Ask Dr. Z

Should a biopsy with a Rotex needle be billed with the biopsy code and 76942 (e.g., thyroid biopsy 60100 and 76942) or 10005 (fine needle aspiration)? The literature that we have found on the Rotex says that material is excised instead of aspirated, so it gets complete cell clusters instead of single cells. Please advise.

Question 11045 was answered in 2018, and I'm wondering if the direction is still the same. We found code S2205 but previously you've recommended using the "normal" CABG codes if done minimally invasive or with robotics. S2205 is not accepted by Medicare, but would commercial payers accept it? We would need to price the code. Would we compare it to the normal CABG codes for pricing purposes?

PROCEDURE:

1. Minimally invasive MICS CABG (minimally invasive off pump coronary artery bypass grafting).

2. Left internal mammary artery to left anterior descending artery with vein interposition.

3. Left greater saphenous vein harvest via open incision.

CPT codes 76376 and 76377 require concurrent physician supervision. I haven’t seen anything clearly defining the term beyond American College of Radiology 2012 FAQs which note that “concurrent means active participation in and monitoring of the reconstruction process that includes: design of the anatomic region that is to be reconstructed; determination of the tissue types and actual structures to be displayed (eg, bone, organs, and vessels); determination of the images or cine loops that are to be archived; and monitoring and adjustment of the 3D work product.” Moreover, the ACR’s Q&A notes that concurrent physician supervision “defines a temporal relationship to creating the 3D image”.

Are you aware of any more recent guidance or clarification of the necessary level of supervision required by these CPT codes given advances in technology that make 3D reconstruction mainly a computer-driven process?

The patient was brought in for a scheduled PCI of the RCA after a recent a diagnostic angiogram showed a 90% stenosis. However, the provider documented they were only able to probe the lesion a couple times with a guidewire and did not have adequate resources to continue. The end result is an unsuccessful crossing of the RCA lesion with plans for another PCI attempt in the future at a different facility. The patient had a coronary angiogram done during this procedure, so the question is: do we code for the coronary angiogram only even though the patient had a prior catheterization? Or do we code for an attempted intervention with a -74 modifier? I was thinking if we can't bill for this second coronary angiogram, we would only code a catheter placement into the aorta.

This is a hypothetical situation with the hope to better understand when an attempt could be coded for scheduled PCIs. There is, of course, grey area when it comes to what the provider might document for such a scenario.

I know your newsletter in August talked about this, but it is being interpreted in different ways by various staff so I'm hoping you can give us an answer that can clarify. Patient has a CTA that shows an aneurysm in the right anterior communicating artery. Patient is brought to the cath lab where bilateral intracranial arteries and bilateral vertebral arteries are selected and imaged. Coils are placed into the right ACA, and follow-up imaging is performed. Dictation states, "A full four-vessel diagnostic angiogram is performed due to inadequate visualization of the anatomy and pathology on prior CTA." Findings are presented. This is the physician's standard workflow for all embolization cases. I would code 36224-50, 36226-50, 61624, 75894, 75774. My colleague disagrees with the diagnostic imaging because the CTA diagnosed the aneurysm and the physician has no grounds for repeat diagnostics: no change in status, no surprise findings. How would you code it?

I have a doctor who feels that he does not need to use the word emergent for when he performs a PCI during an acute MI (92941). Do you know of any documentation per CMS that provides that clarification that I can reference for him to see that understanding? Any references would be greatly appreciated or documentation or articles that I can use to help him understand this reference.

Had a patient for a cath with grafts and was going to discuss the case with other cardiologist and cardiothoracic surgeons to determine re-do CABG or do multi-vessel PCI. The patient was brought back the next day and all wanted a better image of the LIMA graft. What do you suggest I charge for this? I know there is a LIMA charge in interventional radiology, but I believe it's not to a graft. I didn't know if there was anything I could charge for this. 

During an EVAR procedure an open femoral cutdown was done and then an 18 French sheath was placed. Can add-on code 34812 for the femoral cutdown and add-on code 34713 for the closure of the femoral artery both be reported? Code 34713 states "percutaneous access and closure of femoral artery for delivery of endograft through a large sheath..." I am unsure if this would still be considered a percutaneous access when a cutdown was performed.

Would the following procedure note be enough to report code 25065 for this forearm biopsy, or would it still be 20206 since the biopsies were done via needle?

"The skin was marked at the point of needle entry site. 1% xylocaine solution was used as local anesthesia. The skin was incised, and through it a 14 gauge biopsy needle was placed under US guidance. Adequate core tissue samples were obtained."

I'm not sure because of the incision, or is that even relevant since the biopsy was through the 14 gauge biopsy needle? I also do not see closure.

If 3D imaging is obtained but post-processing was not performed, neither 76376 nor 76377 would be billable, correct?

After internal/external biliary drain exchange (47536), below was done. Would this be 47370/76940 or unlisted?

Additional biliary intervention.

Biliary intervention: Biliary endoscopy and ablation.

Location of intervention: Intrahepatic and extrahepatic bile duct.

Device used: Habib catheter and Spyglass discover.

Description of intervention: Using Spyglass discover, endoscopy was performed throughout the biliary tree identifying multiple sites of intrinsic compression from from the like extensions of tumor.  These areas were ablated, and then follow-up endoscopy was performed identifying or patency within the biliary tree.

Which code should we use when CT cystogram of pelvis and CT abdomen and pelvis were done? Is it 51600 and 74176?

"CT imaging of the abdomen and pelvis was performed without intravenous contrast. Coronal and sagittal reformatted images were generated and reviewed. CT imaging of the pelvis was performed after the administration of contrast into the bladder via a Foley catheter using gravity. A total of 275 mL of Cystografin was used. Coronal and sagittal reformatted images were provided in addition to the standard axial images."

For CPT code 64615, Chemodenervation of muscle(s); muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral, is it necessary for ALL those nerve groups to be injected bilaterally in order to use this code? Or would it be appropriate to use code 64615 if only the trigeminal nerve, or ANY of the noted nerves groups, is injected bilaterally?

Can I report code 64640 for posterior nasal nerve cryoablation? Diagnostic nasal endoscopy was done prior to cryoablation, but endoscopy was not used for cryoablation.

How would you suggest coding facet joint aspirations? We have been seeing these more frequently and would like to know your input. Example: "With CT guidance and local anesthesia applied using 1% of subcutaneous lidocaine, the left and right L4-L5 facet joints were entered with 20 gauge spinal needles. Serosanguinous fluid was aspirated." According to question 5136 submitted in October 2013, it was suggested to use 20600 with the guidance code. Is this still your recommendation? Or should this be coded as an unlisted code of 64999?

We are getting conflicting information on CPT code 99221 (initial hospital care). Per CPT instruction it states 99221-99223 are to be used by the admitting physician while initial care by physicians other than the admitting physician should be reported by 99251-99255 or 99231-99233 as appropriate. Some coders say you can use 99221 multiple times by any physician that evaluates the patient the first time. Others say you can only report 99221 multiple times if it is on the date of admission. Yet others say follow the CPT instruction and report 99251-99255 or 99231-99233. Which of these is correct?

When RF ablation (64635 and 64636) and medial branch nerve blocks (64493 to 64495) are done, what is the best documentation to determine the number of levels dealt with? We have a new provider, and I am confused on if there are two or three levels in this documentation. "Needle placed at L2 medial branch nerve location at the junction of the right L3 transverse and superior articulating processes. Bupivacain was injected. Same procedure then repeated for right L3 medial branch at the junction of right L4 transverse and superior articular process and for the right L4 medial nerve at the right L5 transverse and superior articular processes. This was then repeated for left L2, L3, and L4 medial branch nerves." Would this be two or three BILATERAL levels for nerve block? What if for radiofreqency procedure?

I am used to documentation stating L2-3, L3-4, L4-5,  and this documentation is confusing me.

CT-guided biopsy of the right costophrenic angle soft tissue mass. Would the appropriate CPT codes be 20206 (with 77012), or 32408, or 49480 (with 77012)? Or another code altogether?

Would the following documentation be enough to charge conventional shoulder arthrogram and CT arthrogram separately? (Patient had CT shoulder arthrogram right after this contrast injection.)

"The patient was placed on fluoro table. The right shoulder was placed in external rotated position. Fluoro was utilized to select an approach to the medial margin of humeral head. A 22 gauge lumbar puncture needle was then advanced into joint space under fluoro guidance. Approximately 15 cc of omnipaque 300 was injected under fluoro, and needle was removed. Manipulation of the joint demonstrates contrast flowing into the superior subscapularis recess, indicating a full-thickness rotator cuff tear. IMPRESSION: Successful fluoroscopically-guided shoulder arthrogram."

EXAMINATION: CT CARDIAC ANGIOGRAM WITH IV CONTRAST, CT CHEST ABDOMEN PELVIS.

ANGIOGRAM WITH IV CONTRAST (75574, 71275, 74174) for TAVR planning.

Is it appropriate to bill all three codes when all three studies are ordered, images acquired, and findings are dictated for each study?

If a VATS wedge resection is done for known cancer, and we do three wedge resections until we have clear margins, would that be reported with codes 32666 and 32667 x 2? I wasn't sure if 32667 was for all additional resections or for additional resections in a different location of the same lung.

"Under fluoroscopic guidance the pericardial spaces was accessed using a Tuohy needle and contrast guidance. A 035 J wire was placed. 660 cc of bloody fluid was removed using a Boston Scientific pericardial drain. The pericardium was then dilated with a 40 x 10 Powerflex balloon creating a window. Echocardiography documented no residual fluid. Fluoroscopically the left heart border moved well. No more fluid could be aspirated. The drain was then removed and an occlusive dressing was applied."

Provider wants to bill code 33025. I disagree and am leaning toward 33016 since the drain was removed. Thoughts?

Patient with complete occlusion of her SMA with very heavy calcific plaque and pseudoaneurysm with the celiac artery.

"...Supraceliac aorta clamped. Aortotomy completed and minimal thrombus present, removed. End to side proximal anastomosis of cryo preserved SFA graft completed. Aortic clamps removed. Graft was distended and passed into tunnel with aortic clamp and retrieved at the base of the transverse mesocolon. Ends were spatulated and end to side anastomosis completed to the SMA. The proximal segment of the graft was then controlled and one additional segment of cryo preserved femoral artery was sutured end to side and was then distended and anastomosed end to end to the common hepatic artery. An additional segment was sutured to this jump graft. End to end anastomosis between the cryo preserved femoral artery and the splenic artery was created."

Are these considered three separate bypass grafts as the provider listed and if so are we looking to 35631 (aorto-SMA) and then unlisted x 2 for the other two? Your thoughts are appreciated.

History: S/P device occlusion of PDA 3weeks ago (4/2 Abbott/Amplatzer Piccolo occluder delivered prograde)Progressive DAO obstruction with upper extremity HTN and increasing gradient both by BP cuff and by

TTE (gradient 25-35mmHg), diminished femoral artery pulses, Ongoing severe RDS and intolerance of steroid treatment due to aortic arch obstruction.

Procedure: Surgeon performed RCCA cutdown.4 Fr Terumo Slendersheath advanced to aortic arch, angio done by congential cardiologist. Findings: Angiographically patient found to have severe coarctation of the aorta unmasked by Piccolo device closure of PDA. transverse arch is good sized and there is severe discrete isthmic coarctation of the aorta in addition to the aortic retention skirt of the Piccolo device at the coarctation. Decision to stent-36200, 37236. The RCCA sheath was removed, the carotid ateriotomy was repaired, and the cutdown incision was closed by the CV surgical team.

L3-L4 and L4-L5 facet joint injections. Is that coded with 64493 and 64494 or with 64493, 64494, and 64495?

L4-L5 and L5-S1 rhizotomy/radiofrequency. Is that coded with 64635 and 64636 or with 64635 and 64636 x 2?

L3-L4 and L4-L5 transforaminal epidural steroid injection. Is that coded with 64483 and 64484 or with 64483 and 64484 x 2?

Lot of confusion between levels, segments, and joints. I'm tTrying to make this is as straightforward as possible.

Under what circumstances can a radiologist bill for a procedure consult? We have a fair number of biopsy consults that are used to communicate with the referring physician and also with the nurses for scheduling. Are these reimbursable?

Patient is on hemodialysis via a tunneled dialysis catheter. They come in for mapping for future fistula creation. Would you code Z49.01 or Z99.2 to capture that the patient is on dialysis?

Question #7826 was answered in April of 2016. Do you have any update to your answer? We are coding with modifiers and appealing but not having success. According to all the codes and EncoderPro, we can use a modifier and override the NCCI edit. Our physicians document very clearly that they perform the radioactive tracer injection in the Pre-Op area and then when in the OR they perform the Isosulfan dye injection.

If the following is documented with a standard ultrasound, is it appropriate to add a duplex US? Does the information need to be stated in specific areas of the report? If only arterial inflow or venous outflow is documented, may a limited duplex be coded? 

Separate order/accession or comment to explain why duplex is being added.

Gray Scale (B-mode)

Color flow

Spectral Analysis (Acceleration rate, monophasic, biphasic waveforms, triphasic waveforms, peak systolic velocity (w/ measurements), resistive index (RI) (w/measurements), velocity (w/measurements), waveform analysis, pulsed doppler, spectral doppler)

Arterial inflow and/or venous outflow examination with findings

For a case where a cardiac CTA finds an RCA lesion, then, on another day, they place a drug-eluting stent in the RCA (C9600-RC) and do a left heart cath with coronary angio, I know I would drop the 93458, as it's bundled. What I am wondering is would it be appropriate to only code the LHC (93452) with C9600, since that code is not bundled, or is that inappropriate and why? Why did NCCI bundle the angios but not bundle the LHC, RHC, and R&LHC codes into the PCI codes? Should I be adding 93452 when a prior LHC wasn't done, only a CTA?

Provider performs an above-the-knee to below-the-knee bypass with reverse saphenous vein graft. Would it be appropriate to report code 35571 since this bypass graft is from the popliteal artery, above the knee, to just above the AT artery takeoff?

"An arteriotomy was made in the distal popliteal artery just above the anterior tibial artery takeoff. The vein graft was then spatulated, and the distal anastomosis was created with a 6-0 Prolene suture, end-to-side. Prior to completion, all arteries were allowed to backbleed. The lumen was flushed with heparinized saline. The vein graft was flushed, and the anastomosis was hemostatic. The popliteal artery above the knee was then clamped. An arteriotomy was made and extended with Potts scissors. The vein graft was cut to appropriate size and spatulated. An end-to-side anastomosis was created with a 6-0 Prolene suture. Prior to completion, all arteries were allowed to backbleed and flush. The lumen was flushed with heparinized saline solution. I then completed the anastomosis and restored flow to the foot."

Are thrombectomies done in PA now covered by Medicare 37184-37186? I found this on CMS.GOV website.

It is listed as Transvenous (Catheter) Pulmonary Embolectomy

Administrative File: CAG-00457R

I. Decision

The Centers for Medicare & Medicaid Services (CMS) is removing the National Coverage Determination (NCD) for Transvenous (Catheter) Pulmonary Embolectomy (NCD § 240.6), permitting Medicare coverage determinations for Transvenous (Catheter) Pulmonary Embolectomy to be made by Medicare Administrative Contractors (MACs) under § 1862(a)(1)(A) of the Social Security Act (the Act).

See Appendix B for the expected NCD manual language.

Atherectomy with stent was done in the SFA for occlusive disease, and additionally a coil embolization was done for a branch off that SFA. Are we allowed to bill separately for the coil embolization? 37227 and 37242?

Our physician performed a fibulectomy prior to a bypass procedure. I was leaning towards code 27641; however, that code description is for osteomyelitis. The note shows no indication the patient has osteomyelitis. Could I please get your opinion on coding this portion of the procedure? 

"The leg was internally rotated and the knee flexed 60 degrees. A longitudinal incision was made in the distal lower lateral leg centered over the area of intended anastomosis and extending 10 cm. Dissection was extended through the subcutaneous tissues and the crural fascia. All muscular attachments to the fibula were separated bluntly. After an adequate segment of the fibula was cleared of surrounding attachments, the bone was resected proximally and distally with a system 7 power saw. The peroneal vascular bundle was now identified. The peroneal nerve was identified and protected at all times. The artery was freed off its accompanying veins and dissected for a distance of approximately 3 cm."

Our physicians have started documenting FFR in the proximal LV/AO. "FFR was performed in the LV. FFR was normalized in the proximal LV/AO. Pullback across LV/AO was performed." Codes 93571 and 93572 are specific to coronary arteries. Is there a code to capture the FFR for this scenario?

Provider is doing a right robotic-assisted upper lobe wedge biopsy resection with mediastinal lymph node dissection, and very often also has to do extensive lysis of pleural adhesions. He wants to bill the additional 32124, but is not doing a thoracotomy. We are advising that he can't bill the additional 32124, but may in some cases if documented well we may be able to add modifier -22 to the primary wedge resection procedure. Would you agree?

Should this be reported with code 96356 or 93653? "Persistent A fib; A Flutter, Typical; Prior PVI; Here for endocardial portion of convergent. High density mapping catheter advanced into left atrium. 3D mapping to assist with catheter manipulation/construct cardiac geometry. Patient had 4 veins with normal anatomy. Esophagus midline, lesions monitored with esophageal probe directly posterior to ablation catheter. A small reconnection near LSPV toward the roof. Some fractionated signals high and posterior near the roof. For atrial fibrillation and/or substrate modification remaining after PVI, the ablation catheter was used to perform a roof line, achieving complete posterior wall isolation. LSPV was reisolated upon completion of the roof line. No evidence of recurrent atrial fib. Isoproterenol infused up to 6 mcg/min. Short nonsustained bursts of typical CTI dependent flutter. CTI ablation line performed at 40W beginning on ventricular aspect, toward IVC. Bidirectional block achieved/confirmed on differential pacing. Double potentials seen >110ms. Rapid burst pacing failed to induce an arrhythmia."

After right heart catheterization, patient was placed on oxygen mask (15L of oxygen for 10 min) and measurements were repeated. We queried the physician to clarify if any drugs were administered (inhaled or infused) to support 93463. He said they use inhaled NO. Here is his response after we asked him to amend his documentation: “There was no NO in this case; the point I am trying to make is that O2 is inhaled gas that can be used for vasoreactivity testing. I think 100% oxygen should be considered the same as NO.” Can you please advise?

Occasionally one of our physicians will perform an injection of a compounded sclerosant to the distal GSV and do an endovenous laser ablation to the proximal portion of the same GSV on the same encounter. Should we report both codes 36470 and 36478?

Code 32408 includes imaging guidance. Is it appropriate to unbundle 77012 when the fiducial markers (32553) are placed at the same session as the biopsy?

The CPT description of 36252 states selective catheter placement of renal arteries bilateral. The CPT description also states that 36252 includes "permanent recording of images". Does the mean that our doctors are required to take permanent images of the renal angiogram and document this in the patient's record and chart?

What code(s) is/are reported when a patient is having a brand new pacemaker placed, but is only getting an LV lead? So, brand new biventricular can with an LV lead only?The RA lead and RV lead are pin-plugged in the biventricular pacemaker. 

"The patient had loculated pleural effusion. 30cc syringe of 10 mg tPA was instilled via a Pleurx that was already in place. The Pleurx was clamped for 60 minutes, the clamp was removed, and minimal suction was placed on the Pleur-evac." Is it appropriate to assign code 32561, Instillation, via chest tube/catheter, agent for fibrinolysis (eg, fibrinolytic agent for break up of multiloculated effusion; initial day? Or would an unlisted code be more appropriate?

Procedures performed:

Subclavian Angiogram - 36225-50

Right & Left Heart Catheterization w/ bypass grafts - 93461

Coronary Angiography - 93461

Bypass Graft Study - 93461

Peripheral Angiography - 75716

Left Heart Catheterization w/ Bypass Grafts - 93461

Documentation:

· Chronic total occlusion of the mid LAD and mid Circumflex.

· Patent LIMA to LAD and SVG to Diagonal. Occluded SVG to OM2.

· Widely patent stents in the proximal-distal RCA with PDA-Circumflex collateral circulation.

· Severe stenoses of the distal left external iliac artery and distal right common iliac artery by sub-selective injection of the distal abdominal aorta. - 36245-RT and 36245-LT

· Mild stenoses of the bilateral distal subclavian arteries by selective injections of both vessels.

· Normal PA and PCW pressures.

· Left ventriculogram was deferred.

Can you please confirm whether my coding is correct? I am sure about all codes except 36245, 36246, and 75716.

36225-50, 93461-26, 75716, 36245-RT and 36245-LT

I have several cases where our physicians are performing pulmonary embolectomies on the bilateral pulmonary vessels. They are documentation that because of the patient's status (embolism with acute cor pulmonale), the initial aspiration of the right pulmonary vessel is being done based off of the CT angiography. So they do the aspiration on the right side, then bilateral pulmonary angiography, then aspiration on the left side. Would you only bill for the unilateral (left) angiography since the right side isn't being done until after the intervention?

I know a separate CXR cannot be reported for catheter tip location, so my question is can we still report code 36573 without a modifier if catheter placed with ultrasound and all guidance criteria is met but patient does have a CXR (not being coded separately) and the report documents CXR shows catheter tip in the high SVC? We do have all necessary documentation on one report.

Physician catheterized the right subclavian, thyrocervical, costocervical, and verterbral arteries. He also did direct access venogram of neck. He used coils to embolize the vertebral artery feeders. This was a planned procedure. We reported codes 61624, 36217, 36218 x2, 75894, and 75898. Should we code the direct access of neck (36000) and 75774 x2, or would this be included in the 61624?

With the creation of Category III code 0620T, should unlisted code 37799 no longer be used? Can the IVUS codes (37252, 37253) be reported separately with 0620T? 

Is it acceptable to report code 74246 when fluoroscopy isn't used since fluoroscopy is a component of this code? We have a report where double contrast UGI was done, and the technique says: "No fluoroscopy was used. Six spot radiographs of the abdomen were obtained." Should this be reported with a -52 modifier appended?

If an Impella was inserted and removed during a PCI procedure in the cath lab, would you code insertion and removal, or just either insertion or removal? 33990 with 33992, or just one or the other?