Ask Dr. Z

Can you bill code 76000-59 with 33227?

"A 6 French angled pigtail catheter was used to perform left heart catheterization. LV pressures were measures, LV gram was performed, and catheter pullback was performed. Aortic root injection was performed in LAO projection." The surgeon did not indicate the catheter was crossed to aortic valve, but hemodynamic pressure of the left ventricle and aorta are documented with coronary angiography. Are codes 93459 and 93567 reportable for this case?

I'm confused; I see a 93454. Doctor is billing 93456. I thought documentation needed to state they crossed the aortic valve to bill heart cath codes? See the following example: "Right heart catheterization was then performed utilizing a 6 French Swan-Ganz catheter. The catheter was then removed. A 5 French Tiger cath was successfully positioned at the ostium of right coronary artery. RCA was performed in multiple views. Then, the cath was placed in left main ostium, and left coronary angiography was performed. Catheter was then removed." There is no mention of crossing aortic valve.

If a provider does an LVAD interrogation at the time of a right heart cath, can he report both codes 93451 and 93750?

Right internal carotid & right vertebral angiograms from right common femoral access. US used to determine potential access sites and for real-time guidance into the RTCFA. Images saved to patient's record. Catheter advanced into RTII and diagnostic angiogram performed. Shows prompt filling into RTII with atherosclerotic and irregular RTCIA with a chronic dissection. Dissection extends into lower aspect of aorta. Attempts were not made to cross the chronic occlusion/dissection. As such, decision was made to access the contralateral groin. LTCFA accessed successfully and 36224, 36226 were completed.

Is the catheter placement, angiogram and US done on the right side billable? On one hand I'm thinking it's not because 36224 includes access so I don't believe we should bill for this access but on the other it was on a different side. Doctor states diagnostic but it seems more road mapping to me.

Thanks.

Would you report the following with code 33992 or 35206 ?

"The Impella device support was weaned without significant change in left ventricular function on transesophageal echocardiogram. The right axillary incision was reopened using a combination of electrocautery and sharp dissection. The graft was exposed. The Impella device was freed from its securing sutures and removed. The graft was ligated using several heavy sutures and the end oversewn with a 5-0 prolene stitch. The incision was irrigated thoroughly with antibiotic solution. The incision was closed in layers and the skin approximated with staples. The previous exit site of the Impella was packed with iodoform gauze."

Our radiologist performed a CT-guided needle localization of perihepatic gallstones. The patient then went to the OR for surgical removal. Is there a good CPT code for this, or would we use unlisted liver code 47399? From the report: "The patient was placed in the supine position in the CT gantry. An appropriate skin entry site was chosen to access the extrahepatic inflammatory collection with associated extraluminal gallstone. The skin was prepped and draped in standard sterile fashion. Standard timeout was performed, and Universal protocol policy steps were completed for the procedure. 1% lidocaine was used for anesthesia. A 10 cm Hawkins needle was advanced into the appropriate position. A needle localization wire was deployed coaxially through the needle, and the needle was removed. Permanent CT images were obtained for the medical record. Technically successful CT-guided percutaneous needle localization of perihepatic inflammatory phlegmon with associated gallstone."

Is there any C-code to bill when Definity Echo contrast is injected during ICE 93662? PVI was aborted after finding LAA thrombus. Q9957 is on the claim as well as 93656-74. 

Catheter ablation of persistent atrial fibrillation ablation consisting of redo antral pulmonary vein isolation, left atrial roofline, left atrial flutter line, electrical isolation of the left atrial posterior wall, and empiric cavotricuspid isthmus line.

I reported codes 93656 and 93657. Is this correct?

Would this be reported with codes 33967 and 92941? "A BMW angioplasty guidewire was advanced into the LAD but would not cross the lesion. I placed a guide liner for additional support. A Choice PT wire was then used to cross the obstruction, and the lesion was dilated with a 2.5 mm balloon. I then deployed a 3.0 x 15 mm Xience drug-eluting stent. Repeat angiography was performed. During the follow-up imaging a small bubble was introduced into the circumflex, and the patient subsequently deteriorated rapidly. A code was called, and the patient was subsequently intubated and ACLS protocols initiated. I was able to exchange the sheath in the RFA for an 8 French balloon pump sheath and then placed a 40 cc intra-aortic balloon pump into the descending thoracic aorta."

Is there a code for a fibrin glue injection into a fistula? Report summary as follows: "Patient with a known fistula to the rectum. Contrast is injected through the presacral abscess drainage catheter. Given the drainage output color, I suspect the fistula continues to communicate with the rectum and therefore fibrin glue is injected."

Have the guidelines changed as far as reporting the 93623 post ablation? My physicians are wanting to bill this code, but I am finding conflicting guidance on whether I can bill the code when performed to test the adequacy of the ablation performed.

One of my physicians did an MAA mapping procedure where he utilized a Trinav catheter (HCPCS code C1982) to temporarily occlude a vessel. To be specific this patient had abnormal anatomy with a replaced left hepatic from a gastric artery directly off the aorta. I’m being asked to place 37242 on the MAA mapping procedure for the temporary occlusion created by the catheter in the replaced left hepatic artery. When the patient was brought back on a later date the Y-90 treatment was performed on three branches of this replaced left hepatic. Can we utilize the embolization code 37242 for the temporary occlusion created by the catheter on the day of MAA mapping of the same vessel that is going to be occluded later on with the Y-90 treatment? I was under the impression that prophylactic embolization was to cut off flow to other sources other than the source the physician will be embolizing for the Y-90 treatment.

I've been speaking with a coworker here at our practice and she is stating that we cannot bill pacemaker interrogations (93289) along with EKGs (93000) on the same day. It is my understanding that if the EKG is done prior to the pacemaker check we can bill 93000 with a -59 modifier, since they are separate procedures.

"During the CABG procedure, our provider encountered a heavily diseased ramus. Separate and extensive endarterectomy was performed. Unfortunately, this was not suitable for bypass, so the artery was ligated at its mid aspect. The distal location of the artery appeared to be appropriate, so a longitudinal arteriotomy was once again performed. There was once again near complete obliteration of the lumen of the artery due to chronic disease. The distal aspect of the ramus intermedius was ligated."  What is the appropriate coding for this scenario? Do we bill for the failed endarterectomy or just the ligation? Or something else?

A patient had a TAVR procedure (percutaneous TF access 33361). The valve was embolized after in position. The patient was taken to the OR for a valve replacement. I think the cardiac surgeon could possibly bill code 33405 for the surgical portion. For the TAVR procedure, I'm not sure what the interventional cardiologist could bill for. Possible 33361 with a modifier or maybe something different?

Is there a CPT code to report a ganglion plexus ablation, or do you still use unlisted code 64999?

From one of our physicians: Just did a case for a patient with occluded SFA stents. A few of these stents were stent grafts, so I used the Jetstream device to perform thrombectomy. The rest of the SFA had bare metal stents, for which I did atherectomy with Jetstream. In addition to the atherectomy code, would I use 37184 or 37186?

Will you please clarify which code should be used for percutaneous ethanol sclerotherapy of a vascular malformation of the face? There is some confusion between appropriate usage of 61626 (which specifies head/neck) and 37241. No catheter was placed, just an injection of ethanol from a small needle.

Cardiovascular doctor does laser lead extraction in surgery due to RV lead malfunction of a dual pacemaker. Case is then turned over to EP doctor who inserts a new RV lead and then puts in a new generator due to battery end of life. I am thinking the EP doctor gets 33228 but not sure what to give the cardiovascular doctor for the laser extraction in surgery. Also, are there different codes for laser extraction of ICD leads? Laser extraction is not common in our institution.

Is 37242 correct for geniculate artery embolization for OA tibial plateau?

"Under ultrasound guidance the left common femoral artery was accessed with 21-guage needle. A 4 French exchange dilator and Bentson wire was placed into abdominal aorta. A 5 French SOS-2 catheter was then utilized to select the contralateral, right common and external iliac arteries. Bentson wire advanced into the right superficial femoral artery. Indwelling 5 French sheath was exchanged for 6 French Balkan sheath, and advanced to the level of mid external iliac artery. A 5 French Bentson catheter was inserted over wire into distal right superficial femoral artery. A TrueSelect microcatheter and shapable tip Fathom microwire used to manipulate into a branch arising from the popliteal artery which was the superior lateral geniculate artery The superior lateral geniculate artery was embolized with a temporary embolic agent, Primaxin, to a point of near arterial stasis."

Physician did debulking of the tricuspid valve using Inari FlowTriever using TEE manipulation. Seventeen passes of FlowTriever aspiration. Would I get a catheter placement with 37184, or would this be 93799?

For the following, would codes 36252 and 36245 be correct? "Procedure: selective and non-selective renal artery angiogram and direct stent to ostial proximal segment of the right renal artery. Description: A 4 French sheath was placed in right common femoral artery. A 4 French JR4 diagnostic catheter was used to perform selective and non-selective renal artery angiography. With following findings, the abdominal aorta showed no evidence of abdominal aortic aneurysm. Left renal artery had proximal 30% stenosis, large 4.5 to 5 mm vessel. Right renal artery had an ostial proximal 90% stenosis. A 6 French sheath was exchanged for a 4 French sheath. 70 units/kg of heparin given. ACT was 271. A 55cm JL4 guide and 0.01 Prowater guidewire place distal right renal artery. 5.0 x 14 mm EV3 Paramount mini GPS stent placed ostial proximal segment of right radial artery with approx 2 mm of the proximal edge located inside the abdominal aorta. Stent was deployed, and stenosis went from 90% to 0% with TIMI-3 flow." 

Since there are two different levels, is it okay to report codes 64999 and 64483 together in the following situation?

CT-guided rupture of right L-3-4 synovial cyst (64999) and CT-guided L4-5 nerve block (64483)

Which code would you use for incision and debridement of the infected port pocket? "The port pocket incision and neck dermatotomy site were reopened. Using manual pressure, purulent contents were expressed from the incisions. The pocket was copiously irrigated and anterior antegrade and retrograde fashion using normal saline. The port pocket was debrided. The incisions were packed and were then left open and packed with iodoform gauze." If unlisted, which unlisted code would you suggest and what will be the comparable code for it?

The cardiologist performed a TEE, and his documentation states that he performed color flow, but there's no mention of spectral Doppler. Would you bill 93312-26 and 93325-26, or would you include 93321-26 for the documentation of the regurgitation and wall motion? Study details state: "A complete echo was performed using complete 2D and color flow Doppler. During the study the esophageal view was captured. The probe was inserted by the cardiologist. There was no probe insertion difficulty. Anesthesia performed sedation. Irregularly irregular rhythm was present during the study. The study was limited due to hypoxemia. LV is with normal systolic and diastolic function. The RV has normal size and function. Normal wall motion. LA has normal atrial appendage and no thrombus. Mitral valve is structurally normal, with normal leaf mobility and trace mitral valve regurgitation."

With the new PICC codes, the notes state when catheter tip confirmation is not documented to report code 36573 with a -52 modifier. If we placed a bedside central venous catheter with no documentation of catheter tip confirmation, would you also code 36556 with a -52 modifier? 

Patient is ESRD and on HD. Right upper extremity AV graft with swollen arm. Patient had chronic occlusion in the right innominate (central segment) vein stent. Surgeon preformed balloon angioplasty of the stent without a hemodynamically significant residual stenosis. Can I still assign 36907 for it, and chronic occlusion is considered as stenosis?

New HCPCS code C9780 goes into effect October 1, 2021. Do we assign a regular non-tunneled central line CPT code for physician billing or an unlisted code?

"Doctor removed infusaport, inserted AI pacemaker, angioplasty superior vena cava due to scar tissue. This was cut from the port body. Subsequently a Glidewire was advanced down through the port channel through the right atrium and into the inferior vena cava. Over the Supra core wire a 4.0 x 100 mm angioplasty balloon was used to perform angioplasty of the fibrotic scar bands which restricted passage of the sheath. Stenosis in the superior vena cava in this region of sheath was in excess of 90% though the majority of the superior vena cava likely remained patent."

Is 36590 the correct code for infusaport removal? Is this plus 37248 appropriate to be billed with PM insert?

Are you aware of any bundling issues between 34710 and 34718? Patient had prior aorto-bi-iliac EVAR now with leak and new iliac aneurysm. Physician extends the graft proximally in the aorta and distally in the right iliac, then places an iliac branch device in the left iliac. We have coded as 34710, 34711, 34718. Guidelines say, "Do not report 34718 in conjunction with 34710, 34711 on the same side," so we believe we should be able to bill both if done on different sides. However we get an edit that only 34710 is billable and no modifier is allowed. Do you agree with coding?

How would you code this case? 36221, 36902, 0237T?

"Pre/post op diagnosis: left AV fistula inflow stenosis. Description: The right common femoral artery was accessed using a micropuncture needle. This was exchanged for 5 French sheath using Seldinger technique. A pigtail catheter was advanced into the ascending aorta and arch angiogram was performed. Please see above findings for details. Next the left subclavian artery was selectively catheterized and a left upper extremity angiogram and left upper extremity fistulogram was performed. 5 French short sheath was exchanged for 5 French 90 cm sheath positioned in the left brachial artery. The proximal left brachial artery was subsequently balloon anigoplastied using a 4 x 60 drug coated ranger balloon. Completion angiogram and fistulogram revealed widely patent left radial artery without residual stenosis. Findings: high grade proximal left radial artery stenosis successfully treated with atherectomy and balloon angioplasty."

We understand that 71045 is for a single view, 71046 is for two views, etc., and that it is inappropriate to report 71045 multiple times when another CPT code offers multiple views. However, what about multiple single-view radiology examinations NOT done at the same radiographic session? For example, an inpatient with pneumonia may have multiple chest x-rays on the same day but not at the same session, one at 8:00 am, 12:00 pm, 4:00 pm, and 10:00 pm. If all four studies are interpreted by the same physician, what are the correct codes for billing?

I coded 50389 for the catheter removal. Not sure if 50684 and 74425 are correct for the contrast injection into the double-J stent (ureterogram)?

"Right tube nephrostogram was performed. Then a right ureterogram was performed to determine if the double-J ureteral stent is patent. Following identification of contrast flowing into the urinary bladder via the indwelling double-J ureteral stent, the right nephrostomy tube was removed under direct fluoroscopic visualization to prevent inadvertent retraction of the indwelling ureteral stent. Finding: An antegrade tube nephrostogram demonstrates mild dilatation of the right collecting system with contrast flowing through the double-J stent into the urinary bladder."

What statement needs to be in a procedure report to code 93657 now that the physician no longer needs to state additional ablations were performed due to continuing Afib after PV isolation? CPT Assistant Nov 2020 stated 93657 could be coded for patients diagnosed with persistent Afib whether in fibrillation or sinus rhythm at the time of treatment. They stated, "Ablation of fractionated potentials or linear lesions as adjunctive therapy for Afib should be documented, when performed." Patient with persistent Afib. A 3D map of the LA and PVs in Afib rhythm showed conduction into 4 PVs and scar on posterior wall. Wide antral circumferential ablation around LSPV, LIPV, RSPV, RIPV, resulting in electrical isolation. The report states, "Roof line and floor line ablations were performed resulting in posterior wall isolation. The patient remained in AF after ablation, so DCCV with 360J was performed resulting in conversion to sinus rhythm." Code 93657 x 2 or does the physician now need to specifically state the linear lesions were "adjunctive therapy" for Afib?

Is it appropriate to report 37221-50 when bilateral common iliac kissing stents are placed for 100% occlusion of left side and 30% occlusion of the right? Is there a guideline for treating peripheral arteries based on percentage of stenosis, as there is for dialysis circuits and coronary arteries?

I am unsure how to code this delayed endoleak repair. What codes would be best used for the Amplatzer plug and angioplasty?

"A J wire was advanced into the abdominal aorta, and a 5 French sheath was inserted. 2 perclose systems were deployed in the right femoral artery, and an 8 French sheath was advanced. A glide wire was used to get access in the arch, and a pigtail was advanced on it. Then the left brachial artery was percutaneously punctured and a 6 French sheath was inserted as above. Heparin was administered and ACT maintained at about 300 seconds. A glide wire was used on the left arm to get access to the left carotid artery. A 10 x 30 injection of the descending aorta was obtained and the endoleak seen. A 22 mm Amplatzer plug was advanced from the left arm and deployed in the false lumen and in the origin of the subclavian artery. A new angiogram showed no endoleak. Then a Coda balloon was advanced and the distal part of the stent was fully expand, and a completion angiogram showed a decrease of the type 1B endoleak."

What is the difference between using CPT code 33340 and 93580?

"I advanced a JR4 catheter over a J-wire into the lower portion of the inferior systemic venous baffle and advanced a pigtail catheter retrograde into the body of the left ventricle and left the guidewire in it to act as an additional landmark to guide the direction of the transbaffle. I proceeded with closure of the atrial septal defect to eliminate the possibility of a paradoxical embolus given his transvenous pacer leads and atrial shunt. The Agilis sheath was still across the defect, and based on the size, I chose a 5 mm Amplatzer Septal Occluder. This was carefully prepared and de-aired and advanced through the Agilis sheath. The wire and dilator were removed and the sheath carefully flushed. I advanced the septal occluder through the delivery sheath and using intracardiac echo and fluoroscopic guidance, deployed the distal disk in the pulmonary venous side of the baffle, pulled everything back until there was good tension and then deployed the remainder of the device on the systemic venous side."

Are we still able to charge for the diagnostic procedure, in the event that we find disease that we need to fix? So can we charge 93458 and C9600 when we do them in the same day, or does C9600 include the diagnostic procedure in the code with the angioplasty?

Code 34713 bundles with 36245. Is it appropriate to append a -59 modifier to 34713 when it is billed with 36245?

Patient comes in ER with complete heart block, and provider places a temporary transvenous pacemaker that was advanced into the right ventricle using fluoroscopic guidance (33210). The following day, the same provider had to do an implantation of an active fixation temporary pacemaker lead to facilitate ambulation over the weekend, because the primary provider that would perform the permeant pacemaker procedure is not available until the following week. Would I report code 33211 for the dual chamber temporary pacemaker?

From H&P: "Woman with PMHx s/f PAH, pulmonary emboli (PAH thought to be out of proportion, Eliquis) here for PA angiogram." PMH lists CTEPH (chronic thromboembolic pulmonary hypertension) and pulmonary embolism. Cath report states: "Pulmonary artery angioplasty. Right heart catheterization. 60-year-old female with PMH of CTEPH referred for BPA #1. RHC performed with findings (93451). Sheath into right pulmonary artery. Selective angiography (93568). CTEPH treatment: Right lung A9 web lesion and A10 subtotal occlusion. Lesions in A9 subsegmental branch and A10 segmental branch were serially dilated with balloons, restoring flow distally with improved pulmonary venous drainage." How should this be coded: as a pulmonary angioplasty with 92997/92998 (LCD Article A56365 states I27.24 CTEPH is a covered diagnosis) or as thrombectomy with 37184? If patient's have CTEPH, would we code angioplasty because they have stenoses/narrowing of their pulmonary arteries as webs, bands, occlusions form, or would we code as maceration of clot/organized thrombus? (Patient not covered by Medicare.)

If I remember correctly from a seminar it was indicated that if a patient is brought to IR for an embolization for hemorrhage that we are not able to bill for a diagnostic angiogram. Is this correct? Example would be a GI bleed. Patient has had CT angio or endoscopy for diagnosis. Patient is referred to IR for possible embolization. The angiography was performed in multiple arteries to locate the site of hemorrhage with subsequent embolization. Are there any instances that it would be appropriate to charge for both imaging and embolization at the same episode?

I have been told to append a -KX modifier to pacemaker insertions and pacemaker removal/replacements (33206, 33207, 33208, 33227, 33228, 33229) for Medicare patients. In one of your 2021 webinars  you stated that removal/replacements for EOL should have an -SC modifier instead of -KX. I have tried to do this, but now I'm being questioned about it. Can you verify that I should actually be using the -SC modifier for these? Or should I drop it and do as I'm told?

During a venogram of the lower extremity, the catheter placement went as far as the common femoral vein. This was an ipsilateral approach. Is the appropriate catheter placement code 36011 (first order) or 36005 (non-selective)?

For the following would you recommend code 32557 or unlisted code 32999? "Successful fluoroscopically-guided exchange and upsize of left pleural catheters (x2) with the lateral chest tube repositioned into the LEFT lung apex."

For kyphoplasties, do PACS images of balloon usage support 22514, or is this something that should be queried and downgraded if no additional documentation other than cement placement?

The patient comes in with a dual pacemaker at end of life. The decision is made to replace a biventricular pacemaker and add an extra lead. I'm a little confused about how this is coded. Should we use the initial pacemaker insertion/ replacement for these procedures (33206-33208), and is it appropriate to also code the removal of the old pacemaker? We are looking at code 33208 with 33225 vs. 33228/33229. Codes 33228 and 33229 seem like they should be used when a dual or biventricular pacemaker is changed for the same unit.

If a cardiologist who is interpreting pre-TAVR/TMVR/TTVR/Watchman MRI/MRA/CT testing does an extensive amount of surgical planning in addition to the radiology interpretation, is there a way to bill for this extra time other than using modifier -22? The interpreter is not seeing the patient in follow-up nor is she going to be performing the surgery, but she is providing her professional imaging expertise to the surgeons. At times she spends up to over an hour past the additional time it normally takes to do an interpretation of these tests to assist with the surgical planning. We looked into 99358-99359, but I'm unsure if this is appropriate to bill with these codes if the provider is not performing an E/M service, as the primary codes they are billing are for the imaging interpretation. We know that since they are billing for the interpretation they cannot use interprofessional consult codes nor the radiology consult code.

A provider performed atherectomy in the SFA occlusion using a Jetstream device. He then also performed thrombectomy in the same segment using the same device. The atherectomy and thrombectomy were done almost simultaneously. In this case, can we code separately for the thrombectomy, and if so, would it be coded as primary or secondary?