and the LT Gastric a. at the level of the Celiac, extensive lymphadenectomy was completed at this level. The Splenic a. was identified divided and ligated, then mobilized the entire pancreas and spleen dividing all of its attachments and passed off the field."

Are codes 37200 and 75970 appropriate for this case, or should we also add 76937 and 77002? Are there any other codes we are missing? "Utilizing direct ultrasound guidance, access was obtained into the right internal jugular vein. This was confirmed with ultrasound and wire was placed coaxially. The tract was sequentially dilated to ultimately allow placement of a long 12 French sheath system. This was ultimately advanced to the level of the hepatic vein. Selective catheterization of the hepatic vein with small catheter system demonstrated contrast injection confirming location. Via the larger sheath system, coaxially placed was the jugular biopsy kit, which was advanced into the hepatic vein and subsequently into the hepatic parenchyma with multiple passes to obtain small core specimens. Impression: 1) Right internal jugular vein accessed utilizing ultrasound and fluoroscopy and closed with manual compression. 2) Selective catheterization of right hepatic vein confirmed angiographically. 3) Transjugular intrahepatic core biopsies obtained and sent to pathology."

Is it appropriate to separately report the closure of the septal defect created during a MitraClip procedure when done at same session? What about at a later date?

Can you tell me what the documentation requirements are and where I can find them for myocardial strain 93356?

"Patient's clinical history and appropriate imaging was reviewed. Patient is status post lumbosacral fusion. She has responded well to previous left iliac screw injections for her left-sided low back pain and gluteal region pain. Her last injection was completed in June 2019. She presents today with recurrence of her pain for maintenance injection. Using usual sterile technique, fluoroscopic guidance, and local anesthesia, a 3.5 inch, 25 gauge spinal needle was advanced to the posterior aspect of the trigger point. With final needle tip position, a small amount of diluted iodinated contrast confirmed its location. Transient vascular uptake was observed and could be cleared with final needle position. 1 cc of 2:1 mixture of anesthetic: steroid was administered at this location. The needle was withdrawn, restyletted, and removed. The patient experienced no complication." How would I code this? With an unlisted 64999 CPT code or the actual 20552 CPT code with 77002?

I'm aware that FFR (CPT 93571) and IVUS (CPT 92978) are add-on codes and cannot be reported by themselves. I have a situation where a physician is performing the diagnostic left heart cath at one facility, and that same physician a week later is performing a stand-alone FFR or IVUS procedure at another facility. In this scenario, when the FFR or IVUS procedure is performed, it would not be appropriate to bill another diagnostic study, nor would we want to report the specific CPT codes for FFR or IVUS? Would we report the unlisted CPT 93799?

A patient was in IR for the TIPS revision. Splenic vein was catheterized to evaluate for venous obstruction as a cause of liver dysfunction. Findings: There is no webbing, stenosis, or occlusion to suggest venous obstruction as a cause of liver dysfunction. There is a large tortuous splenorenal shunt with drainage of contrast into the IVC. Can 36011 be coded?

A patient was brought in for a diagnostic bilateral heart cath. On the H&P, the physician documents that the patient has been having syncopal episodes with rhythm disturbances and that the patient may need a pacemaker in in the future after the heart cath has been performed. During the heart cath procedure, the patient developed complete heart block, and an emergent temporary pacemaker was inserted. I saw a previous question posted, where you answered that a temporary pacemaker is considered part of any coronary arterial intervention. In this case, only a diagnostic cath was performed. Would it be appropriate to unbundle these procedures by adding a 59/XU modifier to 33210?

My physician is performing endoscopic radial artery harvesting for CABG. Is it still recommended to use CPT code 35600, or should an unlisted code be utilized?

We are starting to get denials from multiple MACs because 36227 has an MUE of 1 and a bilateral indicator of "1". Your book and CPT suggest add-on codes should not be billed with modifier -50. What are your thoughts?

I am hoping you can help with an issue we are having. We are getting conflicting advice as to charging for pre-treatment MRI and CT scans. Patients have an MRI or CT scan prior to SBRT for treatment planning. These exams are ordered by the radiation oncologist. Radiology does 3/4 of the normal sequences, with contrast. They are then read by the radiologist. Should we be charging for these exams according to the body site being imaged with a reduced services modifier, or an unlisted charge?

Is there a recommended CPT code for placement of Shrock shunt? "Median sternotomy was performed to gain access to supradiaphragmatic part of the IVC. Due to the extent of liver injury and likely retrophepatic caval injury, a Shrock shunt was placed."

I had to do a balloon angioplasty but also had to ligate side branches of her saphenous vein bypass graft. How do I bill for the ligation of those side branches (which was the main part of that procedure since it created an AV fistula and was stealing flow from the bypass graft)?

"Status post ICD generator change with partial dehiscence of the ICD wound. Lidocaine was used to achieve anesthesia at the site of the pre-existing incision. An elliptical excision of the scar was then performed and carefully dissected down to the generator. The generator was mobilized and removed from the pocket. 10 cc of 1% lidocaine with epinephrine was used to anesthetize the inferior medial aspect of the pocket, and the pocket was opened and expanded in this direction. The ICD was covered with the Tyrx antibiotic absorbable pouch and placed back into the pocket. The pocket was then copiously irrigated with antibiotic solution. There was no evidence of infection. The pocket was then closed in three layers, a deep 2-0 Polysorb, followed by a 3-0 dermal and 4-0 subcuticular running mattress closure. The wound was then dressed. The patient was transferred to Recovery in good condition. Successful modification of pocket excision and reapposition of ICD wound. This procedure was performed 14 days after the ICD generator change." Would this support CPT code 13160-7?

If the access is right internal jugular, and the catheter is placed in both right and left common femorals and internal iliacs for imaging, is that 36012 x 4?

Patient was planned to get valve replacement and CABG at same time. The note says: "Pre-op TEE showed moderate aortic stenosis with aortic valve area of 1 cm and mean gradient of 36 mmHg. There was moderate-to-severe aortic regurgitation, hence I was planned to do the aortic valve replacement, but after sternotomy when I inspected the aorta, there was significant calcification in the ascending aorta and actual calcification in the aortic root. At this stage, I thought that doing aortic valve replacement has very high risk for stroke, hence I decided to do off-pump coronary artery bypass surgery, and we will plan on doing TAVR in the near future. Since the patient had a moderate-to-severe aortic regurgitation, I was not very comfortable lifting the heart to do the OM anastomosis, hence we ended up doing only two anastomoses LAD and distal right. " I would imagine doing a CABG without bypass makes this more complicated and risky. Should modifier -22 be used? Or, other coding instructions apply here? I'm impressed this can even be done! Wow!

I feel like I'm going to have to use an unlisted code for this, but I'm hoping for a second opinion. "HISTORY: Patient with end-stage renal disease using peritoneal dialysis complaining of a leak around the internal cuff of the catheter. TECHNIQUE: 2.0 mCi of Tc-99m Sulfur colloid was administered into the abdomen with 500 ml saline. Immediate dynamic images of the abdomen were obtained after radiopharmaceutical administration, followed by multiple images of the abdomen and chest at 1 and 4 hours post injection."

Patient is status post CABG. Returned to the OR during same hospitalization for sternal rewiring due to sternal dehiscence (secondary to chronic coughing). Patient also has drainage of posterior pericardial effusion. Is it correct to bill both codes 21750 and 33019 with modifier -78? If so, do either of these codes need modifier -51 or -59?

The P.A. at our cardiology department keeps charging 93294, 93296, and 93297 for pacemaker interrogations and 93295, 93296, and 93297 for ICD interrogations. I have been deleting 93297, as it cannot be billed with those other charges. I know you have addressed this before, but she is insisting there should be another code for 30-day monitoring to go with the other codes seeing 93297 cannot be used. Is there another code that would cover 30 days?

The physician performed a comprehensive intracardiac electrophysiologic. Before the EPS portion, the physician states, “At the beginning of the procedure, pulmonary angiography was performed to identify the left pulmonary veins. Selected cath all segments of the left lung and performed balloon occlusion. They demonstrated normal left-sided pulmonary venous return to the left atrium. There was no evidence of an aberrant left pulmonary vein.” His findings of the pulmonary angiograms were: ”Selective balloon occluded left pulmonary artery angiograms were performed to outline the left-sided pulmonary venous anatomy. From all 3 segments of the left pulmonary artery contrast flowed normally into the left pulmonary veins and entered into the left atrium. There was no evidence of an aberrant left pulmonary vein to the innominate vein.” Despite being treated for supraventricular tachycardia, the doc was unable to identify accessory pathways or inducible arrhythmias. He did not ablate anything. Could you please tell us your code assignments based on this info?

Is Category III code 0569T appropriate for a tricuspid valve clip percutaneous procedure?

We see patients several days prior to a partial mastectomy for placement of SAVI devices. Would the preop placement be appropriate with 19285-RT or 19499? Would the identification at time of partial mastectomy be coded additionally? "The mass with associated clip noted in the right breast at 10:00 was localized with ultrasound. Using sterile technique, under local anesthesia, 5 cc lidocaine 1% was injected in the affected breast. A SAVI needle was placed at the site of abnormality, and the SAVI reflector was deployed. Post procedure mammogram was performed, confirming the SAVI reflector at the level of the clip. Conclusion: Successful deployment of a SAVI reflector at a mass with associated clip at 10:00 in the right breast."

Our cardiologists want to start charging for Definity contrast use with TTE in the office setting. Would codes 93306, Q9957, and A9700 be correct for billing these services?

During a TMVI (0483T) our physician uses a cerebral embolic protection device, and at the end of the procedure the cerebral embolic protection device is removed. He would like to bill for this, but we do not believe he can. Can we bill for the placement and removal of the cerebral embolic protection device?

If whole body planar imaging is performed (78802) with SPECT/CT bilateral feet, do we code the planar whole body, the SPECT/CT, or both? NCCI edit says both cannot be billed, but I am confused planar vs. SPECT. If we bill 78830/78831 does this include the planar whole body? Also, CPT gives example of two-area SPECT/CT as "pelvis and knees". Are bilateral "knees" considered one area or two?

What needs to be documented in the echo report in order to bill 93356?

I understand that 78306 is for a whole body scan and that 78315 is for a three-phase bone scan. However, what code, if any, can be added if the technician performed additional images using SPECT/CT with 78306 or 78315? CPT 78803 or 78830? CPT 78205 was deleted for 2020. CPT recommends using 78803.

If a provider is attempting to perform lower extremity ABI but notates, "Bilateral ABI not obtained due to non-compressible calf arteries. triphasic pedal waveforms observed bilaterally," is this billable with a modifier? I appreciate your assistance!

Is it appropriate to code bilateral fistulogram and angioplasty on both sides for stenosis with 36902-RT and 36902-59LT? I know that this has an MUE of 1. Is there a more appropriate way to code this?

When is it appropriate to use 0570T (additional prosthesis)? My physician states that three Triclip XTRs were used. Is clip the same as prosthesis?

When a supraventricular tachycardia ablation (93653) is performed, and documentation states "left atrial pacing and recording", is that sufficient to report 93621? In your CV book, pg 503, #20, it says, "Report should clearly document that left atrial recording/pacing was performed from the coronary sinus catheter, as it cannot be assumed." Code verbiage states left atrial pacing and recording from coronary sinus OR left atrium.

Can intra-operative carotid duplex (93882-26) performed at time of carotid endarterectomy (35301) be billed together? "Details of procedure: Eversion endarterectomy of external carotid artery performed. Flow restored to external/internal carotid. Intraoperative carotid duplex was then performed, which revealed widely patent right internal carotid artery, proximal common carotid artery, and antegrade flow through the external carotid artery with no evidence of intravascular debris or mobile flap."

CPT Assistant, May 2015, states to use the non-congenital echo codes for "simple" congenital anomalies such as PFO or biscuspid aortic valve. Can you clarify if there are other "simple" anomalies? The article makes mention of complex congenital heart disease... are only those conditions, such as coarctation of the aorta/TOF/etc. supportive of the congenital echo codes?

If a nephrostomy tube is placed using ultrasound guidance, does the report need to document that a permanent record was obtained?

Our physician stated that he performed an AV node ablation recently. I felt his documentation was lacking, so I queried him to ask him to update what he ablated. This is what the ablation portion of the procedure said: “A 4 mm tipped ablating electrode was advanced fluoroscopically to the His bundle electrogram. Catheter ablation at that site produced complete heart block and ventricular demand pacing at 40 beats per minute. She was convalesced for 20 minutes in the EP lab and remained in complete heart block." His response to the query was: “The His bundle electrogram identifies the AV node, which doesn’t produce an electrogram. So that verifies the AVN ablation.” Is this enough to justify 93650?

The physician dictated 100% 26 mm long thrombotic culprit lesion in the mid LC was successfully stented during acute MI. He also states 100% 38 mm long CTO lesion in the second OM was successfully stented. If I bill the STEMI code 92941-LC, what would be the appropriate code for the CTO in the branch?

"Patient comes in with an infected femoral pseudoaneurysm in the left groin. The provider first performs an iliofemoral bypass graft that does not involve the pseudoaneurysm. The physician then makes an incision in the left groin and expresses the clot and old blood. An old femoral/tibial graft is identified, and dissection takes place distally down to the medial thigh. The graft is clamped and transected. The graft is oversewn using prolene." The provider billed 35665 and 35661. Would 35141 not be more appropriate?

Should you apply the -CS modifier to diagnostic radiology CPT codes?