Ask Dr. Z

Ask Dr. Z Knowledge Base houses over 7,000 coding questions and answers dating back to 2010.

Ask Dr. Z Disclaimer

Pericardial Effusion drainage

My physician reopened the chest with a 5 cm incision and gently explored the area around the heart with a "sucker tip" to drain the post op effusion. There is no mention of a pericardial incision that I could use 33025, but there is also no indwelling catheter placed either. Since this is an open procedure, how would you suggest I code this?

Would you report aneurysm repair or bypass?

For the following, would you report aneurysm repair or bypass?

"Indications: Presented with RLE rest pain and heel ulceration. Now for fem-pop bypass. A longitudinal right groin incision was made, the inguinal ligament mobilized, and the distal EIA and distal CFA were then encircled with vessel loops. The patient also had a pseudoaneurysm in the right CFA, which required excision and debridement. Through distal BK medial incision, the BK popliteal artery was exposed. It was obliterated midway down its course without any distinguishable lumen, and I dissected distally and obtained circumferential control of the TPT artery. We could not obtain adequate vein to perform a vein bypass. Right GSV was harvested, reversed, and end-to-end anastomosis was made between the graft and vein for a vein cuff. A subsartorial tunnel was created, proximal distal control of the TPT was achieved, a longitudinal arteriotomy was made. The distal free end of the vein was anastomosed in an end-side fashion to the TPT. In right groin, proximal and distal right CFA longitudinal arteriotomy was made, and the graft was tailored to an appropriate length for spatulated end-to-side anastomosis."

Arch aortogram with left arm angiogram via right common femoral approach

"The patient was placed in the supine position. Both groins were sterilely prepped and draped. Then, 1% lidocaine local anesthesia was infiltrated in the right groin and the common femoral artery. A wire was advanced proximal using fluoroscopic guidance, and the micropuncture dilator and sheath were placed. A Bentson wire was advanced into the ascending aorta and exchanged for a French pigtail catheter. A left anterior oblique arch angiogram was performed. The pigtail catheter was exchanged for a Berenstein catheter, and this was used to advance a Bentson wire. The cath was advanced into the subclavian artery, and a left subclavian angiogram was performed. The cath was advanced into the axillary artery, and an axillary angio was performed. The cath was advanced into brachial artery over a wire, and a brachial angiogram was performed." I want to report codes 36221 and 75710, but I feel I am missing something. What are your thoughts?

75710 with 37221

"Right common femoral artery was punctured. Catheter was placed at the level of the renal arteries and AP and lateral views of the aorta obtained. Catheter was then repositioned at the aortic bifurcation, and bilateral extremity runoff was performed. After review of the images, patient was noted to have 80% stenosis of the left iliac at the bifurcation. Patient has patent left femoral, popliteal, and two vessel tibial runoff. Wire and catheter were placed across bifurcation. Arteriogram was performed, demonstrating previously demonstrated 80% stenosis. A balloon-expandable stent was placed across the stenosis. Repeat arteriogram showed good result with wide patency." There are no other findings documented besides the left leg findings. Would this be 37221-LT, 75710-59-LT?

MRI brain perfusion x 2 for Moya Moya

MRI has seen an increase of orders for MRI perfusion with Diamox for Moya Moya. This is a two-step process that requires two separate orders for the patient. Can I charge for two MRI brain perfusions?

Current process:

1. Order is placed in Epic by ordering provider for MRI brain perfusion with and without IV contrast if ordered correctly.

2. Protocoled as perfusion with Diamox by radiologist

3. Scheduled at 0600 for the first scan – MRI brain perfusion with and without IV contrast (without Diamox)

4. Scheduled at 2 pm for the second scan - MRI brain perfusion with and without IV contrast (with Diamox)

Gastric Band review

I have a question from one of my nurses concerning gastric band review without adjustment. How would you recommend we code for review of gastric band without adjustment under fluoroscopy? They made the decision not to adjust after review. No further details were given. 

Calcific tendinitis lavage and SASD bursa steroid injection?

Hi for the following 2 procedures:

1. US guided Supraspinatus calcific tendinitis lavage/aspiration (Barbotage)

2. US guided subacromial/subdeltoid (SASD) bursa steroid injection

I know to use 20611 for the SASD bursa injection. Which code should be used for the supraspinatus tendon lavage/aspiration (Barbotage)? It was performed using an 18 gauge needle directed into a distal superspinatus tendon calcification.

Should it be considered a percutaneous muscle biopsy (20206), an image guided FNA (10005) or puncture aspiration (10160)?

74455

Do there have to be documented images of the urethra in addition to the voiding images to report code 74455? I have a note where they talk about the voiding images but don't mention the urethra.

Iliac bone lesion biopsy

How do you code Iliac bone lesion biopsy?

The skin and overlying soft tissues at the access site were anesthetized with 1% lidocaine. An 11-gauge Jamshidi bone biopsy device was introduced into the left iliac bone lytic lesion using intermittent CT scanning for guidance. An intact core needle biopsy was obtained and placed in formalin. Aspirate of this lytic lesion was also obtained.

We use 20220- Biopsy, bone, trocar, or needle; superficial (eg, ilium, sternum, spinous process, ribs) and 20225 for deep bone biopsy. Is it superficial or deep? Some radiologist are ordering it as deep bone biopsy. Moderate sedation was also used during the procedure. Would it be considered it as Deep biopsy as sedation was used? Iliac crest is easily accessible, but iliac bone is big pelvic bone and we need your guidance on this. Please advise. Thanks!

Routine exchange of nephrostomy tube

When do we use Z46.6 versus Z43.6? If a routine exchange nothing done to the tract, Z46.6 or Z43.6? Please explain the rationale.

Echo reading

Should the professional portion of an echo be billed the date of service or the date the echo is read?

IVL in the Coronaries

I have seen the codes for the peripherals, but none for the coronaries. What are the rules what this occurred during a stent? the physician placed a stent the IVUS. can you give the basic on this coding? thanks

Page 214 IR book clarification on fluoro guidance requirements

We noticed on page 214 in the 2021 IR book, that on #72 (PICC w/guidance), it states that we are still to follow the guidance for 76937. We are aware of all the documentation requirements for that. However, what are the actual guidance guidelines for 77001? Are you stating that they are the same as 76937? We sometimes simply just have a little blurb about fluoro was used and the vein was patent, and then after confirmation of the catheter position, the catheter was fixed at the skin entry site. We'll see something like this in the impression - "Uncomplicated PICC insertion under sonographic and fluoroscopic guidance."

Ligation Vs. Direct Suture Repair of Mesenteric Bleed due to MVA.

I have a case where a trauma surgeon (not part of of our group) performed an exp lap with drainage of hemoperitoneum, with packing. No bowel resection. He called our vascular surgeon in to control bleeding for a branch of the SMA. Our surgeon, from what I can tell, ligated the SMA branch and suture repaired it. Our surgeon said ligation only in procedures performed. What are your opinions between coding 37617 vs. 35221? Since he suture repaired the artery after he first ligated the branch and waited 30 minutes I am thinking 35221. I also considered 44850 since the main surgeon did not do anything more invasive beyond exp lap and drainage, but our surgeon only repaired or ligated the vessel?

Descending thoracic aneurysm with abberant right subclavian artery

Our patient recently developed a symptomatic distal arch and proximal descending thoracic aortic aneurysm with an aberrant right subclavian artery. The doctors performed a thoracotomy with replacement of distal arch and proximal descending aorta with a 30 mm Gelweave graft and a dissection and ligation of an aberrant right subclavian artery with cardiopulmonary bypass. They coded 33875 and 37616, but I know the latter is incorrect. Can you help?

PAD with Leg Pain

What diagnosis code do you use if the only reason for the test is PAD with right leg pain? After angio only minimal atherosclerosis is identified in calf arteries and no intervention is done. The ABI was slightly abnormal, which lead to angio. Would you code atherosclerosis with claudication I70.211 or code I73.9 (PAD) with M79.604 ( right leg pain). We are debating if the word "claudication" needs to be used or is leg pain with abn. ABI and minimal atherosclerosis is enough to code the I70.211? Also, what code do you use for abnormal ABI?

Pleurodesis via an existing tube

Code 32560 for pleurodesis includes placing a tube to perform the procedure. Does this same code apply when the patient already has an existing tube and the pleurodesis is performed via that tube/drain? Example: patient with drain presents and talc pleurodesis performed via the existing tube.

RT post/ant shoulder joint injection and RT subacromial bursa injection

Will you please help with the coding for this scenario below? "The patient's posterolateral and anterolateral shoulder area was cleaned and prepped in a sterile fashion utilizing Chloraprep. I then proceeded to place a 25 gauge, 1 inch needle through the skin and advanced it into the subacromial bursa (posterior). I then proceeded to inject, after negative aspiration, a 3 mL solution containing 0.2% Ropivacaine and PF Dexamethasone. I then proceeded to perform posterior and anterior intra-articular shoulder joint (glenohumeral joint) injection resulting in a right subacromial bursa injection and right posterior and anterior intra-articular shoulder joint injection with local and steroid."  Would this be coded as 20610-RT x 2 units, or just 20610-RT x 1 unit?"

Radiculopathy and/or myelopathy with spinal condition

A patient presents with an order for imaging for radiculopathy, sciatic pain, neuritis, or radiculitis, and the final impression states the patient has DDD or DJD. The impression does not mention compression or relating the radiculopathy to the disorder, but the patient clearly has the symptoms per the order. Can we still code DDD or DJD with the radiculopathy if a link isn't made in the impression?

Multiple Physicians Billing for TAVR

Seeking guidance on physician billing during TAVR. Can both of the co-surgeons (CT surgeon and interventional cardiologist) and an assistant surgeon bill for a single TAVR procedure? Would the cardiothoracic surgeon and interventional cardiologist bill with modifier -62 and a second interventional cardiologist who serves as an assistant surgeon with modifier -80 or -82?

Can an APRN perform a heart cath?

Can an APRN perform a heart cath? If so, any tips on how these would bill for the training caths prior to their credentialing for this service?

LIver biopsy multiple lesions

Dr. Z,

Now we can code 32408 two times when there are separate lesions the same goes with Liver?

Thank you

Left heart cath with stent in RCA

We have been adding an -XU modifier on left heart cath procedures (93458) that do intervention. It is concerning that we are using this -XU modifier so frequently and was wondering if there is an alternative way to code these. Would the -XS or -XE modifier be able to be used instead as an alternative to overuse of the unspecified modifier?

Ivor Lewis Esophagectomy

When an Ivor Lewis is performed via open abdominal incision and thorascopic approach, what would be the best code choice? I'm thinking unlisted 43499 but not sure what comp code(s) to use. 43117 and 43287 don't seem to fit for both approaches. Any help would be appreciated.

Bundle of HIS lead

Patient has an existing resynchronization ICD, in need of LV lead replacement. Physician explored the CS and LV, but was unable to place a new lead in the CS or LV, so instead placed a new lead in the left bundle. The old LV lead was capped. Would you assign 33216 for the bundle of His lead or 33224 because the lead is being used for LV pacing?

"We accessed the CS. The chronic LV lead was noted to be in an apical posterolateral branch. The existing branch of the lead was the only amenable lead for LV lead placement. There were no other CS branches that were amenable for any lead positioning. At this point, I abandoned placement of the LV lead, and we placed a Medtronic 3830, 69 cm lead, serial number LFFF313853V, date of implant 01/21/2021 utilizing RAO and LAO fluoroscopic guidance into the region of the fluoroscopic left bundle. There was narrowing, but incomplete capture of the left bundle. This was felt to be a good lead position. The chronic RA and RV leads were connected to the pulse generator. The left bundle lead required an LV-1 adaptor"

ICD-10-CM Code displaced nephrostomy tube

What diagnosis should be used for a displaced nephrostomy tube (N99.- or T83.-)?

AMA Guidance on Catheter-based Coronary Angiography Equivalents

During your December 2020 Virtual Seminar, you made reference a couple times to the AMA on what studies they consider a catheter-based coronary angiography equivalent for coding/billing. I have not been able to find any articles for use as guidance from the AMA. Below is a quote from your Ask Dr. Z where you referenced this in April 2017:

"The AMA has stated that a coronary artery CTA is NOT the equivalent of a catheter-based angiogram at this time. You can code for a catheter-based angiogram after a coronary CTA at this time."

Can you tell me where/how I may find this information for use as a reference?

TAVR

Hello, does Medicare pay for 33361? I have tried everything and continue to get the same denial, I use 33361 with modifiers 62/Q0, dx codes i35.0 z00.6, I am using a 8 digit NCT number the hospital has supplied me. I have put it in box 19 and box 23. I have it formatted as 01737528 but I continue to get this denial from Medicare

Missing/incomplete/invalid Investigational Device Exemption number or Clinical Trial number.

What am I doing wrong??

planar and spect on same date of service--NCCi edits

I have a patient who came in for injection of NM on Day 1. Day 2 the patient came in for a whole body planar scan (78802). They noticed an area of interest, so they performed a SPECT on one area only (78803). I have read in your previous Q&As that these two codes can be reported together; however, when I enter them into my encoder, I receive an NCCI edit that states 78802 cannot be billed with 78803 even with a modifier. I realize these are two different scans, and I'm wondering why they cannot be billed together. Which one should I bill, 78802 or 78803? 

32320 for Partial Parietal Pleurectomy?

I have an op note for a total decortication of right lung and partial parietal pleurectomy same lung. Is code 32320 appropriate for this?

Ordering Dialysis Graft US 93990

I have a question about 'ordering' US 93990. Our hospital-based radiologist wants to ROUTINELY set a schedule for their cases to monitor patients and identify patients who would benefit from early fistulograms. I have read the ordering rules for diagnostic imaging, but I'm more confused now. Can the radiologist place this order? And I'm very concerned he's saying "routinely". I need to answer the IR back, but I want to make sure this is okay. Please advise.

Pocket Revision or Unlisted Code?

Please advise how this non-post-op case should be coded: Pocket accessed w/ blunt dissection & electrocautery. Pocket inspected - observed that the ICD generator had somehow slipped under the sewing rings & the leads. This likely resulted in the ICD generator pushing the leads anteriorly resulting in tissue thinning, very palpable leads, & patient discomfort. The ICD generator was removed from the pocket & the pocket was inspected. It was in good condition with early capsule formation. Pocket irrigated with bacitracin. A Tyrex pouch was used to reduce the risk for infection & the ICD generator was placed back in the pocket with the leads adjacent to the fascia. The ICD generator is sewn in place with 0 silk to prevent the can from migrating under the leads again. The pocket closed with continuous 2-0, 3-0 and 4-0 Vicryl. Steri-strips applied and a vasoocclusive dressing placed.

4D

How is 4D reconstruction to be billed, and what should the documentation reflect?

Aminophylline in Nuclear Studies

Can we bill for aminophylline when given as a drug reversal during pharmacological nuclear studies?

Coding Interrogations versus Programing

When is programming separately billable from interrogations?

Example: CPT 93291 and CPT 93285. They are not allowed to be coded together but when would be billing CPT 93291 versus CPT 93285?

93657 and Additional lines

I know the MUE of 93657 is 2, and is used for additional lines and CFAE signals. Based on the below, am I able to code 93657 x 2? "After isolation of all four pulmonary veins, atrial fibrillation remained. Due to continued atrial fibrillation, I felt it was important to perform further substrate for ablation for atrial fibrillation. An inferior line was performed as an additional lesion set. Atrial fibrillation persisted. A roof line was then performed as an additional lesion set." 

ASD vs PFO

ASD and PFO are the same ICD-10-CM code. My physicians are using both terms in the documentation. How do I know when to use congenital vs. non-congenital cath codes when both are documented?

New lung biopsy code 32408

Recently at an AMA seminar they stated that with 32408 (lung biopsy) you can code this more than once when more than one lesion is biopsied of the lung. I am not seeing that in the description. Do you agree if they biopsy two  or more different lesions in the same lung that you can report code 32408 x 2 or more?

Steroid injection of left Cubital Tunnel Syndrome

How would you code an injection of steroids into the cubital tunnel? Unlisted or 64450? "The medial epicondyle and left olecranon process is used to identify the nerve line in-between the structures just posterior to the medial epicondyle. Following the cubital tunnel the nerve is seen lying between the two heads of the flexor carpi ulnaris muscles and beneath the overlying capital to the retinaculum. The transducer is rotated, and the needle is placed through the skin above the lateral aspect of the ultrasound transducer and advanced using a plane approach until the needle tip reached the proper position the elbow. Images were printed to be scanned and saved. The ulnar nerve is identified. Color Doppler was used. Then a 1.5 inch, 25 gauge needle is advanced using and out of plane approach directly under tip in proximity to the ulnar nerve. After careful aspiration 10 mg of kenalog mixed with 1 cc of lidocaine 1% is injected slowly with minimal resistance to the left cubital tunnel and no paresthesia noted."

Is 93571-74 correct code for DPR?

IVUS and DPR were done on LAD with LHC. Is 93571-74 the correct code for DPR for facility coding, with -52 instead for physician coding?

Stent placement via EGD & Overstitch device for suturing

Upper GI endoscopy was accomplished without difficulty. One benign-appearing, intrinsic severe (stenosis; an endoscope cannot pass) stenosis was found 30 cm from the incisors. Stenosis measured 5 mm (inner diameter) x 4 cm (in length). Stenosis was not traversed. This was stented with Hanaro stent TTS 18 mm x 80 mm fully covered under fluoroscopic guidance, proximal margin at 27 cm and distal margin at 35 cm from incisors. Decision was made to use sutures secure stent in place. The endoscope was removed, the OverStitch device was attached to the proximal and distal ends of the endoscope. The scope was reinserted. Device was loaded with 2.0 polypropylene suture. A total of two sutures in an interrupted fashion were placed with cinches on both ends. Good tissue approximation was noted. There was no bleeding during, or at the end, of the procedure.

Question: Is the use of the OverStitch device supportive of an additional CPT code assignment aside from that used to the report EGD w/stent placement?

Thank you for your time.

Cephalic vein banding ligation and extraction of venous pseudoaneurysm

Is extraction of venous pseudoaneurysm bundled with the cephalic vein banding ligation? We cannot find an appropriate code for the extraction to be used along with 37607.

"Venogram performed of the right upper extremity. Cephalic vein aneurysm was identified and visualized. Subsequently, ultrasound was utilized to identify the cephalic vein both cephalad and caudad to the region of the aneurysm. Initially spot, small cutdown regions were performed at each of these sites and ligation of the cephalic vein utilizing banding technique was performed with Prolene suture. Following this, confirmation was performed with contrast injection that there is no significant flow in the portion of the cephalic vein feeding the region of the aneurysm. Thereafter, small cutdown incision was obtained at the level of the aneurysm dissection was performed to the level of the aneurysm which was then extracted. Subsequently, cautery was utilized and deep and superficial sutures were placed. Hemostasis was achieved and dressing applied."

35875/ 35665 ( New ilio-PFA bypass from Ao-FemFem Lt Lim w/thrombectomy)

I have coded this with 35665 and 35875. 1) Thrombectomy existing Ao-BiFem PTFE graft w/ New Ilio-PFA PTFE bypass from Existing left graft limb (prox anasto) Tunneled to PFA for distal anastomosis. Or would this be revision even though no seperate patch plasty for stenosis? 35876? Or code new graft only.

I then turned my attention to the left limb of the ABF graft. I made a longitudinal arteriotomy and then passed a #4 and #5 Fogarty proximally and removed large amounts of clot. Multiple passes were performed until I was able to get torrential inflow. I then attempted to pass a #3 and #4 Fogarty distally and was able to remove some more clot. I then used a 8mm ringed PTFE graft and sewed this in to the left limb of the ABF graft in an end to side fashion using a 5-0 Prolene suture. I then tunneled the graft laterally and brought this out from my thigh incision. I then made an arteriotomy on the profunda femoris and then sewed this in to the profunda in an end to side fashion using a 6-0 Prolene suture. Do you agree with thrombectomy only 35875 and graft 35665?

C codes in an Inpatient setting

In an inpatient setting can codes C9600-C9607 be used for reimbursement for drug-eluting stents? I realize the claim is billed with ICD-10-PCS codes and CPT codes do not go on the claim; however, for revenue purposes the facility wanted to know if C-codes are allowed to be charged.

Iliac aneurysm stent

The physician deployed VIABAHN 10*59 mm covered stent in right common iliac artery for iliac aneurysm. Is this reported with 37236 or 34707?

Requirements for 76881

Could you please help with the clarification of the elements that are required for documentation in order to bill 76881? Are nerves required to be documented along with muscles, tendons, and joint spaces? Peri-articular soft tissue isn't clearly defined.

Shoulder Lavage and injection

Can you please help me on how to code this? I'm going back and forth on 20611 vs. 20551, or using both with a modifier on 20551. This was all done percutaneously under US guidance. 

"BARBOTAGE WITH 1% LIDOCAINE WAS PERFORMED AND ASPIRATION OF CALCIFIC CRYSTALS FROM THE DEPOSIT WAS NOTED. THIS PROCEDURE WAS REPEATED SEVERAL TIMES WITH A MIXTURE OF 1% LIDOCAINE AND STERILE SALINE UNTIL VISIBLE CALCIFIC DEBRIS WAS NO LONGER ASPIRATED INTO THE SYRINGE. AT THIS POINT, THE BURSAL-SURFACE OF THE TENDON IN THE REGION OF THE CALCIFIC DEPOSITION WAS FENESTRATED. FINALLY, THE NEEDLE WAS REPOSITIONED INTO THE SUBACROMIAL/SUBDELTOID BURSA AND THERAPEUTIC INJECTION WAS PERFORMED WITH A 3 ML MIXTURE OF 1 ML OF DEPO-MEDROL AND 2 ML 0.5% SENSORCAINE."

Diagnosis Coding for 93016

Our stress tests are supervised by APPs, and they bill 93016. Currently, we are using the 'reason for exam' as the diagnosis for the supervision and the appropriate diagnosis (based on the documented interpretation) for the 93018 billed by the MD.

Recently an auditor told me that IF the stress test interpretation is available in the chart when we are coding the supervision 93016, we should be assigning the appropriate diagnosis from the interpretation to the supervision.

This doesn't seem correct to me -- if we are coding/billing for the supervision only, we do not know the final diagnosis at that point in time. If the test is stopped for any reason, we DO use that diagnosis code (i.e., tachycardia or chest pain).

Do you recommend coding a diagnosis from the INTERPRETED stress test as the diagnosis for the SUPERVISION of the stress test?

77290 vs 77285

What determines complex (77290) vs. intermediate (77285)? Is it software required for complex simulations and dosimetry calculation? Also, treatment planning 77262 vs. 77263. We have been told by rep that we don't have software to bill complex codes, but tech thinks that CPT descriptions of complex is correct to bill. Is software required for complex billing of these codes (77290) (77263), or do we default to intermediate?

MODIFIER VESSEL

I would like to get your second opinion on appending modifier on code 93571 and 92978. Are modifiers -LM/-RI/-LD/-LC/-RC mandatory modifiers on these two codes when billing?

Need to ask Dr.Z?

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