Ask Dr. Z

"The capsule was incised and the generator removed from the pocket.  The leads were visually inspected and found to be free of any  obvious defects. The pace/sense characteristics of the leads  were found to be functioning normally. The generator pocket was  relocated with extension deeper towards the pectoralis fascia and  more superiorly due to the superficial nature of the original  generator pocket and risk for skin erosion. The pocket was  flushed with Gentamicin irrigation solution. The generator was  connected to the leads and implanted in the pocket. The  connections were tested and found to be functioning  satisfactorily. The pocket was closed in layers using 2-0, 3-0, and 4-0 absorbable suture." I would only code for this replacement of pulse generator. Should pacemaker pocket relocation be also coded since deeper toward the pectoralis fascia and there was a risk of skin erosion? Or there needs to be active erosion and deeper toward subpectoralis instead of pectoralis in order to code relocation?

Should you report 0439T if contrast is only to enhance imaging and not for assessment of viability?

Based on appendix E in the CPT book, 36573 is NOT exempt from modifier -51. But based on Supercoder and Medassets you can't use -51 on 36573. Can you please clarify if it can or can not be used for 2021?

I need some guidance on coding this case. My understanding was it is part of 20550/20551. I am being directed to use 27299 for the needling part.

"Under ultrasound guidance, a 20 gauge spinal needle was advanced into the left gluteus minimus tendon. Needling/tenotomy of the tendon was performed with simultaneous administration of 1% lidocaine solution. Subsequently a solution containing 1 mL (40mg/mL) Depo-Medrol and 4 mL 1% preservative-free lidocaine was injected into the greater trochanteric bursa. The needle was removed and hemostasis achieved."

Would you agree with 37242 for this procedure? "Patient has a post-traumatic right forehead pseudoanurysm. With direct ultrasound guidance, a 23 gauge needle was passed into the pseudoaneurysm, and 0.5 mL of thrombin was then injected. There was immediate, complete thrombosis of the pseudoaneurysm. Successful percutaneous thrombin injection for treatment of an enlarging right superficial temporal artery pseudoaneurysm."

We were wondering from a coding aspect if you would treat LBB leads for left bundle branch pacing any differently than Bundle of His leads? Our facility is leaning towards following the AHA HCPCS guidance from 2019 and using the unlisted codes for the BOH, but since that guidance does not specifically address the LBB leads they are wanting to code them differently:

We have a patient who received a PM insertion with three leads: an RA, an RV, and a BOH lead. They are wanting us to utilize 33999 to encompass the entire procedure (both 33208 + 33225).

However if the same patient receives a PM insertion with three leads: an RA, an RV, and a LBB lead, they are wanting us to bill 33208 and 33999 and map the 33999 back to the 33225 code only.

On the professional side, we have concerns with coding them differently, as we are not seeing a difference in their purpose: both the BOH and LBB leads are replacing the use of the a traditional LV lead. We already have concerns with denials, as we know that MA Products are not going to pay for unlisted codes. What are your recommendations?

I have a case where the patient previously had a Watchman device placed but now has a peri-device leak and they are going in with an Amplatzer vascular plug for closure of the leak. Per reading in your 2020 Diagnostic & Interventional CV coding book on pages 197-198 it looks like the direction is to code 33340 again unless it's the LARIAT II and you state to use 33999-GZ. Am I reading this correctly? Should we be using 33340 for the plug via transseptal approach?

For the following, would 36832 and 36833-XU be correct? "Suffering from Steel syndrome. Incision made and band removed from the AV fistula. There was a thrombus between the arterial anastomosis and the start of banding. Cephalic vein was transected. The stump toward the brachial artery was oversewn. Alpha vein which was the cephalic was treated with thrombectomy by balloon. Clamp placed on cephalic vein. Incision made in the right axilla. Dissection allowed the axillary artery to be mobilized and vessel loops placed for proximal and distal control. Plan was to create proximalization of arterial inflow so inflow would come off the axillary artery. PTFE graft was tunneled along the medial aspect of the arm. Anastomosis was created between the axillary artery and the PTFE graft. At the antecubital fossa the detached cephalic vein was sutured in an end-to-end anastomosis with a portion of the graft. There was strong palpable thrill and audible bruit."  

We had a patient who had right carotid bifurcation stenting with DEP (37215-RT) and then went on to have an anterior communicating aneurysm coiled. Since the stent catheter placement is bundled, can we capture a catheter placement for the embolization? (It appears that there was not a separate access site.)

The provider does bilateral ilio femoral angiogram with catheter placement in distal aorta from left femoral access and then selects right femoral for complete right lower extremity angiogram. Is it 75710-RT? How do we bill for left ilio femoral angiogram? Provider has findings for bilateral ilio femoral arteries and right tibial, peroneal arteries.

New to coding this and trying to understand angiography 36222-36228. Understanding is that we code as far as the cath tip goes. Is there enough info to code 36224 per this per the findings vs. the proc section?

"CEREBRAL ANGIOGRAM: Injection of the left common carotid artery with imaging centered over the head. PROCEDURE: Right common femoral artery was accessed. Catheter was advanced over the angled Glidewire and used to selectively catheterize and inject the left common carotid artery artery. Two-dimensional digital subtraction angiograms of the head were obtained in multiple projections. FINDINGS: Device is in excellent position extending from cavernous to supraclinoid left internal carotid artery left internal carotid is widely patent. The left anterior cerebral artery and the left middle cerebral artery are widely patent. The left external carotid is patent with persistent opacification of a right parasagittal tumor stain via the enlarge left middle meningeal artery."

Our facility radiologist in 2020 performed... "CT fluoroscopic guidance, a 17 gauge trocar needle was advanced from the percutaneous entry site through the lung and was positioned just superficial to the nodule. In a coaxial fashion, 4 x 18g core specimens were obtained. The specimen were placed in formalin and transported to the pathology department for evaluation. Samples was also submitted for flow cytometry. Through the introducer trocar, a fiducial marker was placed along the posterior aspect of the mass. The needles were removed, and a sterile Vaseline gauze dressing was applied."  IR wants to use 77012 (CT/fluoro guidance biopsy), but I'm looking at 77014 (CT guidance fiducial). Can one or both be used?

Can you use 33745 for stent placement in a vein for treatment of severe SVC stenosis in pediatric patient?

I have a lot of physicians using IVUS during their lower extremity procedures. My question is when they use IVUS in the SFA, anterior tibial artery, and posterior tibial artery, do I report code 37252 for the SFA and 37253 x 2 for the AT and PT vessels?

Would the correct codes for this case be 51102, 76942, and 77002? "PROCEDURE: With the patient placed supine on the angiography table, ultrasound was utilized to identify the urinary bladder. This scan in the immediate suprapubic region was anesthetized with 1% lidocaine. Deeper anesthesia with a spinal needle was utilized. Using ultrasound guidance, a 5 French Yueh catheter was introduced into the urinary bladder, and a 0.035 Amplatz guidewire was advanced. Several dilators were then utilized, followed by placement of a 14 French pigtail multipurpose catheter, which was formed within the urinary bladder. Small amount of contrast was injected, confirming location of the pigtail catheter within the urinary bladder. Catheter was secured to the skin using 2-0 Prolene suture. Patient tolerated the procedure well without immediate complications. Conscious sedation using intravenous Versed and fentanyl was provided under direct physician supervision for 30 minutes. Total fluoroscopy time 0.9 minutes." 

Would C9764-C9767 be coded as 3722X on the professional fee side?

If the patient already has an ASD, and the pulmonary vein stent protrudes into the atrium at the veno-atrial junction, can we report code 33745? Are all pulmonary vein stent placements reported with 33745/33746? Also, does a PDA stent qualify as an intracardiac shunt creation (33745)?

"For this patient, a dual chamber ICD generator was replaced with a CRT-ICD generator. Original RA and RV leads were kept, and a third lead was added, placed on the anterolateral RV free wall, and plugged into the LV port of the generator. Lead placement in the coronary sinus/LV was not attempted."  How should this be coded? I’m guessing 33241 and 33249, since no lead was placed in the cardiac venous system, but I would appreciate your input.

I am having issues with code 33508 when billed 33517-33521 for the vein graft. Code 33508 is denying due to 33533 being billed for the artery. For 2021 should 33508 be billed with a modifier, and if so which one? Please provide some guidance.

Physician did a multiple-vessel (R & L) PE thrombectomy for a patient with commercial insurance. Can the physician code separately for the two distinct vascular families? 37184 in the RPA, 37185 in the right upper lobe, 37185 in the right lower lobe. Then code 37184 on a separate lesion in the LPA, 37185 on the left upper lobe and 37185 on the left lower lobe. Is it appropriate to code 36015 for selective cath placement in each of the segmental pulmonary branches, 75743 for each selective diagnostic CTA, and 99152 for moderate sedation?

What is the appropriate CPT code for a sternal clavicular joint exam that is two views only (oblique and PA)? We are currently reporting 71130; however, that code is for a minimum of three views. Code 71120 is for the sternum (not the joints).

For 2021 E&M, should the providers document the risk in their office note now?

In 2018 you answered that you would report a stent in the LVAD graft with unlisted code 33999. So for reimbursement purposes, what CPT would you compare that to? I need to submit, so that we can create a .dot code to the 33999, and I am unsure what this needs to be based off. 

"There was redundancy of P2 with ruptured cords. Ruptured cords were excised. The mitral valve was repaired as follows 2 sets of Gore-Tex neo-cords were placed to the P2 segment and the posterior prolapse was reduced and the valve was tested and was competent. There was a small leak between P1 and P2 which was closed with a 4-0 Cardionyl suture in a mattress fashion. Then we placed a 36 mm Cosgrove annuloplasty ring with 2-0 interrupted Tycron sutures and the Cor -knot device. The valve was then tested and it was competent and the cortex Neo-Chord for type II proper left. A folding plasty of the P2 segment was then performed using a 4-0 Cardionyl suture to reduce the height of the posterior leaflet." Would this be coded as 33427 or 0543T? Does 0543T include the ring if used? Or, does the "radical reconstruction" cover the artificial chordae placement?

In the past we have used code 37236 for a stent placement in the pulmonary artery for congenital cardiac treatments. Would 33745 be the appropriate code to use now?

Patient came in for calf mass excision, and vascular surgeon was called in to assist. Vascular surgeon harvested saphenous vein graft, then the vein was non-reversed in order to keep proper orientation for the venous reconstruction. An end-to-end venous anastomosis was created using a running 6-0 Prolente suture distally. The vein was then pressurized by releasing the distal control. MD then replaced and bulldog clamp on the saphenous vein segment. Then MD sewed end-to-end venovenous anastomosis with a running 6-0 Prolene suture. Following this, the proximal and distal clamps were removed. The right greater saphenous vein harvest site was irrigated with warm saline solution."

Should we go with unlisted because we can't find another code that would describe such procedure?

I have a diagnosis question. In your case of the month for October 31, 2018, type II endoleak is coded to other specified complication of vascular graft. However, in 3rd Quarter Coding Clinic 2020, pages 3-5, type II endoleak is coded to I97.89 (other postprocedural complications of circulatory system). Can you explain which is the correct coding for type II endoleak?

This is the only documentation for Doppler during a stress echo:

Doppler Measurements & Calculations

MV Peak E Wave: 0.6 m/s

MV Peak A Wave: 0.44 m/s

MV Peak Gradient 1.46 mmHg

TR Velocity: 2.34 m/s

MV Deceleration Time: 220.8 msec

TR Gradient: 21.93 mmHg

Is this enough to indicate spectral and color flow velocity were done?

If a report documents the abnormality was approached from the craniocaudal aspect using an upright digital tomographic mammography unit, and a biopsy needle was placed adjacent to the abnormality under computer guidance, and confirmatory stereotactic mammography images were obtained to document needle placement, would the post mammography imaging still be billable? Would the tomographic mammography be considered the same as stereotactic mammography biopsy?

If a physician performs the reprogramming and refill of an implanted pump (62370) under ultrasound or fluoroscopy guidance (used to locate the reservoir fill port on the implantable pump), are we able to separately report the guidance? If the guidance can be separately reported, which code would be appropriate for ultrasound guidance (76942)? Or for fluoroscopy guidance (77002)?

We know that a gastrostomy tube insertion without the use of fluoroscopy should be coded with an unlisted CPT. Would it be more appropriate to use code 49999, Unlisted procedure, abdomen, peritoneum and omentum, or code 43999, Unlisted procedure, stomach? The CPT code book classifies a percutaneous G-tube insertion within the Abdomen, Peritoneum, and Omentum section.

We have a patient who has pancreatic cancer. Patient is here for CT-guided celiac nerve block followed by celiac neurolysis with alcohol. Can we code both 64680 and 64530? Previous advice from 2016 said to only code 64680. Is this advice still correct for 2021?

"Patient was brought to the cath lab. He was draped and prepped in sterile fashion. A micropuncture needle was advanced from the subcostal approach. Pericardial cavity was reached. Straw-colored fluid was drained through the micropuncture needle, then a micropuncture wire was advanced and a micropuncture sheath was introduced into the pericardial cavity. A J-wire was advanced through the micropuncture sheath, and a pericardial drainage catheter was placed in the pericardial cavity. Around 450 cc of fluid was drained from the pericardial cavity. Afterwards, the drain was left in place and sutured." In this case can I report code 33016 (pericardiocentesis with image guidance) along with 33017 since the physician left the drain in place? Or does 33017 include the work for 33016?

The radiologist removed an infected port (36590) and packed the pocket with iodoform gauze and loosely closed with interrupted 3-0 Vicryl sutures and steri strips. The patient returned two days later for packing removal and full closure of the site. Can we bill 36590 with a -52 modifier for the first procedure and 36590 with a -58 modifier for the second procedure, or is the second procedure included in the first?

At the end of an atrial flutter ablation a vascular closure device is deployed but cannot be removed by the EP physician. A vascular surgeon is consulted who then performs a cutdown, removes the device, and suture repair of the femoral artery. Is this reportable with 35226?

Would Z45.2 (encounter for adjustment and management of vascular access device) be an appropriate ICD-10 code for the placement of central line (36556) or arterial line (36620)? One source says that these are appropriate, while another one does not define this diagnosis as including placement.

"No pulse in the right hepatic artery. Gastroduodenal artery clamped, aneurysm was entered, resection of aneurysmal tissue was performed. Saphenous vein was harvested and then anastomosed to the gastroduodenal artery in a reverse fashion. I then redirected my attention to the left hepatic artery. I extended the arteriotomy approximately 1/2 cm to widen the artery. I then fashioned the vein graft to fit this arteriotomy. A functional end-to-end anastomosis between the vein graft and the left hepatic artery was performed."  It has been suggested that I code this with code 35121; however, in my opinion, this is should be coded with an unlisted code 37799, as this was a hepatic artery - gastroduodenal bypass (no current CPT code for this procedure) and not a repair of an hepatic artery aneurysm. It is my understanding that code 35121 is for repair of aneurysm with graft insertion, not an actual bypass. Please advise which would be the more appropriate coding and the rationale behind your opinion.

Per Chapter 21 guidelines in ICD-10-CM, c., #3: “A status code should not be used with a diagnosis code from one of the body system chapters, if the diagnosis code includes the information provided by the status code.” Therefore: if stenosis is present in a coronary artery stent, T82.855A only would be reported; however, what if there is one patent stent in a distinctly separate coronary artery? Would this not warrant reporting both codes, and is it permissible?

Regarding NCD 20.33 TEER update: when is this effective, and will it be retroactive?

We need clarification regarding review of image, tracing, or specimen under the old E/M guidelines (prior to 2021). Can a cardiologist receive credit for personally reviewing the images and documenting a finding of their own services? Can this be done if their group are the ordering physicians and have billable CPT code? And are there any limitations? For example, re-reviewing the same records at each visit?

Is it appropriate to separately code a TEE during a pacemaker/ICD procedure? One example we have seen is a TEE done during a pacemaker upgrade. The TEE was performed to evaluate the pericardial space and the cardiac structures during lead extraction. This question is for both the facility and the physician coding.

Hoping you can help us resolve a dispute over medical necessity for use of arch study code 36221. Because the code describes diagnostic imaging, I assume that we need documentation of indications and findings to use it. Without an indication, I assume it is just a guiding shot to find the orifice of the subclavian or innominate for angiography of the arm. Cath lab staff wants to apply this code without indications (i.e., trauma to the arm only). Is a history of PVD enough? What if there is no history of PVD or problem with the arch vessels? Could you please provide some examples of indications?

Regarding the new office E/M guidelines, what list of conditions fit the definition of "1 acute or chronic illness or injury that poses a threat to life or bodily function" or "1 or more chronic illnesses with severe exacerbation, progression, or side effects of treat" for cardiology? In particular, considering unstable angina can come in a rainbow of different grades (some requiring hospitalization, some can be managed with outpatient LHC or a stress test), would this justify a level 5 for dx criteria? Please advise.

I'm needing some help with understanding proper coding and modifier use within a surgical global period.

Patient has fistula placed (36821) as well as tunneled catheter (36558) placed. Two months later, superfistulization (36832) is performed. Two weeks after that (still within 90-day global period) the tunneled catheter is removed in the office. What would be the proper modifier use in this scenario? Can catheter removal code 36589 be reported within this period in the office setting?

Or in the case where a fistula is placed in the LEFT arm, but fails in two months and a new one is placed in the RIGHT arm within the 90-day global period, would this be reported with modifier -79 because it's different arms or -78 because it's related, but not anticipated?

"Patient with AF burden 5-10% on most recent event monitor, also atrial aflutter (recent EKG), presents for PVI/CTI. The left pulmonary veins were circumferentially encircled as a pair. Adenosine was given within the left superior vein, and a PV reconnection was seen, suggesting breakthrough at the carina. Additional lesions were given in the carina and on the posterior aspect of the left superior vein. Adenosine was given again in the left superior vein and no PV reconnection was seen. The right superior and inferior veins were circumferentially encircled as a pair. Pulmonary vein isolation was performed until there was no further evidence of atrial activation within the veins. Adenosine was given and no PV reconnection was seen. The catheter was withdrawn into the right atrium into the cavotricuspid isthmus. A CTI line was created. Pace-testing confirmed block." Aside from 93656, should I report also 93655 (since atrial flutter was mentioned on history), 93657 (breakthrough at the carina), and 93623?

The CPT book now states to report an additional code if the Impella is removed via open approach. So if the provider takes the patient back to the OR to do an open removal and sutures the femoral artery, do you think we should report 33992 and 35226-XU?

Is the scout CT separately reported prior to US-guided liver biopsy: Code 74150?

"The lesion was difficult to initially identified on ultrasound. Therefore, a scout CT was performed. This demonstrated that the lesion was present behind one of the ribs. A second look with ultrasound was able to demonstrate the lesion using breathing techniques. The skin was marked. The patient was prepped and draped in the usual manner. The liver lesion was again identified with sterile ultrasound.  The skin and subcutaneous tissues were anesthetized with 1% lidocaine. Under direct ultrasound guidance a 17G coaxial guidance needle was advanced to the margin of the liver lesion. Three 18G core biopsies were then obtained."

A hysterosalpingogram was attempted on a patient but the procedure was terminated. What would be the correct code/s to report for this situation? "Patient was placed on the IR fluoroscopy table in the lithotomy position and the perineum prepped and draped in the usual sterile fashion using maximum sterile barrier technique. Preliminary scout radiograph of the pelvis is unremarkable. Duplicated speculum was inserted. Cervical os was never identified. Patient complained of moderate pain and procedure was discontinued. Collaboration with OB/GYN he will be required to complete the hysterosalpingogram."

There is a code for removal of an infected graft in the lower extremity, but I can't seem to find the code for removal of a graft that is not infected. The patient had a removal of a fem-pop PTFE bypass graft x 2.

What is the correct code for degeneration of the pubis symphysis? And can you give your rationale for the code selection?