Ask Dr. Z

The IR physician can only code for the catheter placements and angiogram. The infusion of the drug is not billable because it is not treating anything. The neurologist will bill for the WADA testing with code 95958; is that correct? Or if the interventional radiologist injects the anesthetic but does not perform all the testing, should the radiologist report 95958-52?

"Same day return to OR after ax-bi-fem bypass. We reopened the left groin incision first and noted there was no obvious pulse in the graft. We then opened the right groin incision and noted that there was a great deal of redundancy to the graft here. When we opened the incision we were actually able to see that there was a pulse within the graft at this point, and now there was a pulse in the left groin as well. We became concerned that this was possibly a technical issue with the right groin with the redundancy of the graft. We then accessed the left limb and obtained an angiogram, which showed no technical issue within the graft. We then also imaged the inflow, which appeared to be without any issue and brisk flow through the graft, which was patent in its entirety without any evidence of any thrombus. We then turned our attention to revising the right groin redundancy. The graft was transected and spatulated. A portion of it was resected and was re-anastomosed, removing some of the redundancy from the graft."

What's appropriate to code here? 35879, 35883, or 35860?

My question is regarding how to code correctly for Wada testing when done during an embolization procedure for an arteriovenous malformation. Listed under operation performed is "superselective neurophysiological provocative testing (Wada test) and neurophysiological monitoring with EEG and SSEP recordings". The documentation within the report states, "Injected 5 mg of methohexital through the microcatheter over 5 minutes. There were no neurophysiological monitoring changes. This was considered a negative provocative test, and we felt that we were in a safe position for embolization." Does this qualify for billing 95958?

Due old laminectomy changes at L5-S1 there is no posterior epidural space available for injection from an intralaminar approach. Therefore left L5-S1 transforaminal ESI as well as a sacral hiatus approach performed with separate needles and contrast injection followed by injection of dexamethasone with Marcaine.

Can we code 64483/64484? Or only 64483? Please advise.

We have a provider that is performing CT-guided injections of the pars interarticularis defect trigger points. The needle is placed via CT guidance into the posterior aspect of the pars interarticularis defect trigger points. Is this coded as a facet injection or as a TPI?

Can you tell me whether or not the great saphenous vein has to be imaged and documented in order to bill a complete study?

"Removal of infected fem-pop bypass. Creation of ilio-profunda bypass w/cryo-preserved fem artery.Multiple stents were removed from pop artery w/no blood return from above-knee pop to suggest adequate revascularization.Tunnel was created w/end-to-side anastomosis with the segment of cryo-preserved fem artery to the profunda bypass.Graft was tunneled w/end-to-side anastomosis b/w the cryo-preserved fem artery and the above-the knee pop. GSV in upper thigh was harvested for 20cm. End-to-side anastomosis b/w cryo-preserved fem artery and reverse GS. Below knee pop was exposed. Then the vein was tunneled deep in the pop space w/end to side anastomosis b/w below knee pop and reverse GSV." 

Would this be considered a sequential composite graft (ilio-pop with vein) and add-on bypass graft, composite, prosthetic to vein (unlisted 37799, 35681), or would we look to multiple bypass codes? It reads like like multiple bypass grafts "jumping" off from one another.

Would the Impella be coded if RFA sheath was exchanged for Impella CP?

Patient's surgery included aortic valve replacement (mechanical) and left coronary sinus aortic root annuloplasty.

"During the aortic annulus debridement, it was noted that there was gross amount of purulence that was cultured and negative for any bacteria. It was felt that the best course of action would be to patch this left coronary sinus to help strengthen as a result of the chronic inflammatory nature of the native valve, which had been slightly weakened. Therefore a small patch of autologous pericardium was sewn in place as a patch to the left coronary sinus directly below the left coronary ostia to help strengthen the annulus for eventual valve sutures in this area. The valve annulus was then sized with valve specific sizers."

Is there a specific CPT code I should use for the aortic root annuloplasty, or would this be included with code 33405?

Do we append a -25 modifier to an office visit when they do an EKG same day? I am getting conflicting answers on this.

"Patient had a gastric bypass surgery and now needs a gastrostomy tube insertion. Under CT guidance, access was achieved with a 5 French Yueh catheter. The stomach was insufflated, and four gastropexy sutures were placed within the remnant stomach. Intraprocedural spot CT images demonstrated there to be gas and contrast within the gastric lumen, confirming positioning. Sterile dressings were applied, and the patient was transferred to the Interventional Radiology department for gastrostomy catheter placement." Can anything be coded for this CY portion, or is it part of the gastrostomy insertion? The catheter was placed in IR.

We are a cardiology group. Can you explain the rule on how many diagnosis codes payers want on a claim? I see articles about one of the most common billing errors is too many diagnosis codes being used, then I see articles about making sure we have the complete picture of the patient's health; using acute and chronic diagnosis codes. 

The CPT Codebook description for code 34708 states that all non-selective catheterizations are included. The notes preceding the Endovascular Repair of Abdominal Aorta and/or Iliac Arteries section of the book state, “Non-selective catheterization is included in 34701, 34702, 34703, 34704, 34705, 34706, 34707, 34708 and is not separately reported. However, selective catheterization of the hypogastric artery(ies), renal artery(ies), and/or arterial families outside the treatment zone of the endograft may be separately reported.” Can you please clarify these instructions for us, just so we’re sure we understand? If we are coding 34708 and there is a selective catheterization performed, but it is within the treatment zone (e.g., 36246 for an external iliac that has ruptured), are we to exclude the cath code?

Would you code this with 35141, 35142, or 35226? "Pre- and post-operative diagnosis: Pseudoaneurysm of right femoral bypass graft. Patient with history of of right femoral to tibial bypass graft with cryovein that was done four weeks ago. Patient presented today with acute bleeding episode. CTA confirmed arterial extravasation from the proximal aspect of the bypass graft. Previous groin incision was opened with a scalpel. The subcutaneous tissue was divided with electrocautery. The inguinal ligament was identified. Sharp dissection was used to clear the femoral artery. The bypass graft was palpable and clamped. Pressure was held proximally for control. There was a large defect in the anterior surface of the graft hood with active bleeding. It took several clamps to gain control. The defect was repaired with a running prolene suture. Clamps were removed. Pressure raised, and there was no active bleeding. Wound was irrigated. Tissues were re-approximated in layers. Skin was re-approximated with nylon. A closed suction dressing was placed."

If a patient is brought to IR for pre-op mapping for a liver tumor embolization and they embolize the gastric artery for treatment protection of the stomach, would this be code 37242? The patient has the Y90 embolization of the hepatic arteries five days later.

My docs are doing 3D echos and TEEs. I understand that code 93356 should be reported with 93306 and 93312, but I am confused with the reasons for doing the 3D as opposed to doing the standard tests. I have checked the Medicare website, and it sounds like doing 3D is for pre-op for a procedure such as TAVR, MVR, valve repairs, biopsies, etc.

Would 36902 and 36907 be appropriate to code in this case?

"Patient brought back to the hybrid room and placed in supine position on the table. Right arm prepped and draped in sterile fashion. I accessed the AV fistula. A micropuncture needle and sheath were placed. A fistulogram was performed with retrograde filling into the artery. There was a severe stenosis in the right innominate vein into the SVC associated with the TDC. A stiff angled Glidewire was then brought in, and we brought in a 7 French sheath. The patient was systemically heparinized. I then used a Mustang 12 x 60 millimeter balloon angioplasty, which was performed multiple times. After the angioplasty, a repeat fistulogram showed good flow. At this point in time wires were removed. I used a pursestring 4-0 Monocryl stitch and more pressure. Occlusive dressings were placed. The patient tolerated the procedure well and was transferred to the recovery room."

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

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?

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.

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?

Would this be 50431XU, 50389, 50688-52? Diag exam is to check ureters; not nephrostomy. I can't find a code for removal only of ureter stent. "History: Urology requests antegrade nephrostogram via right ext nephrostomy. If antegrade drainage through ureteral stent is identified into the urostomy, removal of both right and left ureteral stents is requested. Proc: Injection of contrast was performed with fluoro guidance to evaluate the nephrostomy tube. Antegrade nephrostogram demonstrates catheter to be in excellent position within the right renal pelvis. Right and left ureteral stents are in excellent position. There is brisk antegrade drainage through the right ureter/ureteral stent into the stoma. Both ureteral stents were then removed with gentle manual traction from the urostomy. No resistance was encountered. Next, the backend nephrostomy catheter was cut, reducing his retention loop and a 0.035 inch guidewire was placed through the nephrostomy tube, reducing the retention loop and the nephrostomy tube was removed under fluoro guidance." 

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?

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."

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?

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.

"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?

"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.

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."

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."

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?

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?

"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?

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?

"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?

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.

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?

"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?

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?

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

“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.

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."

"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?

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.

"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?

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?

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?

Background: Newborn with supracadiac TAPVR and ASD had surgical repair by anastomosing common pulmonary vein confluence to the LA. Residual malaligned atrial septal tissue was resected, and ASD was closed with a patch, very carefully aligned along the ridge of the resected septal tissue. Two days later echo showed IVC draining into the LA. Surgeon explored the anatomy very carefully and determined that the IVC to LA was truly a congenital anomaly and not an iatrogenic redirection from the previous ASD patch. Second surgery: “I removed the suture line from the ASD patch, excised the lower part of the atrial septum all the way down to the IVC opening, and then excised the residual separation between the IVC and the right atrium all the way down below the level of the coronary sinus. Then, I sutured the ASD patch posteriorly onto the left atrial wall using 7-0 Prolene continuous suture. With this, the IVC was clearly now on the right side, and then I closed the right atrium with 6-0 Prolene continuous suture in two layers.” How would you code the second surgery?

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?

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?