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follow up to Question ID 9252

Does the recommendation remain to bill 93307 if a TTE is performed with only spectral or only color flow and not both?

CPT 37799 or 37241? Please help.....

I need your help to assign the correct code for the procedure below:

"The posterior left calf percutaneous access was obtained in the midline posterior calf, below the lesion, and two parallel cryoablation probes were placed through the long axis of the malformation. An ultrasound-guided cryoablation performed.

SITE: Left calf intramuscular low flow venous malformation. The lesion measures approximately 3 x 3 x 2 cm diameter..

ABLATION TYPE: Cryoablation. Two parallel V probes were utilized.

ABLATION PROTOCOL: 10 minutes at 60 percent power; eight minutes passive thaw; 10 minutes at 50 percent power. After active thaw, the probes were removed.

ANESTHESIA: General anesthesia

IMPRESSION: Ultrasound-guided cryoablation of intramuscular left calf low-flow venous malformation."

Mammo and US Breast localization

Our radiologist did an ultrasound breast localization (19285), but the post-images showed the wire wasn't positioned correctly. He then redid the localization, but this time with mammo guidance (19281). Are we able to charge for both?

Interrogations of a Pacemaker during a radiology MRI

One of our Cardiology providers are sitting in to oversee an interrogation of a pacemaker / ICD during a radiology MRI. What CPT can we use for her time overseeing a Pacemaker during the MRI.

PEG REPLACEMENT IN ED FOLLOWED BY CONTRAST INJECTION IN RADIOLOGY

Patient had PEG tube replaced in the ER (43762). Patient was then sent to Radiology to have PEG tube checked for position or extravasation of air or contrast in the peritoneum. Radiology department is charging code 74190 for this tube confirmation. Should code 49400 be charged as well? We are not sure if the coder should charge code 49400 in addition to code 43762 on the claim. Please advise.

G-tube bedside

Facility setting, patient presents because G-tube fell out to the ED. IR provider comes to the ED and places new tube bedside with no imaging guidance and orders X-ray to be performed to confirm positioning. Should this be included in the facility E/M or be reported with 43762?

26040 vs 26989

Hello,

A Physician is doing US guided needling/aponeurotomy (percutaneous approach) , a fenestration technique was utilized for treatment of Dupuytren's contracture. Is this considered 26040 or is the unlisted code (26989) more appropriate.

Thank you

PULSED radio-frequency pudendal nerve ablation 64630 or 64999

Procedure says Pulsed RF was then applied for 2 minutes at 42 degrees C. Our debate is whether to use 64630 or 64999. 2020 CPT assistant states The instruction to report code 64999, unlisted procedure, nervous system, for "low grade thermal energy (<80 degrees Celsius)" applies only to codes 64633-64636 because the instructional parenthetical note before code 64633, Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint, lists these codes specifically. The chapter instructions notes say Do not report a code labeled as destruction when using therapies that are not destructive of the target nerve (eg, pulsed radiofrequency), use 64999. The CDR description of 64630 says The pudendal nerve is destroyed using chemical, thermal, electrical, or radiofrequency techniques. So which is it? Does the "PULSED" RF technique change the code to 64999 or do we use 64630? Thanks for your assistance with our great debate.

CRT-D Implant Post Initial Device System Removal for Infection

I understand that we would report the implant of a new CRT-D system with 33249 and 33225 after removal of the initial system due to infection on a prior date. Would we still apply the -QO modifier?

93452

My provider is saying I can report code 93452 with this note. I see no edits for billing 93452 and 92928.

However, the coronary arteries were also imaged, therefore I would code 93458, which is bundled with the intervention. There are no indications to support the LV was assessed for monitoring purposes. Should I code the 93452? 

"A diagnostic cath was performed five days prior to this procedure confirming disease. Patient has no new symptoms. Diagnostic images were completed with a JR4 and JL3.5 diagnostic catheter. The JR4 was used to assess the LV, the right coronary artery was not re-imaged given that it was a known chronic total occlusion. Instead of a JL3.5, we actually chose an EBU 3.5 guiding catheter, which gave good imaging although dual ostium were present between the LAD and circumflex. This identified known two-vessel coronary artery disease and a known chronic total occlusion to the right coronary artery with collateralization. Intervention: Stents were placed in the LC and LD."

tomography breast biopsy

What would you code for this? 19081 or 19499?

"The calcifications in a segmental distribution at 3:00 axis are visualized on scout image and subsequently targeted using tomography. Through a small dermatotomy, the rotating automated vacuum-assisted biopsy device was advanced to the appropriate coordinates and positioning was confirmed using tomography guidance."

Ultrasound guidance was then used to deploy the biopsy clip. Would this be 76999?

0523T

Can CPT code 0523T be used when 2D mapping is performed (i.e., a single-view method that creates a 2D image) instead of 3D functional imaging? The only difference in the procedures is the 2D vs. 3D image.

How would you code a central venogram?

"Patient was scheduled for a CRT-D implant. A pocket sized for the device was formed. A guidewire was placed and advanced into the central vascular was attempted. The guidewire only advanced into a tortuous posterior vein identified as a large azygos. A central venogram was performed, which demonstrated an occluded SVC thought to be secondary to mass effect from the pectus excavatum. Due to complicated vasculature and narrowed SVC, the leads and CRT-D placement was aborted."

Since there is not a code for pocket creation, it appears the central venogram would be the only thing we could code for this procedure. What code would be used for a central venogram?

Exclusion of Pulmonary Sequestration

"Patient with pulmonary sequestration has a first order feeder artery coming of the descending thoracic aorta at T8. Via percutaneous femoral access a thoracic endograft stent and extension were placed." Would this be reported with 37243 and 36200 since there is no aneurysm or occlusive disease? Thoracic surgeon planned robotic resection of the sequestration the next day.

PICC/Drainage cath removal/ bedside in the inpatient setting

Our providers are being asked to remove catheters such as PICCs or drainages for inpatient patients. What code can we bill for inpatient removals with no fluoro?

Example: "The existing catheter was evaluated at bedside. There is no further drainage from the catheter. The retaining suture was cut, and the catheter was removed. The site was bandaged. There were no complications."

Removal aortic cannula

Dr. O was called in during a TAVR procedure by another provider. During the TAVR the aortic Cannula got stuck. I would like to bill something beside a unlisted code but I am not finding one. Dr O small cut down was created, dissected down through the subcutaneous tissue. Pro glides remained intact and in place. proceeded with manipulating the aortic cannula with a gentle twisting motion the cannula came free. I would suspect that it was likely hung up on the pro glides or subcutaneous tissue alone. with gentle manipulation the aortic cannula was removed and the wire access was maintained. then proceeded securing each pro glide. next the wire was removed and again we secured each pro glide no evidence of bleeding. Dr K took over continued management of the pt and continuation of this case.

Primary thrombectomy

Should we report code 37184 for the following part of the note? Provider is stenting the bilateral common iliac along with primary mechanical thrombectomy.

"After complete anticoagulation was achieved, primary mechanical thrombectomy of the soft thrombus of the left common iliac artery was performed using an 8 mm x 60 mm Mustang. Subsequently, bilateral common iliac PTA and stenting was performed using a 10 x 37 mm Express LD stent on the right and a 10 mm x 37 mm Express LD stent x 2 (conjoined) on the left common iliac artery."

Amputated Toe Revision with Debridement

Would revision of an amputated toe with debridement of skin, subcutaneous, muscle and bone be 28810 again for the revision along with 11043, or is the debridement bundled?

IVUS with Fistulagram/Angioplasty

When performing IVUS services, is the entire dialysis circuit considered one vessel? Can 37252 be billed for the peripheral dialysis segment and 37253 for the central segment?

Roof and floor line ablations post PVI--93657 x 2?

"After EPS, 3D mapping, ICE, with ILAM mapping, we noticed crowding inferior to the LIPV and along the ridge. We started ablation along the ridge, then proceeded with roof line, and then proceeded to isolate the posterior wall with a floor line, respecting esophageal temperatures. We then proceeded to confirm that all pulmonary veins were isolated with antral ablation. Isolation of PVs and the posterior wall was confirmed with entrance and exit block pacing."  Then at the end it states 93657 billed twice for roof and floor line ablation for posterior wall isolation in the left atrium for additional treatment of a fib after completion of PVI. Would you code this to (2) 93657s for the roof and floor line ablations?

SURGEON AND FACILITY BILLING FOR US GUIDED THORACENTESIS 49083 76942

MY SURGEON PERFORMS AN ULTRASOUND GUIDED THORACENTESIS (49083) DOCUMENTS THAT U.S. WAS USED TO LOCATE AND ISOLATE LARGEST POCKET OF FLUID. THE PROCEDURE IS DONE IN A HOSPITAL FACILITY AND THE RADIOLOGIST BILLS THE GUIDANCE (76942) , AND DOCUMENTS THAT US GUIDANCE WAS PROVIDED FOR DR A, IMAGES SHOW LARGE LEFT PLEURAL EFFUSION. THE PERMANENT IMAGE IS STORED IN THE FACILITY'S PACS.

WHAT IS THE APPROPRIATE CODE TO BILL FOR MY PHYSICIAN, 49082 OR 49083?

CPT code for stenting of the RV-PA homograft conduit

Our providers are stenting stenotic areas of the RV-PA conduit in patients with TOF repairs. Here is a snip of what is being done: The conduit is balloon dilated with a 12 mm Atlas (18 atms), 14 mm Atlas (18 atms), and 16 mm Atlas (18 atms) with simultaneous RCA angiography.

"A 10 mm x 40 mm Palmaz XL transhepatic biliary stent is placed across the conduit on a 16 mm BIB. Post-stenting, RVOT angiography shows an unobstructed distal stent with proximal narrowing at the previously placed stent. The stented conduit measures 14 mm distally and 11.8 mm at the proximal conduit where the previous stents were placed."

What would be the appropriate code in these cases, 33745 or 37236? Or another code altogether?

Cerebral Venous Manometry (profee code for specific cath?)

IR provider dictates cerebral venous pressure reading taken with pressure monitor catheter. In previous Q&A explains no charge for this. Given that this is a special type of catheter with ability to be set to zero for readings, I want to rule out any additional professional fee that could possible be gained. (Transduction of venous pressures was performed via the microcatheter as it was withdrawn back thru venous sinus system. The transducer was zeroed. Sequential manometric pressure readings were obtained as the microcatheter was withdrawn & were found to be: A benchmark catheter was advanced to RT internal jugular vein. This was placed on heparinized flush line & a XT27 microcatheter was advanced carefully to RT transverse sinus. A pressure monitoring catheter was attached & zeroed. with selective measurements obtained frm the Torcula, prox, mid, distal transverse sinus, sigmoid, internal jugular vein.

Multiple generator changes prior to generator implantation.

"Patient had dc pacemaker generator and electrodes removed due to infection. Patient had a temp perm lead placed via the external jugular to the RA and the chronic generator was connected as the external pacemaker. Approx. a month later, the temp perm lead via the jugular was pulled and replaced with a new temp ra lead via the LSVC and the externalized chronic generator was swapped with a new generator but that generator was not implanted. Finally a few weeks later the most recent generator was swapped again for a new dc generator and implanted with new RA and RV leads, with the LSVC lead removed. All were done by the same provider."

1st procedure: 33216, 33233, 33235?

2nd procedure: 33216 and 33234 (not certain how to bill the generator as it wasn't implanted)

3rd procedure: 33234 and 33208? Since the second generator was never implanted and replaced with the third I figured single system lead removal and new generator implant, or is there a way to incorporate the original generator change out with this procedure?

Complete Bilateral ABI 93923

Does documentation support 93923? My concern is the 93923 requires segmental pressures at three or more levels?

Interpretation Summary: The resting ankle/arm index on the right is normal. Right tibial artery stenosis. The left ankle/arm index is minimally abnormal at rest. Small vessel disease of the foot on the left.

Lower extremity pulses are documented at RT/LT femoral, RT/LT popliteal, RT/LT dorsalis pedis, and RT/LT posterior tibial. Lower extremity segmental pressures are documented at RT/LT dorsalis pedis, RT/LT posterior tibial, RT/LT great toe.

Nurse practitioners and invasive procedures

I have a group of physicians who are wanting the NPs to perform services related to CPT codes 20220, 47537, 49180, and 50432. Our state guidance is very limited regarding invasive procedures. The NPs have performed these and have billed Medicare and Medicaid, and we are getting denials indicating that the procedure is not reimbursable when performed by this type of provider. Anyone out there with the same issue?

37184

Regarding Q&A# 15103 you indicate to report 37184-50 for the initial right and left thrombectomies; however, per CPT guidelines, code 37184 is reported for the primary thrombectomy once per vascular family for the initial vessel treated. Per CPT Appendix L, the pulmonary artery system is a singular vascular family. Can you please explain the rationale for using modifier -50 on 37184?

Mechanical thrombectomy of the atrial clot (RA/RV chambers)

"Evaluation of the transesophageal echocardiogram was performed by an anesthesiologist, demonstrating a dumbbell-shaped thrombus in the right atrium to the right ventricle. Then the catheter was navigated up to the SVC, and T24 FlowTreiver catheter was introduced into the right atrium. Initial two sessions of aspiration were performed using the T24 catheter, unsuccessful. Under fluoroscopy and TEE, a curved T20 catheter was introduced into the right atrium and then navigated towards the tricuspid valve. After additional three attempts of mechanical thrombectomy, the thrombus was successfully evacuated with the curved T20 catheter under TEE guidance. Repeat TEE was performed, demonstrating only minimal residual thrombus noted."

I believe this would be an unlisted 93799. Would you agree, and if so, what other code could I could compare for pricing?

Hospital Cardiac Cath Log-signed by provider

For professional coding, may the hospital cardiac cath or procedure log be used in conjunction with the provider's dictated procedure note to code for services performed? Example, if the provider provides all the findings for angiography and heart cath along with details for any PCI performed in their dictated procedure note, but they don't include details such as catheter placement for coronary angiography and heart catheterization, can the log be used to confirm catheter placement and once confirmed can coding be assigned for these services using this information? The log is signed by the provider who performed the service.

Lastly, if the log can't be used to support catheter placement, is provider documentation of type of catheter used for "diagnostic exam", "coronary angiography", or "left ventriculogram" enough to support coding coronary angiography and heart cath without the provider detailing placement of the catheter in the left ventricle for heart cath or a coronary artery or stating "selective" coronary angiography was performed?

Percutaneous Extra-anatomic Veno-veno Costoclavicular Bypass

How would you recommend coding this?

Access obtained in rt brachiocephalic AVF, EJV, cephalic vein.

Wire snared from cephalic access through the fistula and catheter advanced over wire from the fistula access and exposed through cephalic access.

A catheter was tunneled from subclavian vein to the EJV access and advanced wire through jugular access. The end of this wire was then externalized through the fistula access.

At this point, there was wire from the fistula access out the cephalic access through subcutaneous tunnel and into the EJV access and IVC. Attempts made to advance sheath over the wire, but this would not advance beyond the tunnel despite attempt to dilate with balloons.

Therefore, sheath placed in AVF over wire, through this a smaller sheath advanced which easily passed through tract and then delivered into right brachiocephalic vein. Extra-anatomic bypass created using overlapping Viabahn stents extending centrally into the brachiocephalic vein into the fistula with good overlap into normal outflow vein.

genicular arteries

The descending genicular artery and inferior medial genicular artery were catheterized. Would you code 36247 only, or 36247 and 36248?

Cardioversion

“Successful DCCV with 1x 200J.” Is this enough documentation to code a cardioversion (92960), or do we need the report to give more details (for example, pad placed and internal vs. external)? I assumed this is enough with DC (direct current) meaning it was done external and the amount of Jules for how much current.

Explantation of infected axillobifemoral bypass graft

Would you code this as 35903 x 2 for the graft explant? Would you code anything for the interposition graft at the axillary artery?

"The graft was resected from both groins as well as the axillary site and sent for microbiology. The axillary artery at the site of the anastomosis was fairly inflamed and friable. I decided to perform a segmental resection and interposition graft using a cryo SFA graft 8 mm."

Nerve block injection on Quadratus Lumborum

What procedure code we can use on nerve block injection on quadratus lumborum?

Block Procedure #1

Block procedure type: Quadratus Lumborum

Procedure laterality: Bilateral

Nerve block: Single injection

Needle gauge to anesthetize skin entry site: 27G

Needle gauge for procedure: 20g and Touhy

Block technique: Ultrasound guided

Ultrasound guidance used to identify relevant anatomy.

Ultrasound guidance used to visualize local anesthetic spread around nerve(s).

Ultrasound guidance used to guide needle to targeted nerve and avoid vascular puncture.

Brief medication summary

IV sedation as documented on MAR. See MAR for full medication details

Local anesthetic medication: Bupivacaine

Local anesthetic volume: 30cc each side mL

Complications: None

Thank you

35141 aneurysm repair help with code for hematoma evacuation 35860?

"Patient had TAVR and developed pseudoaneurysm in femoral artery. An incision was made in the left groin and extended because it was a large aneurysm. It was dissected. After dissection it began to bleed. Vessel loops/clamps were placed. Once bleeding was controlled we explored the vessel. We evacuated the hematoma, which extended below the inguinal ligament and beneath the pubis into the inguinal canal and down into the scrotum. The artery was debrided, and a large hole was found where closure devices had been placed, which was repaired. The rest of the hematoma was evacuated and closed deep layers and wound vac was placed."

I'm looking at 35141 for aneurysm repair, but I'm struggling with what to use for exploration of left groin/hematoma evacuation. It was all through the same incision. Can you please advise?

abscess catheter removal under fluoro

If an abscess catheter is removed with fluoroscopic guidance (not just the suture cut and pulled out), can we show something for this? They didn't really do a contrast injection to evaluate the tube. The one in question is a hepatic abscess catheter. They actually put the guidewire in, but don't state an injection of contrast was done. Then, under fluoroscopic guidance, they removed the tube. We realize that if they just cut the suture and pull it out, we'd be at an E&M.

septo-pulmonary bundle ablation

"PVI ablation (93656) completed. A left atrial roof line and left atrial floor lines ablated for afib were also performed post PVI ablation. An ablation of a septo-pulmonary bundle connecting the epicardial with the endocardial atrial layers in the postero-inferior aspect of the right inferior pulmonary vein that triggered and maintained atrial fibrillation now performed." How would the septo-pulmonary bundle be reported? Or would it not be reported?

Cast change with arthrogram and EUA with range of motion tests

Hi Dr. Z: Our ortho docs will do cast changes under anesthesia. During the change they do what they call "an exam under anesthesia" where they inject contrast and do range of motion tests calling the injection of contrast arthrograms and using fluoro to take images. Our question is, would the cast change bundle in the EUA and the arthrogram? We believe that the EUA would be bundled, but we're thinking that the arthrogram is part of the EUA? Thank you for your help

Pulmonary Artery Balloon Angioplasty Segments/Sub-Segments

Can you please elaborate on how to code for this (92997/92998)? We are specifically wondering how many times we should code 92998 in the following scenario: successful balloon pulmonary angioplasty in two subsegmental branches of the right A5 segment, one subsegmental branch of the right A4 segment, and two subsegmental branches in the right A3 segment.

We are also wondering if selective catheterization can be coded with the intervention?

Cardiac arrest during MI revascularization procedure

If a patient develops ventricular fibrillation during MI revascularization and has to be converted multiple times to restore sinus rhythm, is there anything I can code for that?

Reposition indwelling abscess drain

Our physician completed a successful ultrasound-guided repositioning of an indwelling abscess drain. Patient came in for drain placement, but the existing drain just needed repositioning. Would you agree that the appropriate code would be 49406, with modifier -52 for reduced service?

Can 32097 be billed with 32220?

Our provider did a thoracoromy with decortication of the left upper and left lower lung for fibrothorax. He also did a left upper lung wedge biopsy because of abnormality seen on CT scan (pathology report came back as inflammation tissue). Can 32097 and 32220 be billed here?

TAVR by innominate surgical cutdown

What code would you recommend using for TAVR by innominate surgical cutdown approach? 33999? 

Coding a second read of 19083

We have a radiologist who is performing a second read of procedures 19083, 77065, and 76641 that were performed at an outside facility. Codes 77065-26, 77 and 76641-26, 77 were coded, but we are unsure how to code the second read by the radiologist for 19083 since the -26 modifier isn't allowed for the code and the 77 modifier also would not be completely applicable. Can you please help?

Dual Chamber PM replacement and pocket revsion

We noticed you no longer get an edit with 33222 and 33228, so we were wondering in this scenario if we could charge for both. "The device was removed from the pocket, and the leads disconnected from the device. The pocket was enlarged inferiorly to relocate the PM lower to accommodate radiation therapy. The leads were tested and reconnected to the new generator."

93922 or 93923 Counting levels evaluated

When determining the number of levels evaluated for the assignment of 93922 or 93923, CPT instructions state, "Potential levels include high thigh, low thigh, calf, ankle, metatarsal and toes." Do you count metatarsal AND toes as one level or two? For example if the documentation states, "Segmental waveform analysis at the bilateral ankles, metatarsals, and toes show no definitive abnormalities", would that be 93922 or 93923? If the metatarsals and toes can be evaluated separately, can you explain how this is done?

Subclavian stent

What CPT code would you use for a subclavian in-stent restenosis requiring a stenting procedure? The physician documentation states the stenosis is threatening the LIMA and causing the patient to have angina symptoms. This is currently being denied based on the LCD that is looking for a PAD with symptoms code in order for this to be payable. The patient doesn't have arm symptoms of the upper extremity, so a diagnosis code of T82856A and I25119. Any suggestions? We appealed with the procedure note documentation and again received a denial.

EP STUDY FOR AF ABLATION

Patient had EP study for AF ablation, CS pacing and recording, 3D mapping, ICE mapping. Physician documented as, "Small area of residual connection on the carina of the left-sided veins, which was addressed with single ablation lesion and all four veins then demonstrated both entrance and exit block." Is 4 veins ablation related to pulmonary vein ablation? Can I report code 93656? Please clarify.

CPT 74420 bilaterally

CPT 74420 – Urography, retrograde, with or without KUB has an MUE of 2. If a retrograde pyelogram is performed bilaterally, is it appropriate to report a quantity of 2 representing each side imaged? Would we also report a quantity of 2 for 52005 for catheterization and injection of contrast on each ureter (MPFSDB shows 52005 carries an indicator of “0” for bilateral surgery indicator so modifier 50 is not appropriate but this code, too, has an MUE of 2)?

Aspiration arterial thrombectomy in lower extremity vessel

Is it appropriate to report code 37184 for an arterial aspiration thrombectomy performed in a lower extremity vessel? Code 37184 specifically states "mechanical" thrombectomy. I'm wondering if this follows the same guidance for the coronary thrombectomy (CPT 92973).

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