Ask Dr. Z

Can LA-LV fistula suture repair be reported when done in conjunction with AVR? If so, what code could be used for that procedure? I've looked at 33305 and 33315, but neither seem quite right because those codes are associated with trauma; also considered unlisted code but with the fistula repair having been completed during the AVR and no significant extra time or effort documented I'm not sure it qualifies for an additional CPT and payment.

"The old aortotomy site was reopened. This provided good exposure with findings as described. The valve was removed. All pledgets were removed and everything sent for cultures. The annulus was debrided further. Using a right angle clamp, we were able to find the fistula between the ventricle and the atrium. This was closed with a pericardial pledgeted 4-0 Prolene suture."

"Patient has had a previous PVI performed in the past but continues to have paroxysmal atrial fib. The patient is brought to the EP lab where it is noted the pulmonary veins are still isolated; however, there is evidence of dependent slow conduction into the posterior wall after mapping. A LAPWI is performed leaving no conduction into the veins." Would this be 93656 or 93653?

Would the below exam info qualify as "comprehensive" under either 95 or 97 guidelines for an initial hospital visit?

Patient name is a 86 y.o. female who is in no acute distress 

Vitals:

03/30/21 2249 03/31/21 0020 03/31/21 0254 03/31/21 0714

BP: 101/60   112/69 106/66

Pulse: 106 116 115 114

Resp: 18   17 16

Temp: 97.5 °F (36.4 °C) 97.3 °F (36.3 °C) 97.5 °F (36.4 °C)

SpO2: 95%   96% 97%

Weight: 150 lb 4.8 oz (68.2 kg)  

Body mass index is 27.49 kg/m².

HEENT Normocephalic and atraumatic. Normal nose, normal oral mucosa.

Neck: Supple without masses or tenderness.

CARDIOVASCULAR: Regular, S1S2, murmur

RESPIRATORY: Clear to auscultation bilaterally with no adventitious sounds.

GASTROINTESTINAL: Soft, Non tender.

EXTREMITIES: No edema appreciated.

NEURO: Patient oriented X3. Speech is clear. Affect is appropriate.

INTEGUMENTARY: Incision not viewed.

I don't count it as comprehensive but others do. Please advise. Thank you.

Access site is left popliteal vein; cath was moved up into the IVC (75825) was performed. Cath moved back down in the left (ipsilateral) leg into the common femoral vein and extremity venogram (75820) performed. Is that cath placement 36012 because it made it to the IVC and now being moved back into smaller vessels? Or, is it 36010 IVC due to the access leg is considered non-selective but able to code the IVC and not 36005?

I have an MD who is questioning whether we can charge a limited extremity angio to evaluate for patency in the vessel after access to evaluate for dissection or pseudoaneurysm caused by the access. It is also used to evaluate for closure device. I realize that imaging done to evaluate if the vessel is appropriate for the closure device is included, but am wondering if this encompasses more. Below is a typical note in the rad report.

"A limited right common femoral angiogram was performed to evaluate the vessel diameter and puncture site. This demonstrated normal anatomy without evidence for vessel injury or spasm. Good flow was seen in the common femoral and superficial femoral arteries. The introducer sheath was removed, and hemostasis was achieved with Angio-Seal."

How would you code ERCP with stent replacement plus additional stent in bile duct? We understand coding of two new stents or replacement of two stents; however, the CPT book states, "Do not report 43276 in conjunction with 43262, 43274 for stent placement or exchange in same duct."

"Biliary previously placed biliary stent was extracted with a snare. Stent appeared at least partially occluded. Bile duct was deeply cannulated with a balloon and a wire. Donor native duct mismatch was again evident. Choledochocholedochal anastomotic stricture appearance is markedly improved. Bile duct was swept in the bifurcation. Debris was cleared from the bile duct. A 10 French 9 cm biliary stent was then placed across the level of the anastomosis. Subsequently a 10 French 10 cm biliary stent was deployed alongside the first stent."

Please advise. "Placement of sheath into the right superficial brachial vein and right heart cath performed. Attempted to access right radial but unable to advance wire. Right femoral was accessed. Left heart cath was performed and ascending aortogram." The facility wants this coded as 93458 and 93451-59. I don't think this is correct. What would be the correct coding?

We are puzzled if we can use 37187 for dural venous sinus thrombosis thrombectomy. "A 6 x 40 mm Solitaire stent retriever was deployed, and thrombectomy was performed in the right internal jugular vein then right sigmoid and transverse sinus." What are your thoughts?

I am not sure what is the correct coding: 33226 or 33207/33233.

"Insertion of new right ventricular septal lead. Upgrade of existing dual-chamber permanent pacing system to a biventricular pacemaker, with new RV septal lead inserted into the RV port and existing chronic RV apical septal lead inserted into the LV port. Atrial lead pin (implanted 1999) was inserted in the atrial port of the new device."

I was reading the Q&A ID # 10826 in regards to the use of 74420 if the RPG is used to guide the stent placement. The answer confuses me as most of IR coding prohibits coding angiograms for guidance, and this in essence is the S&I to an pyelogram to guide the stent placement. Could you please clarify that we can report the 74420 in this case? The actual RPG code 52005 edits and is bundled with the stent placement, and it confuses me that we can code the S&I when we can't show its parent code and since it's used to guide the stent, it seems like the S&I 74420 should be bundled as well. 

"Under fluoroscopic guidance, the pump was attempted to be accessed with the access needle; however, this was unsuccessful. At that time, a large amount of thin serosanguineous fluid was expressed upon entry with the access needle. The seroma fluid was expressed from the access site. Following expression of the seroma fluid, the pump was able to be palpated. The site was again prepped and draped in normal sterile fashion.

Under fluoroscopic guidance, the pump was accessed and 26 mL of saline and heparin were aspirated from the reservoir. Once the port was accessed, the cancer center nurse fill the pump with FUDR and performed programming."

What would the CPT codes be for charging? I am a fairly new IR coder and wasn't sure if this should be 61070/75809? Please advise.

A patient with hypertrophic cardiomyopathy and sustained VT will be having the following procedures:

Plan: 1 adenosine challenge test. (If adenosine challenge is negative, then the MD will proceed to do the EP study/ablation.)

How would I code for the adenosine challenge test? (This procedure would be done prior the EP study.)

Our vascular doc tried to place a carotid stent with DEP at the bifurcation of the common and internal carotid arteries. DEP was placed. Dissection occurred at the proximal carotid artery. He couldn't get past all the calcifications, so he angioplastied the bifurcation and placed a stent in the dissection. I'm not sure if the dissection occurred at the thoracic carotid or if it was considered cervical, just not at the bifurcation. (He's just calling it "proximal carotid".) What CPT codes would you report? Since he really didn't get the bifurcation stent in, can I report code 37215 since he did use the DEP and did place a carotid stent? Or am I at a stent and an angioplasty? What codes do you suggest?

What is the correct code to bill for the embolization of MMA? Is it 61624? Or 61626 since the MMA is part of the ECA? For this procedure, selective cath placements/angios were done on the bilateral CCA (intracranial), bilateral ECA and bilateral MMA, along with the embolization. I am coding 36222-20, 36227-50, 75894, and 75898... I'm just unsure whether to assign 61626 or 61624. Our coder says it should be 61624, but provider thinks it should be 61626. Please advise.

"The abdomen including the PEG were prepped and draped sterilely. I made transverse incision including the gastrocutaneous tract around 5 cm in length. This was carried down to subcutaneous tissue following the course of the PEG. The adjacent tissues were not inflamed or infected appearing. The PEG was partially within the stomach and within the abdominal wall along the tract, no evidence of perforation or communication into the abdomen. The PEG was then removed. The opening into the stomach was then closed using a 2-0 Vicryl suture in figure-of-eight fashion. Fascial was then closed using running 2-0 Vicryl suture transversely. Wound was irrigated and sutures were used to close the dermis." FINDINGS: PEG bumper wedged within the gastrocutaneous tract, no infection. PROCEDURE: Abdominal wall exploration and PEG removal. Coders are in disagreement whether this is 43500, or 43870, or 43999. Please advise.

How should this be coded? "In the cath lab a physician places a catheter in the aortic arch from a right femoral artery puncture to perform an angiography. Fluoroscopic imaging is performed by the physician." Should this be coded as 36221 or 36200/75605-26? Should there be documentation of "non-selective angiography extracranial carotid and/or cerebral vessels and cervicocerebral arch" to report code 36221?

I am receiving a denial for code 35571 for a pop-pop bypass with reverse saphenous vein. Can you please confirm if this is the correct code for a pop-pop bypass?

A mixture of doxycycline and normal saline is instilled through an existing right-sided tunneled pleural drain. Would this be coded as 32560?

"After PVI ablation, noted frequent PACs of one dominant morphology. Activation mapping was performed using 3D Carto and area of earliest atrial activation was noted to be on the floor of LA with QS unipolar and 25ms pre P wave. RF application delivered with termination of PAC." Not sure if this is 63656/55 OR 57?

"An incision was made over the prior scar. Bovie dissection was used to enter the device pocket. It was quite superficial. The device was removed from the pocket. We then carried the Bovie incision down to the prepectoral plane to allow for a more ergonomically friendly location. We then dissected the leads as proximal as we could. The two baroreceptor leads were then cleaned, dried, and affixed to the new pulse generator with the wrench provided."

Manufacture reimbursement guide (facility billing) suggests using T0268 for baroreceptor generator replacement (Barostim). MD stated that this procedure should be coded as a dual-chamber ICD per national norms. I am not sure if it is appropriate to use 33263 for this procedure.

Our providers use code code 75820 for innominate/veno-venous collateral vein angiographies during cardiac catheterizations. Is this the correct code for these angiographies? We are thinking an unlisted code would be the correct code (76499). Please advise on what codes to use for these angiographies.

Is the following reported with 10035 or C9728?

"TECHNIQUE AND FINDINGS: The patient was brought to the procedure suite, placed in the prone position, and a timeout was performed. Preliminary ultrasound was then performed, demonstrating the target hypoechoic right leg mass. A safe posterior needle entry pathway was selected, and the overlying skin was marked. The site was then prepped and draped in standard sterile fashion. Subsequently, after administering 1% lidocaine as local anesthesia, a 20 gauge 5 cm introducer needle was advanced through the posterior soft tissues into the target lesion under ultrasound guidance. A 15 cm localization wire was then advanced through the needle into the lesion. This was confirmed both on ultrasound and CT. Follow-up ultrasound imaging demonstrated no evidence of hematoma or other complication. The patient tolerated the procedure well without any complication and was transferred to the recovery area in stable condition.

IMPRESSION: Ultrasound-guided percutaneous right leg mass fiducial marker placement."

Can you provide some guidance on ICD-10 coding of cardiogenic shock with other cardiac issues? There is a Coding Clinic from the 3rd quarter 2020, page 26, that states: "Question: When a patient is admitted and is diagnosed with both cardiac arrest and cardiogenic shock, how is this coded? Answer: Assign only code I46.9, Cardiac arrest, cause unspecified. The cardiac arrest is coded rather than cardiogenic shock, since code R57.0, Cardiogenic shock, is located in Chapter 18, Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not elsewhere Classified, and the cardiac arrest is a more definitive diagnosis." Would this also apply in cases where the patient is admitted with acute heart failure and/or cardiomyopathy? Since cardiogenic shock is a sign and symptom code, would you ever code it in addition to cardiac conditions, or only when it is cardiogenic shock alone, with the underlying condition not yet determined?

If we do a full echocardiogram (93306) and four days later a follow-up echocardiogram with Definity contrast (C8924), can both be charged?

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?

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."

Radiofrequency ablation of the S1, S2, and S3 lateral branches of the sacral dorsal rami.: "A 3.5 inch 22g spinal needle was then used as a marker to gauge depth and was inserted into the S1 foramen. This was repeated at the S2 and S3 foramen with separate needle... Each level was pretreated with 1 ml Bupivacaine 0.25%. Radiofrequency lesioning was performed, at 80 degrees C for 90s." We reported code 64625. Can you please explain the difference between codes 64625 and 64635? Code 64635 has sacral in its description as well as 64625. Also, codes 64625 and 64635 cannot be billed together, even with modifier-59? Is that correct?

"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?

"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 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)

We coded 35355 and 35302 for this case. Is this correct "Thromboendarterectomy of bilateral EIA/CFA/SFA/profunda femoris artery was performed in standard fashion. After adequate endarterectomy was performed, the arteriotomy was repaired using bovine pericardial patch with running 6-0 Prolene sutures. Before the completion of the repair, the arteries were allowed to forward bleed and back bleed. After the completion of the repair, we noted flow in the bilateral iliac system and femorals artery system. Satisfied with the results, heparin was reversed. After adequate hemostasis was achieved, all three incisions were closed in layers using 2-0 vicryl and 3-0 vicryl. Bilateral groin incision skin was closed using skin staples."

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. 

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.

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.

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

I have not been able to find much information regarding “eversion” endarterectomy. Does an iliofemoral endarterectomy have to involve an abdominal and a lower extremity incision? And if just the external iliac and common femoral arteries are endarterectomized, is this enough to bill iliofemoral endarterectomy?

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?

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?

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?

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.

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?"

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?

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? If so, any tips on how these would bill for the training caths prior to their credentialing for this service?

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?

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.

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"

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

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? 

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