Ask Dr. Z

Aneurysmal cryo-artery bypass section removed. Is it 35883, 35286, 35141?

"Identified the proximal most portion of the old bypass which was normal and the above-knee portion of the bypass which was also normal. A transverse incision was made in the proximal thigh. We identified the previously placed cryo superficial femoral artery bypass which was normal and Vessel loops were placed across it. In the distal thigh, made a transverse incision. Distal portion of the cryo femoral artery which was normal was identified and Vesseloops were placed across it. Tunnel was created in the subcut plane, lateral to old bypass and a 7 mm PTFE was placed inside this tunnel. The proximal most portion of the old cryo femoral artery was transected. Distal portion of the bypass was suture-ligated. An end-to-end anastomosis was made between the PTFE graft and the normal portion of the cryo femoral artery in a continuous fashion. In the distal thigh area, the previous bypass was transected and the aneurysmal portion was suture-ligated. End-to-end anastomosis was made to the PTFE graft using 5-0 Prolene, run in a continuous manner."

The surgeon harvested the femoral vein a day before he plans to do the bypass. Code 35572 (for the harvest) is an add-on code, so since it was done alone how would you suggest reporting?

I need help with a code for a rectosigmoid decompression tube. "Patient initially had a CT lung biopsy. During the same encounter the patient complained about abdominal distention. This was present prior to biopsy also. A rectal tube with attachment of a flatus bag was inserted into the rectum with immediate decompression."  What code would you use for this? 

Physician documents, under "Brief Clinical History: ...Due to concerns for accelerating angina, he is referred for invasive coronary angiography." Under Impression she states, "1) Severe vessel native CAD; unable to perform PTCA/PCI due to severe vessel tortuosity and stent under expansion in the proximal RCA. 2) Severe distal RCA stenosis." Can I code I25110 even though she didn't mention the angina in the Impression? 

Can 93552 be billed by the physician when the contrast is administered by hospital staff if the test is performed in the hospital along with 93351, 93320, and 93325?

"Eleven stab phlebectomies were performed over varicose veins of her abdomen." Since 37765-37766 are for extremities, would this be unlisted (37799)?

"Patient developed left-sided breast cancer and is awaiting left-sided mastectomy. Patient presents for left-sided system extraction and implantation of a right-sided device. RV lead was removed, and a new lead was placed. The previously implanted generator was placed on the right side in the new pocket with the new RV lead." Would you recommend billing 33234 and 33216, or would you bill 33234, 33216, and 33222? We are questioning the relocation since the old generator was used, and the work was done to move pockets.

Is thoracic duct ligation (38380) reportable as described here with 35694?

"Indications: Dissection, proximal descending thoracic aortic aneurysm. Left SCA to carotid artery transposition performed. Metzenbaum scissors used to enter carotid sheath. IJ vein mobilized and retracted laterally. The left CCA dissected and mobilized. The left SCA identified and dissected proximally to the arch and distally to vertebral take off. The thoracic duct was noted overlying the vessel along with the vertebral vein, and both were controlled with clips and ties. A right angle clamp was placed proximally and a profunda clamp distally proximal to the vertebral artery takeoff on the left SCA and it was divided ~3-5 mm distal to right angle clamp. The proximal end was then oversewn with double layer of running 5-0 prolene suture and reinforced with a 5-0 prolene pledgeted suture with the proximal right angle clamp removed and hemostasis noted. The left SCA noted to have adequate length to reach the left carotid artery. The left carotid artery was clamped proximally and distally, opened on posterior lateral aspect of the vessel. A 6-0 prolene running suture was then used to anastomose the arteries."

We’re looking to see if the following operation was a bone debridement of an infected below-knee amputation stump (11044) or a re-amputation (27886). Only the tibia was cut, not the tibia and fibula per the code description. Would it be appropriate to report code 27886 with a -52 modifier for reduced services?

“I then incised the skin on the anterior flap transversely and excised the portion of the skin so as to expose the bone more proximally as well. I then used an oscillating saw to transect the bone where it was a little healthier and free of purulence, on the tibia only. As such, I basically just revised the below-knee amputation more proximally; however, there was no tissue left to flap."

Patient came in and had fistula created (36830) and then the very next day developed steal syndrome and the patient returned to the OR and the graft was removed. Would you go with 37607 or unlisted 37799?

Second day: "We began by reopening the antecubital incision as well as the axillary incision. The stitches were cut, and we were quickly down to the graft. The graft was clamped right next to both arterial and venous anastomoses. It was divided and the bulk of the graft removed easily. The stumps of graft on both the artery and the vein were oversewn using a 5-0 Prolene in a running baseball style stitch. Vascular clamps were removed. We had adequate hemostasis. The incisions were irrigated and closed by reapproximating the subcutaneous tissue using running 3-0 Vicryl followed by skin closure using 4-0 Monocryl in a running subcuticular fashion. Sterile dressings were applied, and the patient was awoken and taken to the PACU in good condition."

For code 36818, does the cephalic vein always have to be tunneled, and does the procedure always have to be performed in the upper arm? If a fistula is created using the brachial artery and cephalic vein, is it always 36818 or is it sometimes 36821 (like when it is performed at the elbow)?

"Patient presents for stage 2 of staged PCI. After approximately 10 balloon inflations, several balloon exchanges, and three Shockwave therapies of 20 pulses each on a heavily calcified area of the LC, patient developed slow flow and changes in ST segments. Expo cath was advanced across patient’s Sapien 3 valve (only 2 months old) into LT vent and hemodynamic data was collected. PCI on LC continued, with no mention of removal of the LT heart cath." Hemodynamic data was entered into the log, but was not included in dictated report. Can this LT heart cath legitimately be coded with 93452-XU? My feeling is that this seems to have been done for monitoring purposes and in response to a physician-caused indication, so it should not be coded. Cath lab tech makes a case that it was medically necessary and probably done to check overall function and see if additional support would be needed. Eager to hear your thoughts on this, as we find no published precedent for use of 93452 in this way.

"Ordered lumbar myelogram and CT post lumbar myelogram: Report reads: A 20 gauge 6 inch spinal needle was advanced into the subarachnoid space via a left parasagittal approach at L3/L4. Approximately 9 cc of Omnipaque 180 was subsequently infused into the subarachnoid space with intermittent CT confirmation of intrathecal positioning and contrast opacification.Intrathecal contrast column opacifies the visualized lumbar thecal sac. The most superior extent of the contrast column is not visualized. The conus medullaris terminates at L1. The visualized cauda equina roots are normal.L1-2, L2-3, L3-4, and L4-5: There is no disc herniation, spinal canal, or neuroforaminal stenosis.L5/S1: There is shallow disc bulge projecting into the epidural fat without spinal canal compromise. There is mild circumferential prominence of the epidural fat. There is moderate right facet arthropathy contributing to severe right neuroforaminal stenosis. There is mild to moderate left neuroforaminal stenosis."

Would this be reported with code 62884 or 62304?

Our pain clinic providers see patients who have chronic lumbar pain with radiculopathy and also documentation of lumbar spondylosis. We are using the combination code (M4726) for lumbar spondylosis and radiculopathy and routinely get denied because of coverage under ART 57203. We have tried appealing these without any resolution. Under the coverage documents we have multiple things that would be considered covered if we were allowed to code them out separately (low back pain, lumbar radiculopathy, etc.). Any suggestions on the scenario above in order to get reimbursed? Would it be common to have these conditions (lumbar spondylosis and radiculopathy) not related to each other to support coding them out separately (if documentation supported)?

Need your opinion for DFT testing on a system, not at the time of implant, on an ICD system with only epicardial leads. Code 93642 specifies "transvenous pacing cardioverter-defibrillator". Since the leads are epicardial, not transvenous, what do you recommend for reporting? Unlisted?

Is there a diagnosis code for LVOT calcification? It's being documented more often, likely due to research in relation to TAVR outcomes.

If a CT surgeon has his/her NP or PA do the endoscopic vein harvest during CABG, but the NPP does not assist in any other portion of the procedure, should we only report 33508 under the CT surgeon? Since 33508 is an add-on code, the payer would likely deny the NPP's charge if they do not report 33508-AS with a primary procedure code.

Is catheter placement included in 37215?

Our physician on one day embolized (with glue) the left MMA and the left occipital artery for an "infratentorial torcula AV fistula".  He noted that there was "persistent feeding from the right MMA and occipital arteries". Then, two days later, he went back in and embolized the right posterior branch of the distal MMA. Would I use 61624/75894 (75898 if done) and catheter placements the first day and then on day 3 for the second embolization use a -76 modifier on all my other codes since he repeated it? Or since it was "staged" do I use a different modifier? Or do I use no modifiers at all? Since he actually embolized a different artery (but for same fistula) would it even be considered a repeat embolization?

"Right anterior scalene muscle and pec minor injection with ultrasound guidance. Using a high frequency ultrasound probe, the anterior scalene muscle on the right side was identified tracing up the brachial plexus from the supraclavicular position. Next, the same 30g needle was advanced out of plane in to the inferior medial aspect of the anterior scalene muscle ensuring intramuscular location prior to giving, after negative aspiration, and 0.5mL of 0.25% bupivacaine was given without paresthesia under ultrasound guidance revealing intramuscular injection throughout. Next the pec minor muscle was identified inferior to the coronoid process. 1% lidocaine was placed in the skin just superior to the probe. Next a echogenic 100cm 22 g needle was advanced in plane to the pec minor muscle without issue. After negative aspiration 3mL of injectate containing plain PF 0.25% bupivacaine was given incrementally in to the pec minor muscle without paresthesia.” 

Is it okay to report code 20552 for anterior scalene muscle and pec minor muscle?

Are costochondral joint Injections considered small or intermediate joints?

Surgeon performed a planned tracheostomy (31600) and in same session did the following:

"We then proceeded with the bronchoscopy through the tracheostomy, and we were able to see if there was any potential bleeding and there was some mucus on the left side, which was completely suctioned out using the BAL. We used approximately 25 mL of saline on the left side, the right side was otherwise clean. Both sides were completely suctioned out. This confirmed that we were in the airway and we had good tidal volumes at this point."

He is wanting to report 31615 and 31624 in addition to the 31600. Is this appropriate?

Is the arcuate artery a separate structure that you can bill for within the tibial/peroneal area? The doctors that I work for document atherectomy and/or angioplasty being performed in the arcuate artery. This is usually in addition to interventions also being performed in the dorsal pedal and plantar arteries.

Patient returned for stage II following stage I brachial-basilic AV anastomosis and was noted to have steal syndrome/stenosis subclavian artery. In addition to stage II procedure, a proximal subclavian artery balloon-expandable bare metal stent was placed. How would you code this? Is the additional procedure considered dialysis circuit?

Patient had a duodenal hematoma subsequent to IVC placement. The general surgeon opened patient repair site, and the vascular surgeon removed IVC. How would the open retrieval be coded? Unlisted?

Can you please assist in CPT code for right renal hilar nerve block?

"1% lidocaine was instilled into the skin and surrounding soft tissues. Under intermittent CT fluoroscopy, a 20 gauge spinal needle was advanced into the right renal hilar region. Aspiration was performed to ensure the needle was extravascular. A test injection using dilated contrast was performed. Approximately 20 cc of a 50-50 mixture of 2% lidocaine and 0.5% bupivacaine was instilled. 40 mg Kenalog was also instilled. The needle was cleared with a small injection of air and removed. MEDICATIONS: 3 mL 1% lidocaine,10 mL 2% lidocaine,10 mL 0.5% bupivacaine,40 mg Kenalog. CT images demonstrate adequate positioning of the needle within right renal hilar region. CT images demonstrate adequate positioning of the needle within the right renal hilar region with dilute contrast visualized as expected. Pre-procedure pain 7/10, post-procedure pain 2/10. Technically successful right renal hilar nerve block."

Would codes 35371, 37221, and 34201 be appropriate to use? I do not think 35371 is billable.

"Vertical incision left CFA exposed opened femoral Fogarty balloon multiple passes through iliac thrombus removed pulse restored femoral opened back wall was mended w/ multiple stay sutures decision made to perform patch angioplasty bovine pericardial patch sewn end to side, prior to completion of anastomosis vessels backbleed poor backbleed from left SFA Fogarty catheter passed down SFA return of small chronic thrombus after this backbleeding excellent, angio left iliac residual thrombus distal portion CIA stenosis distal to stent in EIA selected stent advanced to level of mural thrombus deployed w/o difficulty attention turned distally a VBX balloon expandable endoprosthesis deployed w/o difficulty angio reveals excellent flow patch angioplasty completed."

In an office setting, when performing CT or MRI exams with contrast, is the 3-5 mL of heparin used to flush the catheter separately coded with J1644?

What is the correct CPT code for a femur that's imaged from hip to knee on a Dexa unit for the detection of atypical femur fractures?

I know that a discharge summary is not billed on same day as heart cath in an outpatient setting, but can you charge 99238 on the same day as a heart cath in an inpatient setting? Should we never charge a discharge on the same day as a heart cath?

Patient was taken to OR with expectation of ligating AV fistula. Is this an E/M, or is there a code we can capture?

"The patient was taken to the operating room and placed in the supine position. Cardiopulmonary monitoring was initiated. General anesthesia and perioperative antibiotics were given. Single lumen endotracheal intubated was performed without issues. The lower abdomen and right lower extremity were prepped and draped in the usual sterile manner, including the tourniquet that was in place around his right thigh. The tourniquet was released slowly, and we did not visualize a pseudoaneurysm or signs of infection. There was brisk bleeding from a puncture site in the body of the graft in the lateral aspect, which was easily controlled by applying digital pressure proximally. A single pledgeted 4-0 Surgipro suture was performed with control of the bleeding. Doppler probe interrogation documented a bruit, but a pulse was still palpable. A pressure dressing covered with Tegaderm was applied."

We are pretty confused on how to code procedure below, so we need an expert!

"Dr. A and his surgical team scrubbed into the procedure and created a via a subxiphoid pericardial window with lysis of adhesions. Dr. B and his team re-scrubbed back into the procedure and an electroanatomic map was created of the epicardial surface. The epicardial ablation target was noted to be in close proximity to the distal PDA. This was not thought to be amenable to ablation with the Atricure EpiSense ablation catheter given its wide area of ablation. The Flexability ablation catheter was thus used to make several lesions on the epicardial surface targeting the site of focal break out, directly opposite of the endocardial lesions set."

Pericardial Window: 33025 - Dr. A

Lysis of Pericardial Adhesions: 33999 - Dr. A

Ablation: 93654 - Dr. B

ICE: 93662 - Dr. B

Any help or guidance would be appreciated!

Our doctors brought the patient back the next day after placing a port because the patient presented back to the ED with oozing from the port pocket. He infiltrated the subcutaneous soft tissues in the region of the incision of the port pocket, irrigated, and cauterized for ten mins at site of oozing and then closed the pocket. How would you recommend coding this? We have thought of 11042 but because no sq in was mentioned hesitate to utilize that code. We have also thought of 10140 however hesitate on grounds it is not a hematoma. Any help you can offer is very appreciated.

Can modifiers -80 and -Q0 be billed together for a Mitraclip (33418)?

My physician did a partial pulmonary decortication and wedge resection of mass as well as a pleurodesis. The codes are 32651, 32650, 32666. Can these be billed together, or am I supposed to only code the one with the highest RVUs?

I think this will be an unlisted code, but I cannot find anything similar to what they have done as a comparison code for billing. Below is part of the op note:

"Dissection was carried down through the subcutaneous tissue. Sternal wires were removed. There was a small amount of hematoma around the anastomosis of the right Glenn.  The left Glenn looked good. The left hemiazygos vein was identified, and a clip was placed. The pleural spaces were aspirated out. The chest tubes were cleaned."

We have a case where physician performed core breast biopsy under stereotactic tomosynthesis guidance, and after couple of hours patient presents for preoperative mammographically-guided needle localizatin by the same physician for the same lesion. Can we code both 19081-LT and 19281-XU-LT for these? If the same guidance is used for the same scenario we may not code needle localization separate; however, in our case different type of guidance used. Please advise.

Provider performed bypass on a patient for aortoiliac occlusive disease. He used a 20 x 10 mm Hemashield graft and took the right limb down to the femoral artery and was able to sew the left limb to the left common iliac bifurcation.

Should I use codes 35637 (aortoiliac) AND 35647 (aortofemoral)? Or 35638 (aorto-bi-iliac)? Or 35646 (aortobifemoral)?

"Indication: Persistent Afib. Patient in Afib upon arrival, performed cardioversion at 200 joules, this converted the patient to sinus rhythm. Through the internal jugular CS catheter inserted, 1:1 AV node conduction from the CS is less than 500. Coronary sinus pacing is performed. A Biosense Webster ablation catheter inserted in the right atrium, gating was performed and limited 3D mapping of the CS performed. Next ICE catheter was positioned into the mid RT atrium, contours of the left atrium were taken. While taking contours there seemed to be a thrombus in the left atrium, procedure aborted."

Question is would this be reported as 93656-74, 93662, 93613, or should it be reported as only 93602 (atrial recording) and 93610 for atrial pacing (limited information in this report? This is for outpatient hospital setting... If the ablations catheters are inserted, would this be reported as the aborted ablation procedure? Please let me know what charges could be reported.

Can we use codes like 77295, 77300, 77334, and 77370 with HIFU procedures? We are doing uterine, neuro, bone, and prostate HIFUs. Currently we are billing these codes, but should we stop using these codes even though the treatment planning is not specifically stated in the CPTs? Is the treatment planning and everything associated with the HIFU implied in the CPT codes as part of the routine procedure, similar to other interventional procedures that bundle everything?

"There is a short segment occlusion of the radial artery upstream to the AV fistula anastomosis. Via retrograde access of right common femoral artery, the catheter was advanced to the left subclavian artery, brachial artery then into the left radial artery where balloon angioplasty was performed." To code this, I'm thinking 36217-LT and 37246-LT. Is this correct?

I am confused on what I can code here. "Under ultrasound, the right IJ was occluded. A needle was introduced into the left IJ, and a wire was placed down in the IJ. A 5 French sheath was placed over the wire, and a venogram was performed. This showed occlusion of the left innominate vein. Multiple attempts were unsuccessfully attempted to cross the left innominate vein with the angled Glidewire and the Berenstein catheter. After multiple attempts, the wire and Berenstein catheter were removed, the sheath was removed, pressure was held, hemostasis was obtained, and a sterile dressing was applied."

We are currently billing our PM and ICD interrogation remote associated with a download. After reviewing this practice it appears we are missing consistency and not capturing each patient within every 90 days. Is it proper to bill remote interrogation on a schedule at the end of the third month for each patient instead of synching with a download feed?

Can we bill RVOT stent placement (33745) with a Melody Valve for narrowing of the RVOT? "A P4010 stent was mounted on a 24-5 BIB catheter and advanced through the long sheath into the RV outflow tract. The stent was uncovered without difficulty and deployed by inflating the inner and outer balloons to 6 atmospheres, and repeat angiography through the long sheath into the RV demonstrated stable position of the stent across the narrowest dimension. We then proceeded with placement of the Melody valve. On the back table, the 22 mm Melody valve was prepped per protocol with a P3110 stent mounted on the outside of the Melody valve. RVOT pre-stented with Palmaz 4010 stent bare metal stent using 24-5 BIB catheter. Melody valve 22 mm placed using 22 French, 22 mm Ensemble delivery system with a Palmaz 3110 stent mounted over the Melody valve."

My BD rep is telling me that with their Rotarex device I can code for both atherectomy and thrombectomy. Is that true? If I can, would it be considered a primary thrombectomy?

"Patient's left upper extremity and indwelling sheath were prepped and draped. Fluoroscopic images demonstrated the Unifuse catheter tip to project in the axillary vein. Contrast Injection demonstrated short segment high-grade stenosis of left axillary vein. Angioplasty was performed of the stenosis of the axillary vein. Angioplasty was then performed throughout the venous outflow as well as balloon-assisted clot maceration. This resulted in significantly improved patency of the venous outflow however there was still no flow through the dialysis circuit as the inflow had not yet been addressed. Under US guidance, the graft was accessed in a retrograde fashion. The Kumpe was advanced beyond the arterial anastomosis into the radial artery. Fogarty balloon was advanced into the radial artery. Three sweeps were performed with Fogarty balloon to remove arterial plug across the anastomosis." Would the correct code be 76937, 36905, and 37214-XU?

For the following procedure, would you recommend adding code 36000 (vs. a different CPT vs. no CPT) for the attempted/failed left subclavian vein access?

"The patient presented for an ICD upgrade. A left subclavian venogram was performed, demonstrating patency of the distal subclavian vein, but possible occlusion after crossing the clavicle. The decision was made to attempt the upgrade from the left side, but if occlusion was encountered, the LV lead would be placed via the right subclavian vein and tunneled over to the left-sided pocket. After the ICD pocket was opened and the existing generator removed, the left subclavian vein was accessed with a micropuncture needle under fluoroscopic guidance. However, the micropuncture wire could not be advanced beyond the clavicle due to occlusion. The right subclavian vein was then accessed successfully, and the procedure continued. The LV lead was tunneled across the chest to the left-sided ICD pocket."

My IR doc is performing a carotid stent on a patient using hemodynamic monitoring and is asking if he can separately bill for the hemodynamics during this procedure. To me it would be included, but I want to be sure before I take it back to him.

I have a question about 3D reconstruction. I have a facility that wants to bill for reconstruction for pre-op planning for patients that have liver cancer prior to Y90. They are performed on a separate day than the MRI scan. This is the dictation: "3D reconstructions were performed on imaging data under concurrent supervision on an independent workstation at the request of referring doctor. For hepatocellular carcinoma. Please reference accession number XXX for associated exam." This does not sound like enough dictation. Also concurrent supervision. Does that mean the radiologist needs to be in the room with the tech re-formatting the images?

The patient is part of a REACT (renal autologous stem cell therapy) study. As treatment they received percutaneous sub capsular injection of autologous stem cells using CT guidance. How is this coded in CPT?