Ask Dr. Z

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

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?

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."

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?

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.

Patient returned for a routine exchange of a modified nephroureteral stent. The distal aspect of the catheter terminates in the distal ureter instead of the bladder. Should CPT 50435 or 50387 be coded? "Spot fluoroscopic image of the catheter demonstrated to be well-positioned within the renal collecting system. The catheter was pulled back by 2 cm. A small amount contrast was injected through the catheter confirming appropriate positioning and demonstrating slight improvement in left hydroureteronephrosis since the prior study. The catheter was cut and removed over a guidewire and exchanged for an identical 8 French modified nephroureteral stent, the distal aspect of which sits in the distal left ureter. The proximal locking loop was formed under direct fluoroscopy in the renal pelvis. A small amount of contrast was injected confirming appropriate positioning. Uncomplicated exchange of an 8.5 French modified nephroureteral stent for identical catheter."

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).

"A 5 x 40 mm Bard conquest balloon was then positioned across the arterial anastomosis and the proximal fistulous inflow and a prolonged and insufflation performed with balloon achieving profile. Kumpe catheters repositioned in the brachial artery angiography performed. 1.5 cm cleaner device was passed from the distal sheath and attempt to break up thrombus within the aneurysmal segment of the cannulation zones fistula without success. This appeared to be very mature thrombus. Despite further attempts at balloon angioplasty and balloon maceration never achieved beyond temporary patency with residual thrombus occlusive in nature unable to be removed. Selective left upper extremity angiography was performed via the fistula using Kumpe catheter positioned in the brachial artery proximal to the anastomosis. Serial dynamic imaging obtained from this location distally to the fingertips."

They want to bill 36905, but I would like your opinion of the failed thrombectomy.

What is your recommendation on coding the following study for hyperparathyroidism with after study no CT evidence of parathyroid adenoma? Technique: 4D parathyroid protocol axial CT images of the neck were performed after the intravenous administration of 80 mL of Isovue 300. Coronal and sagittal reformations were provided. An adaptive iterative reconstruction technique was utilized for dose reduction.

Should this be coded as a CT soft tissue neck w/contrast 70491 or does the "4D" technique indicate at least 3D imaging was performed and this should be coded as 70491 & 76376? We cannot find any information on how to code "4D" technique CT exams, and this technique does not seem to meet the 3D code requirements so would seem to only be coded as 70491. Any guidance you can provide on coding "4D" CT exams would be very appreciated.

In the CPT manual, it states that "Duplex scan (e.g. 93880, 93882) describes an ultrasonic scanning procedure for characterizing the pattern and direction of blood flow in arteries or veins..." However, CPTs 93880 and 93882 only have the description for arterial studies in their CPT description, and per your Diagnostic Radiology Coding Reference, only mentions the need for imaging documentation of arteries. How would you code an extracranial venous duplex study, as they are imaging the veins and not the arteries of the neck?

I understand if there is a pseudoaneurysm of the femoral artery and stenoses of another femoral artery, we report either 37236 or 37226, but not both. But what about the case where say the popliteal artery has a pseudoaneurysm and a stent is placed, and one of the femoral arteries has a hemodynamically significant stenosis and a stent is placed? Can we report both codes or just one?

This is a two-part question. First we are hoping to get clarification on what documentation is needed in order to code out a post biopsy mammo for clip placement. Some of our rads only dictate: "POST BIOPSY FILMS CONFIRM CLIP PLACEMENT" or "AS A SEPARATE PROCEDURE IN A SEPARATE ROOM WITH A DEDICATED MACHINE, POST PROCEDURE DIGITAL MAMMOGRAPHIC IMAGING DEMONSTRATES THE LOCATION DEVICE AT THE TARGETED AREA". Is this enough to code out 77065? The second part is, if they just say post biopsy FILMS (along with proper documentation of clip) and they don't specifically say post bx MAMMOGRAM, can we still code out 77065? We were told that films are the same as x-rays which is what mammography is, therefor based on that verbiage it's ok to code out, but we want to be sure.

How would you code a wrist radial artery access with catheter navigated into brachiocephalic AV fistula and PTA of fistula peripheral segment?

If you perform a limited color and spectral Doppler during a thyroid ultrasound to check for vascularity of nodules, would it be appropriate to bill 93998 for those services?

Should the following scenario be coded as a CT-guided lung biopsy (32408) or as a CT aspiration biopsy (10009)?

"Limited computed tomography again demonstrated the fluid collection centered on the left lung. The preliminary scan is otherwise unremarkable. After the administration of local anesthesia, a 5 French one-step needle was advanced into the larger fluid collection within posterior left lung. A total of 27 cc of purulent fluid was aspirated and sent for testing. CT guidance confirmed successful placement of a biopsy needle. Completion images demonstrate expected post procedural change. Technically successful CT-guided aspiration of a probable abscess within the posterior left lung."

Doctor performs a thoracotomy and does wedge resections of a nodule in each lung. Code 32505 does not allow a -50 modifier. It also has an MUE of 1, and it is a date of service edit, so we cannot bill two units or with a -59 modifier. The only way we can see is to bill 32505 with 32506 even though the add-on code 32506 is intended for an additional resection of the same lung. If this were done by VATS (32666) it allows a -50 modifier. Do you have any insight? Would you agree with 32505 with 32506 for a left and right wedge resection by thoracotomy?

INARI Medical has a new device called the FlowTriever II and it is intended for peripheral vasculature only.

Key Features:

-Laser cut element with proximal open cell design for optimized clot clearance.

-New disk shape designed to disrupt clot, improving effectiveness for aspiration.

- Increased usable length (120 cm) for more distal treatment.

- 52% shorter deployment length.

- Versatile sizing to treat vessels 6-16 mm in diameter.

Will you please clarify if this an aspiration thrombectomy catheter or mechanical?

As soon as the patient arrived to our facility, he had a "rescue PCI".  He was a transfer from another facility after thrombolytics were given. Would this be considered "emergent?" They never say "emergent", and some time had passed from when he was at Urgent Care, then to the ER, and then transferred to our facility for PCI. The cath lab knew that he was coming so he presented straight to the cath lab.

What is the appropriate code for SFA stent due to hemorrhage? No occlusive disease. Right groin bleeding into a hematoma/pseudoaneurysm. 37226 or 37236?

"Ultrasound-guided vascular entry in conjunction with manual palpation, fluoroscopy-guided vascular entry in conjunction with manual palpation, and vascular entry accomplished utilizing manual palpation. Left heart catheterization with selective coronary angiography, left ventriculogram. The risks, benefits, and details of the procedure were explained to the patient. The patient verbalized understanding and wanted to proceed. Informed written consent was obtained. Right femoral artery was accessed in a retrograde approach utilizing sterile technique."

Can 76937 or 76942 be billed with 93458?

"PROCEDURES:

1. Repair of left femoral to tibial bypass aneurysm with Gore-Tex interposition using hybrid graft.

2. Intraoperative arteriogram.

3. Balloon angioplasty to left femoral-tibial bypass.

INDICATIONS: The patient has a 7 cm aneurysmal dilatation to a left femoral to posterior tibial bypass that was felt to be in need of repair.

FINDINGS: The area of the aneurysm had significant inflammation that did not allow for good end point dissection. Because of this, the aneurysm was punctured for wire and balloon control and then an interposition graft was placed using hybrid grafts on the proximal and distal ends for control."

I'm confused with this one. I was thinking 35884, but they also placed a graft on the distal end of the bypass as well as the proximal end. Would we then code this with LE repair codes?

CTA and MRA = diagnostic study. Is a CT venogram diagnostic quality? Does a CTV mean we cannot charge diagnostic venogram when an intervention is performed?

Biopsies of two different iliac nodes in the right lower quadrant were done. One was core and another was FNA.

1. Successful uncomplicated CT-guided core needle biopsy of larger and more inferior mildly PSMA avid right common iliac node.

2. Successful uncomplicated CT-guided FNA biopsy of smaller more cephalad and more PSMA avid right common iliac node.

Would you code 49180 and 10009 only, or would you code 49180, 10009, and 77012-XS?

Is there any guidance on how to code an MRI pelvis and MRI sacrum? If ordered separately and medical necessity provided, would they be coded separately, or are they only considered a single exam since they are performed in the same session? If they can be coded separately, would a -59 or -76/77 modifier be appropriate? The only guidance I have found is that if the sacrum is imaged alone, it's coded as an MRI pelvis, and if it's imaged with the spine, it's included in the spine, but nothing on coding both when ordered separately as pelvis and sacrum exams. We have a provider that is stating that they have different protocols on the machine and they cannot just add a few images for the sacrum. Any information you have on this topic would be fantastic.

Stage 2: The coder believes this is 36832-58, and the doctor thinks it is 36819-58. Who is correct and why?

"A second oblique incision was made distally, near the area of previous arteriovenous fistula. This was taken down to the level of the basilic vein using electrocautery. The brachial artery was also identified. Branch points were identified and ligated using clips and 4-0 silk ties. Two additional incisions were made proximal to the first incision in sequential fashion. These incisions were taken down to the level of the basilic vein and a branch points were ligated using 4-0 silk ties. A curved tunneling device was then used to tunnel and transpose the freely mobile basilic vein through the subcutaneous tissue laterally, bringing it near the surface of the skin. incision at the distal end of the basilic vein. The brachial artery was then identified and vessel loops were applied proximally and distally. A #11 blade was used to make a small incision in the brachial artery. The arteriovenous end to side anastomosis was then created."

If a Fogarty is used to remove clots from the left external iliac, common femoral, popliteal, and left anterior tibial through the same incision, and then a separate incision was made to complete the left posterior tibial clot with Fogarty, could we report 34201 and 34203 for the first incision and then 34203 for the second incision? Or would we report only the most comprehensive code 34203 for each incision? 

Please help. This seems like quite a simple case, but I just cannot decide on the correct code(s) to use. The IR physician states that he placed a nasogastric feeding tube and removed the tube in the same setting, due to patient having pain/complication. What codes do you think best describe this scenario? Yes, code 43752 for placement, but since there is no code for removal of feeding tube, could we consider using unlisted code 43999 for the whole encounter?

Is it appropriate to report both codes in this scenario? Complaining of epigastric/chest pain. ECG showed ST elevations and Q waves V2-V4. Patient was taken urgently to cath lab for LHC and possible PCI. The report indicates, "Mid LAD lesion and decision for PCI."

Is documenting "appendage flow is >40 cm/sec" enough documentation to support CPT 93325 during a TEE? Here is the full sentence: "Vessels The aortic root is normal size. Ascending aorta measures 49 mm. The pulmonary artery is normal size. Other There is no pericardial effusion. There is no pleural effusion. Appendage flow is >40 cm/sec. No clot or smoke noted in LAA."

"AO 134/71. Aortic valve was not crossed. Right heart catheter was inserted into the right heart. Appropriate RH pressure measurements were obtained. 02 saturations were obtained, and cardiac output results calculated."

Provider billed 93456, but I think it should be 93451. What are your thoughts?

My physician is placing a central venous access device. The internal jugular is blocked, so he inserts a balloon. Would I report code 37248 along with the device code?

In a review of onpatient E/M leveling for cardiology, the providers questioned the risk portion of medical decision-making due to patients being on a Cardizem drip (99223 for initial and 99233 for subsequent hospital visits). The providers believe medications adenosine, IV Lopressor, or Cardizem automatically qualify the patient as "high risk " for MDM and therefore the highest-level E/M should be reported. These drugs are not included in the list of high-risk medications. Is there an expectation that the providers should document the importance of administering these drugs in the care of the patient to substantiate meeting high risk MDM? The providers stated a coder should know to move to high risk if the patient is on telemetry. Please advise.

If physician performs a cardioversion on a patient, and the procedure was performed completely but were unable to convert the patient to normal rhythm, would we need to append a -52 modifier to report?

When a stent is placed into the aorta for stenosis, is the aorta then considered "selective"? From the Dr. Z IR guide: "Code separately for selective catheter placement when using codes 37236-37239. Iliac stent grafts, EVAR, and FEVAR procedures bundle certain catheter placements." Example given in IR guide: "Patient with known abdominal aortic stenosis presents for stent placement. A catheter is advanced from the right femoral artery to the aorta (36200), and aortography confirms the stenosis (no code). Pre-dilation with an 8 mm balloon (no code) is performed followed by placement of a 14 mm stent (37236). The stent is post-dilated to 16 mm (no code). Follow-up angiography shows excellent results (no code)."

The 36200 is added because the aorta is considered "selective" in this case?

"Utilizing spot CT fluoroscopy, a 19 gauge coaxial needle was advanced into the lesion from an anterolateral approach paralleling the anterior margin of the lower iliac bone. Epigastric and iliac vessels were avoided. 1% buffered lidocaine was utilized for local anesthesia. Multiple 20 gauge core samples were obtained through the coaxial guide with CT fluoroscopic confirmation of biopsy position. IMPRESSION: Uncomplicated CT-guided core biopsy right pelvic sidewall mass in a patient with history of colon carcinoma. Path: Metastatic colorectal adenocarcinoma, moderately differentiated."

We reported code 20206. Is this correct?

I have had a few cases where the fellow or resident has done the procedure with the attending radiologist is present in the room. The coder has placed a hold on processing the procedure because the physician did not do the procedure. Should the coder be processing the procedure as long as the attending is in the room? And if the fellow/resident dictates the report, does the same rules apply as long as the attending signs off on the report.

When a stent is placed in the subclavian, does this qualify as 33880 (involving subclavian)? Or, would this be 33881 and 37236?

"Bern catheter was removed over the Amplatz wire and the 38x100mm Terumo Relay thoracic aortic endograft was deployed antegrade in zone 2. Fenestration of the graft was created using #11 blade into the left subclavian artery dilated with a Sarot clamp and then Glidewire was inserted through the fenestration in the left subclavian artery and 11mmx39mm Gore VBX self or balloon expandable stent was deployed with 4mm of the stent jutting out of the fenestration made onto the thoracic aortic endograft. The mammary was 3.5cm away from the ostium. Next, a precurved 28mm Gelweave graft was then brought to the field, bevelled and sewn to the transverse arch in end-to-end configuration using a 3-0 Prolene suture in running continuous fashion. This anastomosis was reinforced circumferentially using multiple pledgeted 3-0 Prolene suture in a horizontal mattress fashion."

Can 61645 and 61640 be reported together I can't find anything prohibiting it?

Patient presents with STEMI involving both left anterior descending and left circumflex coronary arteries. Provider places drug-eluting stent in proximal LAD, mid LAD, second diagonal, and 3rd marginal branches. Based on being allowed to bill 92941 once during the procedure, would appropriate coding be 92941-LD, 92928-LD-51, 92929-LD (as hb charge), and 92928-LC-51? Or would the second stent in the LAD be considered part of the 92941 and should we only bill 92928-LD as a facility charge in the diagonal branch?

Procedure was done for occipital neuralgia. Report describes 22-guage Radio-frequency probes intermittently advanced in tandem under CT guidance into the perineural fat adjacent to the left Greater and Lesser occipital nerves. Omnipaque was injected for localization purposes. Sensory stimulation occurred at 2.5 volts. Continuous radio-frequency ablation was then performed for one one minute at 80 degrees Celsius, trice in each area. Therapeutic injections were done afterwards, which I believe to be bundled into the RFA. For the RFA, would it be coded with 64640, unlisted 64999 or something else? Question ID 10938 references 64405 or 64450 for Greater & Lesser occipital RFA and Question ID 5437 says TON RF ablation is 64640. Can you explain what makes the occipital nerves fall under the peripheral codes? Thanks!

What is the G modifier at the end of 75571G?

We understand that for the CPT coding of cardiac caths and echos, an isolated PFO is not considered to be a congenital heart disease. That being said, when percutaneous transcatheter closure of an isolated PFO is performed, may we use code 93580? This code specifically states "congenital". Should we use unlisted code 93799 instead?

Are there any billing guidelines regarding this issue? Is EKG 93010 considered to be part of the interrogation cardiac device evaluation (e.g., 93279) and not billable with device? We get an NCCI edit that 93010 has unbundle relationship with the procedure 93279. The procedures are performed on the same DOS.

Would you recommend reporting a Tarlov cyst aspiration with CT guidance as 62328 or 62329? In your IR coding reference, the instructions state that drainage of this fluid is considered part of a spinal tap and to use 62270. Isn't a drainage like this considered a therapeutic drainage? In the example below, two cysts were aspirated. Would 62329 x 2 be correct in this scenario?

"The patient was positioned prone. Initial CT imaging was performed. Local anesthesia was administered. Each cyst was accessed using two access needles. Position within the cyst was confirmed, and fluid aspiration was performed for each cyst. All instruments were then removed.

- Initial imaging findings: Multiple Tarlov cysts

- Aspiration needle/catheter: 20G spinal needles

- Post-aspiration imaging findings: Near-complete drainage of two of the Tarlov cysts"

We are doing large volume blood patches with our neurointerventional doc in the cath lab. These are patients with an unknown leak location or multiple leaks, or who have had a standard blood patch that provided only temporary relief. He puts a small sheath (4F) into the epidural space at the lumbar spine, threads a diagnostic catheter in, and goes all the way up to the cervical spine, and under fluoro starts slowly pulling back the diagnostic catheter while infusing a large amount of the patient's blood that we draw right before the infusion. He infuses about 100 cc of blood all the way from the cervical spine to lumbar spine. Myelography is also performed. Procedure time is approximately 1 hour 15 minutes. Sedation is managed by an anesthesiologist. How would you code these? Standard blood patch (62273)? Therapeutic infusion (62321/62323)? Unlisted code? 

Coding for pro-fee here for procedure performed in a hospital by multiple physicians, but only coding for the vascular surgeons.

Vascular Surgeon A places a bypass graft from the external iliac to the SFA (35665), and then turned the case over to surgical oncology surgeon for tumor resection, who then turns the case over to plastic surgeon for reconstruction post tumor resection. The plastic surgeon noticed that there was no longer a palpable thrill in the graft that Vascular Surgeon A placed, but Vascular Surgeon A was no longer available, so Vascular Surgeon B came in and created a new incision and performed an open embolectomy of the graft and then placed a stent in the proximal anastomosis (35876). Since the embolectomy was performed at the same surgical session as the placement of the bypass, but after the first vascular surgeon turned the case over to surgical oncology, can we code both codes or is it all included in 35665? If we can't, since both surgeons are in the same specialty/same group same group, would the second surgeon get an 80?

We have a patient who had a loop recorder implanted, but fifteen minutes after became unresponsive. Once he came back aroused the doctor decided to put in a temporary pacemaker overnight, and the next day plans on inserting a dual pacemaker. The next day, he inserted the dual pacemaker and removed the temporary pacemaker and the loop recorder. Would we be able to bill out the following: 33285, 33210-XU, 33286, 33208?

For hospital reporting: procedure was atherectomy and intravascular lithotripsy with drug-eluting stent to the proximal circumflex. We are getting an edit that C1761 (lithotripsy balloon device) cannot be reported with C9602. The atherectomy of the circumflex was performed prior to the lithotripsy. Would this not be correct?

How should I report PACs ablation? Patient was admitted originally for redo AF ablation. However, according to report, "We noticed that the prior PVI lesion set of all four veins was electrically still isolated from prior. Next, we then started the patient on Isuprel and noticed consistent presence of unifocal PACs (these had CS 5,6 to be the earliest dipoles of activation). Given this, we then proceeded to perform mapping of these PACs. We noticed these to be mapped to the inferoposterior aspect of the LA. After confirming these findings, ablation was then begun. A total of two set of lesion sets were applied and the RF ablation was guided by contact verified on ICE image, EGM appearance and impedance changes. After these set of RF ablation lesion sets, we then started the patient back again on Isuprel and despite burst pacing in combination, we did not observe any evidence of AF. We did observe multifocal PACs which subsided by the end of the case. At this point of time, the procedure was concluded."

We have a physician at the hospital who is doing the COOLIEF procedure. If he does RFA on the left L4 (meidial branch at the transverse process), an RFA on the left L5 (medial branch at the transverse process), and then an RFA at the base of the sacral ala for the dorsal ramus, would we be at 64635-LT, 64636-LT, and then a 64625? Since 64625 bundles imaging for CT and fluoro (this was fluoro guided), would we report it for 64635 and 64636?