Ask Dr. Z

Since the new 33741 code contains the description "for congenital cardiac anomalies" and the deleted codes (92992, 92993) it replaces did not have the "congenital" description, do you think that an unlisted code should be used for "non-congenital" conditions requiring the transvenous balloon or blade septostomy? If so, from which CPT section? Surgery (33999) or Medicine (93799)?

"There was a saccular aneurysm at the distal anastomosis of the patient's previous aortic graft just prior to the bifurcation. Two 8 x 59 covered stents were placed in the distal abdominal aorta instilled into the iliacs. Two additional 8 x 59 covered iliac stents were placed more distal for proper coverage and molded to form a new conduit within abdominal aorta." Are we able to use 34710 and 34711 x 2, or would this be 37236 and 37237?

When using CPT code 76000, do you need to have a permanent image?

Would the unlisted vascular surgery CPT be used? "DX: intraoperative hemorrhage. The patient was undergoing a TAH, and significant bleeding was encountered deep in the pelvis that proved difficult to isolate and control. The provider was called to the OR to assist in isolation and control of the source of the hemorrhage. The patient was already under general anesthesia with her peritoneal cavity exposed via a midline laparotomy incision. The peritoneum was copiously irrigated and examined. Several small areas of bleeding were controlled with cautery. The area was carefully examined, and better exposure was achieved by ligating and dividing several small bundles of tissue. A 2-3 mm diameter thin-walled vascular structure was identified and noted to be bleeding steadily. The vessel was then oversewn with 0 vicryl suture. Hemostasis was excellent. The peritoneum was again inspected and copiously irrigated, and no further bleeding was evident. At this time, the provider scrubbed out and left the abdominal closure to the OBGYN team."

During a minimally invasive mitral valve ring repair, the TEE probe could not be placed. Two providers tried and failed, so the cardiac surgeon called in his thoracic surgery partner to do a flexible esophagoscopy to evaluate why. Thoracic surgeon did not find a reason to prevent the TEE probe being placed. They tried again and TEE probe could not be placed, and surgery done with TTE. Is the thoracic surgeon's esophagoscopy separately billable? I think it is; please advise.

"Fluid was drained from the pericardium by insertion of an 18 gauge thin wall needle in the Subxyphoid area. A J tip wire was inserted followed by sheath insertion. An 18 mm balloon was then inserted to the pericardium and inflated. Balloon was then removed out the window created in the pericardium. One 60 cc syringe was utilized to drain 45 cc of fluid. A drainage tube was attached to a bottle for drainage. Procedure was complete and no tissue samples taken." Would this procedure be reported with code  33017 since the procedure is being performed via percutaneous needle and use of the balloon is to create a small hole or "window" large enough to drain the fluid?

Is the following sufficient for 93656, 93657, 93655 x 2? "Indication: Persistent A-Fib. Procedures performed: Comprehensive EPS with attempted induction and PVI ablation of A-fib, isolation of anterior wall for A-Fib. Report: Ablation catheter advanced into the left atrium. Mapping showed isolation of left veins, but right veins reconnected. Lesions placed along the posterior wall right side veins. Additional lesions placed along the floor of the left atrium to achieve a floor line. Block across the floor line confirmed by pacing. Additional lesions placed along the roof of left atrium, along a roof line, until the posterior wall was isolated. He remained in a-flutter, so additional lesions were placed, creating an anterior line. All lines were confirmed by re-mapping. Mapping showed several fractionated electrograms that appeared to be reentrant triggers; these were also targeted. During the ablation he had five separate activation patterns. He then developed a sixth pattern after ablating the fractionated areas. He was cardioverted. His recorded and EPS done."

I was asked if 76145 would be utilized by the cath lab. It has a status indicator S. What work is required of the department to submit this CPT code?

I had a patient who had a CRT-P downgraded to a single chamber pacemaker (His, RA leads capped, RV lead remains, old gen out/new gen in) and coded this to a 33227. The patient came in later that day for a CardioMEMS implant. This I coded to 33289. I am receiving NCCI edit that 33227 is component of 33289, not bypassable with mod. Should I attempt to send these two codes through and appeal, or do I really have to consider the pacemaker procedure a component of the CardioMEMS implant? This edit seems to make no sense to me, unless there is a clinical rationale why they should not be rendered on same DOS? What course of action would you take?

Would you recommend reporting code 96450-52 for a Spinraza injection where the radiologist is not directly puncturing the spinal canal, but rather injecting via an intrathecal port already in place, since by code definition 96450 "requires spinal puncture"?

Is an EKG with the reason "pre-op" and on the same day as a procedure always non-billable/bundled no matter what the IR procedure, or is it bundled with only certain procedures?

I coded this with unlisted code 49999. I am having trouble finding a similar comparable procedure or code. Can you please help? "TECHNIQUE/FINDINGS: Imaging guidance for device/catheter insertion: Fluoroscopy with permanent image storage. Access device: 5 French dilator. Insertion technique: Around the previous existing catheter site for gastrostomy tube the abdomen was prepped and draped in usual sterile fashion. 1% lidocaine was used to anesthetize the soft tissue around the original gastrostomy site. A 10 French dilator was inserted through the tract and used to confirm placement within the stomach. A short Amplatz wire was then placed into the stomach. Next, the inner portion of the gastrostomy site tunnel was scored and aggravated with the 10 French dilator now scored. Pressure was held at the site to achieve hemostasis."

When performing a cemontoplasty, may I report the hydrodissection of nerves as a separate unlisted code, or is it considered part of the main procedure?

"Transaxillary TAVR performed by interventionalist and cardiothoracic surgeon. Right CFA was accessed percutaneously with a 6 French sheath. Two guidewire technique was planned. Access was obtained in the left subclavian artery via cutdown by surgeon and 14 French sheath placed. Valvuloplasty performed. 29 mm Evolut PRO was inserted into the aortic valve. Hemostasis was then obtained in the left subclavian artery with sutures by surgeon. A Perclose device broke off in the right common femoral artery, so this was retrieved via cutdown, and a 7 mm x 7.5 cm Viabahn was placed for hemostasis. A crossover technique was used for this. Hemostasis obtained in the left common femoral artery using a Perclose device." Both physicians are billing 33363-62. What can be billed for the retrieval of the Perclose and the placement of the stent for hemostasis?

We have a new physician who is performing nerve blocks prior to performing an ablation and documents that the medication was injected "for procedural nerve block and postprocedural pain control". My understanding is that if it is for the procedure we CAN'T code it separately because it's considered bundled, but if it's for post-procedural pain we CAN code for it separately. But I usually see this procedure with moderate sedation or under GA, so this whole nerve block thing is throwing me. Do we, or do we not, code separately for the nerve block when performed in the same setting as a percutaneous radiofrequency ablation procedure?

I’m trying to understand question ID #12035 that states an AtriClip is considered part of a CABG, as well as question ID #9209 that states the same with CPT guidance “If excision or isolation of the LAA by any method, including stapling, oversewing, ligation or plication is performed in conjunction with any atrial tissue ablation and reconstruction (Maze) procedures it is considered part of the procedure”. In the below case, would you code 33999 for the atriclip ligation, and if not, as an ablation or MAZE is not performed as stated in the CPT ref, what ref do I use and or how do I explain this to the surgeon? "DX: Severe symptomatic multivessel CAD OP: CABG x4, left IMA to LAD, radial to PDA (proximal radial to aorta), saphenous vein graft to diagonal-1 (proximal saphenous vein graft to aorta), saphenous vein graft to obtuse marginal (proximal saphenous vein graft to aorta). ADDENDUM PX: Because of the patient's history of atrial flutter and need for anticoagulation, the left atrial appendage ligation was performed utilizing a #40 mm AtriClip."

"Access was gained in both directions. Multiple injections of intravenous contrast were given, and a fistulogram was performed and evaluated. Arterial anastomosis and JA segment stenosis occluding more than 80% of the flow. 6 mm balloon angioplasty was performed. The flow was sluggish. Therefore, a catheter was introduced into the upstream radial artery than 10 cm away from the arterial anastomosis. Digital subtraction imaging revealed patent upstream and downstream radial artery with sluggish flow into the fistula. The more inferior collateral vessel was smaller and more tortuous. This vessel was then coil embolized. Follow-up imaging shows cessation of flow through this collateral vessel. The larger collateral vessel within the arterial limb of the fistula had more laminar and direct flow to the more central circulation and therefore required ligation. The skin anesthetized with lidocaine, and a 1 to 2 cm incision was made overlying this collateral vessel. The vessel was bluntly dissected/ligated." Can 36832, 36909, 36215, 75710 be coded?

Report documents comprehensive electrophysiology study with coronary sinus catheter. Nowhere is left atrial pacing/recording stated, so I queried provider to make it clear in his report that the CS cath was used to pace/record LA. His response was, "It is always used to record left atrial activity, which is why it is there. It was also used to pace, which is mentioned in the report when we document bidirectional block." Here is the section of the report where bidirectional block is mentioned: "Additional lesions back to the IVC isthmus completed the line with bidirectional block at 125 milliseconds in both directions." Then he goes on to say, "Four ablations were placed near the coronary sinus os without any junctional beats, and mid catheter position without His potential was then applied, which demonstrated excellent junctional tachycardia with intact VA conduction for about 10 seconds and then resumption of normal conduction A-V." I think this is ambiguous and not clear enough to support 93621. Your thoughts and how would you respond to his reply?

"Patient admitted for EVAR for iliac aneurysm on the back drop of an aortic dissection where a steel core wire was advanced to the thoracic aorta and through the false lumen in right lower extremity. A 31 gooseneck snare was used to capture the steel core wire and externalized through the right femoral sheath. A pair of 6-French Raabe sheaths were advanced to top of wire crown then proceeded to fenestrate dissection plane by pulling the sheaths and wire distally from just below the left renal artery to iliac bifurcation. Wires were then directed to the true lumen from both fem sheaths to thoracic aorta where a 31 mm x 14.5 mm x 13 cm Gore ipsilateral trunk device was deployed through right femoral sheath at a position below the renal arteries and extended with 14.5 mm x 13 cm iliac limb extender down to right external iliac. Through contralateral sheath a 23 mm x 10 cm contralateral limb was deployed in over lapping fashion." How would you recommend coding this case?

"The surgeon created a femoral to tibial artery bypass with in-situ saphenous vein conduit. The surgeon then accessed the hood of the femoral anastomosis with a micropuncture needle, wire, and sheath. A right leg runoff angiogram was done, which demonstrated three large AV fistulae. These were marked, skin cutdowns made over each, and the offending venous tributary ligated with clips in each zone. Repeat, completion angiogram showed no further AV communications; the graft pulse improved markedly. Each cutdown was now in layers and skin glue applied."  What would I code for the AVF ligations?

The question and response below are from Ask Dr. Z in 2018. Are there any newer coding updates for the AngioVac procedure?

Question:

Are AngioVac thrombectomies reported with codes 37187 and 37799, or is the entire procedure (thrombectomy and bypass) included in unlisted code 37799? What would be a good comparison code for 37799?

Question ID: 10926

Answer:

Only report the unlisted code for the entire procedure. There is not really a comparison code, but would be based on what your physician does in each case. Catheter selection, veno-veno bypass, mechanical thrombectomy, and possible imaging are some of the things performed to add to the RVU chosen for the unlisted code. -Dr. Dunn

When billing for an intracranial embo, I use 61624, 75894, and 75898 x 2. Often the doctor does more than 2 follow angiograms but I read that the MUE is 2 per day for this. Another coder disagrees with me and says I should be billing for all of the follow up angiograms done. It doesn't make sense to me to bill for more than the 2 that are allowed, but maybe I am wrong. What do you advise?

Thank you.

How would you code a deep vein arterialization procedure? The procedure is described as a bypass with the proximal anastomosis with an in situ vein, and there is not a distal anastomosis. Vein valves are lysed. This is to cause the distal vein from the anastomosis to become arterialized (fistula?) as a last resort for limb salvage. Would it be appropriate to report the bypass code 35587 alone, or 35587-52 (for the single anastomosis) with add-on code 35686? Or can you give a clinical example of proper use of add-on code 35686?

"Next, given the patient's cardiogenic shock as well as her anemia, blood transfusions were continued and given the patient's cardiogenic shock again suspected secondary to the patient's HVAD thrombosis, we performed a retrograde left heart catheterization after exchanging for a J wire and inserted a 6 French pigtail catheter in the left ventricle. Then 2 mg of tPA were given directly through the pigtail catheter followed by 1 mg per hour for continued catheter-directed thrombolytics. After this the patient's sheaths were sewn in place. Access was obtained in the left femoral artery to allow for continued pressor infusion done using ultrasound and micropuncture technique. The sheath was additionally sewn in place." Since the thrombolysis was performed in the left ventricle, would this be reported with unlisted code 33999?

Dictation reads: "Under ultrasound guidance, 14 gauge Angiocath was advanced into the fluid collection from a left midline approach directed laterally. Approximately 18 mm of dark red serosanguineous fluid was aspirated. This was relatively thin, but became slightly thick towards the end of the aspiration. The entire collection was able to be aspirated from the left-sided Angiocath. Next, sclerotherapy was performed by slowly infusing a total of approximately 13 mL of 98% dehydrated alcohol. This was manually manipulated throughout the entire collection. The catheter was left in place for approximately 30 minutes while continuing to perform ultrasound imaging. The fluid within the cystic collection slowly became irregularly echogenic. The catheter was then removed and a pressure dressing was applied." I coded 49185, but it was returned internally due to no contrast. A senior coder is suggesting 10160/76942. I am concerned we are not capturing the injection of the sclerotherapy. What are your recommendations for facility coding? 

"Patient with thrombosed AV graft taken to operating room for TDC. The TDC was placed via right IJ, but the arterial port aspirated with resistance. There was a kink at the apex of the catheter at the insertion site into the IJ. After several attempts to correct, decision was made to remove all wires and catheters. Attention was turned to the left side and TDC was placed via left IJ. Ultrasound guidance and fluoroscopy were used on both sides." Should we assign code 36558-53 for the right side? Would we report codes 76937-26 and 77001-26 for both sides?

"Patient was seen for diagnostic cerebral angiography. Ultrasound-guided access into the right radial artery was gained. Simmons 2 glide cath was advanced over glidewire into the subclavian artery. While attempting to selectively catheterize the right vertebral artery, there was significant patient motion and inability to hold still despite sedation. The procedure was terminated."  Should we code discontinued vertebral imaging or extremity access? 

My surgeon placed an intact vascular tack into the proximal peroneal artery for dissection after he did angioplasty for occlusive disease. Would this be reported with an unlisted code (37799)? I am not finding information on coding interventions done on the lower extremity vessels for dissection. No aneurysms. Details are as follows: "The peroneal was angioplastied with a 3 mm balloon, there was a dissection, and intact tacks were placed in proximal peroneal. The left iliac was stented with an Absolute Pro 10 x 60 and post dilated. Completion showed excellent flow through the peroneal. The wires and catheters were removed, and the long sheaths were exchanged for short sheaths. Protamine was given for reversal. Pressure was held at all access sites."

Should the following be reported with code 37223 or 37236? "Based on the measurements of the previously placed AFX endograft, coverage of the area of leakage would require a 16 mm iliac limb from W.L. Gore and Company. There was a separation endoleak or a type 3 endoleak between the right iliac limb of the AFX device and the previously placed VBX stents extending the repair into the external iliac artery. We decided to put a bridging stent. We placed a 12 French Cook sheath over the stiff wire via the right common femoral artery, which was advanced under vision into the aortic reconstruction. We advanced a Gore 16 x 16 x 11.5 cm covered stent across the area of extravasation. This was then ballooned in place using a 14 x 4 Atlas balloon. Completion angiogram demonstrated excellent result with seal of the area of previous extravasation and good flow down both limbs of the aorto-bi-iliac reconstruction. The right iliac access was closed with an 8 French Angio-Seal device, and angiography revealed satisfactory flow down the right leg. No extravasation at the puncture site was noted." 

Is this reported with 33017 if the physician instilled fluid in the pericardial space during VT ablation? "40 mL of fluid was instilled within the pericardial space, then 3D mapping of the pericardial space was performed and the earliest breakout on the endocardial surface was identified. It was decided to do more extensive endocardial mapping with both the aortic approach, as well as the mitral approach with the HD grid was performed. The endocardial spot was much earlier than any of the epicarial spots. It was decided to give a single burn at this location, and following the burn, the patient still had inducible VT. It was clear that the VT focus was mid myocardium and was not accessible via the pericardial space or the endocardial space. A long guidewire was placed, and a standard pericardial drain was placed and the Agilis sheath removed. Then, 40 mL of blood-tinged fluid was removed and then 10 mL were injected back with 150 of Solu-Cortef. The pericardial drain was left to gravity drainage. It was sutured in place. The patient was then taken to the ICU in good condition."

Patient has two left vertebral arteries, one arising directly off the arch and one from the left subclavian. Both were selectively imaged. The MD also selected and imaged the right vertebral. Given the MUE for 36226, how would you recommend coding for the two left vertebrals?

How would you approach a case where a stent for stenosis is placed in the right pulmonary artery during the same session as a Melody valve placement? It doesn't appear that the two areas overlap. If stent placement is separately reportable, how should we handle a catheter placement code?

If the doctor does a left lower venogram and gives findings for the IVC as well as the lower veins does that mean I should bill for an IVC venogram also? This was done through the access sheath. In this case the doctor did go on to place her catheter into the IVU and did IVUS which I billed.

Should the catheter be in either the SVC or IVC before I bill 75825/75827? This is from your book: Vena cava angiography can be performed from a peripheral injection at the time of extremity venography (36005) or by placing the catheter centrally into the vena cava (36010). Essentially it seems that would be billing for 2 studies when done from one access. I really struggle with the Venous system. Thank you.