Ask Dr. Z

Can code 76937 be reported with 33418, or is it bundled in the procedure?

Is a discharge service reported the next day after a planned ablation procedure?

Mechanical thrombectomy of left popliteal artery and mechanical thrombectomy of left peroneal artery, two different accesses. We coded 37184 and 37184-59. Is that correct, or should it be coded 37184 and 37185?

Our EP doctors are wondering if there is a way to capture a vein of Marshall ethanol injection during A-fib and/or flutter ablation? Should this be coded as unlisted? If so, do you feel that 93799 or 33999 would be a better fit?

My physician did a left and right heart cath and CardioMEMS implant at the same time. I reported codes 93460 and 33289. Medicare is declining to pay for 93460. I'm wondering if the right heart cath is included in 33289, and maybe I should have billed 93458 and 33289. Please clarify. Also, do I need an -XU modifier on the cath?

In IR for embolization of the prostate for a diagnosis of prostatomegaly (right and left) the doctor catheterized both iliacs and left and right prostatic arteries. He also did angiograms in all these areas (a total of five). Can we bill for all the angiograms performed?

If the catheter is placed to the torcula and venography performed of the transverse sinuses, would the codes be 36012, 75870 one time? Documentation: "Access was obtained at the left common femoral vein using micropuncture set. 8 French sheath was placed. Neuron MAX catheter was advanced into the right internal jugular vein. 4 French angled taper catheter was advanced to the torcula. Venography was performed, showing minimal narrowing of the transverse sinus bilaterally."

When a left heart catheterization is performed in the outpatient setting due to an abnormal stress test and history of chest pain, and the findings are "mild coronary artery disease", would the first listed diagnosis be the abnormal stress test or CAD? Would the abnormal stress test even be coded in this scenario? The provider doesn't make any recommendations for further testing, only states "continued medical therapy" in the Impression.

What would be the best code for a duplex Doppler ultrasound of the internal jugular veins?

Per provider documentation: "We then attempted to wire the vessel to see if we could open any potential branches and none were visualized. We contemplated placing a lead anyway, but the vessel was so tiny in LAO not even crossing the spine. We then decided to abort the procedure. The pocket was flushed with antibiotic-containing solution, and the old DDD generator (see data below) was connected to the leads, and the leads and generator were inserted into the pocket."

Do we report code 33225 with modifier -74 and 33249 with modifier -74 since the procedure was aborted due to small atretic coronary sinus and no LV lead could be placed? Please advise.

Provider performs a diagnostic procedure to determine if the patient has May-Thurner syndrome.

From the right jugular vein, the provider selects the left renal vein and performs a venography (36011-59LT, 75820-LT). The provider selects the left common femoral vein and performs a venography (36012-LT, 75820-LT). He then performs IVUS and takes measurements of the common femoral, external iliac, common iliac and IVC (37252, 37253x3). Next the catheter is placed in the right femoral vein and takes IVUS measurements of the common femoral, external iliac, and common iliac (36012-RT, 37253x3). Right side venography was NOT performed.

I know 37253 has an MUE of 5. My question is whether it is okay to bill for all these IVUS codes? Since he was performing a diagnostic study to determine whether this patient had May-Thurner, I thought this may be appropriate? I know we are not supposed to bill additional units of IVUS for routine pullback. I am having difficulty determining what would constitute pullback during a diagnostic or interventional procedure.

Do you have any information regarding reporting C1761 during coronary interventions for hospitals? Our physician performed an orbital atherectomy, DES placement, and Shockwave IVL therapy to a 90% stenosis on the RCA. According to the manufacturer, C1761 is paid a pass-through payment when reported with C9600 or 92928. We are wondering if we can report C1761 with C9602 as well.

Patient presents with flank pain for a nerve block injection, with the abdominal cutaneous nerve entrapped by a muscle of the right flank. Although not specifically documented, this sounds like anterior cutaneous nerve entrapment (ACNES), which would involve the nerve endings of the lower thoracic intercostal nerves. One injection is made into the flank muscle near the entrapped nerve, as demonstrated by injection of contrast and fluoroscopy. Would you recommend 64420 intercostal nerve block for this, or another code like 64450?

Two vascular surgeons performed left carotid endarterectomy with patch for severe carotid stenosis. For the areas of stenosis they couldn't endarterectomize they placed a 6x5 Viabahn stent. Can we bill both 35301 and 37215, or the stent is included with the endarterectomy procedure?

What are your recommendations when coding axillary lumps when the breast is also imaged? Should the breast axillary tail lump codes N63.3- be used or upper extremity lump codes R22.3- be used? How do we know if a lump is specifically in the "axillary tail" versus truly in the axilla when typically the only indication is "axillary lump"?

Would maybe a good rule of thumb be to use the breast axillary tail lump if study performed is a breast ultrasound (which includes the axilla when imaged) and to use the upper extremity lump codes if only the axilla is ultrasounded to match the upper extremity ultrasound code for an axilla-only ultrasound?

When doing a MitraClip procedure and a tricuspid clip at the same time, can these be coded together as 33418, 0569T? Is the MitraClip device approved for use on the tricuspid valve?

At the same time as common femoral artery endarterectomy is performed, balloon angioplasty is performed of the superficial femoral and popliteal arteries on the ipsilateral side. Is this reported separately or considered a way of establishing outflow? Establishing inflow and outflow is included in all of the lower extremity endarterectomy codes.

There is only one code that addresses x-ray imaging for a foreign body - code 76010 (Radiologic examination from nose to rectum for foreign body, single view, child). I know that a 1-view chest and a 1-view abdomen should be coded when it takes two images to include nose to rectum on patients longer than 17 inches from nose to rectum. However, how should a 1-view image that goes from the nose to the top of the pelvic bones with the foreign body seen within that one image be coded? The intent is to see where the foreign body is.

Our facility is starting to perform ECMO during procedures. Within the session, the cannulae are being placed, ECMO started, and cannula removed at the end of the procedure. Is it appropriate to bill for all components of ECMO in addition to the procedure?

"Successful placement of 12 French, internal/external, locking pigtail biliary drainage catheter using a right anterior intrahepatic biliary duct. Successful placement of 12 French, internal/external, locking pigtail biliary drainage catheter using a left intrahepatic biliary duct. Successful removal of a right hepatic and left hepatic biliary stent into the small bowel. Successful cytology brushing of the tumor. PLAN: Bag to drainage. Monitor output Flush catheters every shift with 10cc normal saline. See Dr. X in clinic in late September with follow-up LFT and possible biliary stent placement."

What would you code for the biliary "stent" removal? 47534x2 for the int/ext cath placements(new punctures) and 47532 for the brush biopsy. The only thing we can come up with for the biliary stent removal is unlisted?

The provider couldn't cross the lesion in the right superficial femoral artery. The question is, can I still code for 37224 or not??

"Ultrasound-guided left radial percutaneous arterial access. Iliac and right leg angiogram, catheterization of aorta and femoral artery, supervision and interpretation. Intra-arterial administration of nitroglycerin and verapamil, ultrasound-guided right dorsalis pedis percutaneous arterial access, catheterization of right anterior tibial artery, and percutaneous closure utilizing TR band."

How will the following be reported? Coronary orbital atheterectomy was attempted but unable to cross a lesion in the left circumflex artery. Shockwave lithotripsy then performed successfully with delivery of a drug eluting stent. C9602 -LC or C9602-74-LC are being considered, but it is not included in the 2 codes, C9600 or 92928, that CMS listed for receiving pass-through-payment when reported with C1761. Please advise, including rationale. Thank you!

Can you tell me what CPT I would use for the aortic arch angiogram that is done with a congenital heart cath and balloon angioplasty of coarctation of the aorta? I am unsure if the 93567/75605 are the correct codes.

For CPT code 49465, we have patients who have the service done without fluoroscopic guidance. Instead, a portable x-ray machine takes a series of about ten films within a few seconds of each other. How would this be coded? Although normally provided with fluoroscopy, the code description simply says image documentation.

During a tunneled CVC, angioplasty was done of the right innominate vein. The catheter was then placed; however, the physician does not state that a final image was taken (CPT states radiographic documentation of final catheter position). He does state a fluoroscopic radiation summary in the report, so with all this work, can we report code 77001?

I have a provider attempting to bill 93312 for a TEE. My provider's statement however is as follows: “Intubation: The patient was administered general anesthesia by the Anesthesiology staff. Prior to starting the procedure, the TEE probe was advanced in to the patient's esophagus by Cardiology staff and images were obtained by Cardiology staff and interpreted by myself after completion of the procedure.”

Can these images be obtained by staff under supervision? Our coding software says supervision concept does not apply. I don't feel we can give him credit for the 93312 since the provider himself didn't place the probe, but can I give credit for 93314 since he didn't acquire the images either? He states he only interpreted the images after the procedure. Is there any billable service for the physician in this case?

The cardiologist is requesting a pre TAVR CT without contrast for a calcium score of the aortic valve. The exam will need to be gated and post processing to provide the calcium score. Only the aortic valve will be scanned. I'm wondering what the correct code would be. Code 75571 specifically states coronary, so I don't think we can use that CPT. I'm thinking a CT limited (76380) or an unlisted CT (76497) code. What are your thoughts?

My doctor states he did a left and right cath with coronary angiography only, no ventriculogram. By description of the code it states "including intraprocedural injection(s) for left ventriculography when performed". Can I bill code 93460 with the understanding that it can be with or without the ventriculography?

"External genitalia was prepped and draped. Contrast was injected through the existing Foley catheter. His urinary bladder is free of evidence of extrinsic mass effect and debris. No contrast was seen to travel in a retrograde fashion to the distal ureters. The balloon was deflated, and the catheter was removed. I immediately replaced it with a 20 French catheter. It was inflated with dilute contrast and remained well in place. The catheter was attached to a urine bag, and free flow was noted." 

What would the correct codes be for this report? I think the injection would be 51600 and 74430. What code would you use for the Foley catheter exchange?

Can we charge for a PTCA in the RCA (92921) when a DES balloon is used for the PTCA? Patient had a DES in the RPL and PCTA in the proximal RCA using the DES balloon. 

Our doctor inserted a tunneled Pleurx catheter for malignant ascites (49418). After the catheter placement he connected to the drainage tube, and 1 liter of ascites was removed (49083). I was told before not to code the paracentesis 49083 at the same time as 49418 when the tunneled catheter is what he is using to describe 49083. He says because 49418 description is just for placing "insertion" of the intraperitoneal catheter, that we can bill the paracentesis during the same session. What is your expert advice on this? There is no CCI between the two codes.

"Under sterile conditions the skin above the left clavicle was prepped with chlorhexidine and covered with a sterile drape. Local anesthesia was applied to the skin and subcutaneous tissues. Using anatomical technique, the finder needle was inserted under the clavicle at an appropriate angle and venous appearing blood was obtained. Needle was removed and an 18-gauge needle was then inserted into the same location and angle. Venous appearing non-pulsatile blood was obtained and a guide wire was then passed easily through the needle. The needle was then withdrawn. An incision was made and a dilator was subsequently passed over the guide wire then withdrawn. A 7.0 French triple-lumen catheter was then inserted into the vessel over the guide wire. The guidewire was then removed. All ports aspirated and flushed without difficulty. The catheter was sutured into place. A chlorhexadine biopatch and Tegaderm dressing were both placed." Is this CPT 36556 or 36561 since ports were mentioned? However,  there is no two incision, no tunneling, no pocket done. 

How do I report percutaneous cryoablation of the trigeminal nerve of the face? Is this 0442T or 64999?

"CTA IMPRESSION: Occlusion of celiac and proximal/mid SMA, second to severe atherosclerotic plaque. Moderate/severe atherosclerotic burden of abdominal aorta, distally occluded. Occlusion of bilateral common/external iliac arteries. Occlusion of aorto-bi-femoral graft. Occlusion of bilateral common/superficial femoral arteries. Occluded left common iliac to popliteal graft. Occlusion/severe stenosis of bilateral popliteal arteries. Stenosis/complete occlusion of left anterior tibial artery."

Question one: How would you code the occlusion of the bypass graft? T82.898A or I70.312? The physician was queried for the cause of the bypass graft occlusion, and this is what he would document. What would be the default diagnosis in general (if more documentation can't be obtained)?

Question two: If the same was documented, but PTA was performed in the OR at another setting, would that default the diagnosis to a complication code as intervention was required?

7-year-old female status post cardiac arrest thought to be secondary to dilated cardiomyopathy. Patient presents to cath lab for "septostomy to decompress the LA".  Procedures performed: RHC, ASD creation, and stenting under TEE guidance. Septostomy was performed. She had a "thinned out appearance of her ventricle", so the cardiologist felt a more stable decompression by placing a stent was in order. I don't see that this patient had a previous history of congenital heart disease, but would the "dilated cardiomyopathy" in such a young patient be considered something she might have been born with, or is that something that happens from an injury to the heart? What would my CPT codes be? 33999?

How do you code this? "Right below-knee popliteal to distal posterior tibial artery bypass with ipsilateral reversed greater saphenous vein. Completion angiogram was not performed due to limitations."

Physician removed a large vegetation from the right atrium due to an infected pacemaker lead. Diagnosis code is the root operation extirpation of matter or revision.

If Y-90 and chemo are both given in the same surgical site, I know we can only get 37243 for the CPT, but can we show both S&Is (96420 and 79445?) Do they have to be separate tumors to use both?

Is ICE code 93662 bundled with 33991? Or can it be billed together?

What CPT code would you assign for an exchange and conversion of a right basilic vein PICC line to a tunneled right basilic vein infusion port?

Please let me know if this is correct coding on this unusual case. 

"Patient has infected pacemaker pocket (dual chamber). Removal of generator with debridement of pocket with swab sent to lab. I was unable to access left axillary vein using approach that did NOT involve the pocket. So instead, right atrial lead was freed up, and guidewire used to obtain new access to the left axillary vein. Using this access, new lead placed in RV. Using pacing through the pacing system analyzer to avoid asystole and then removed the old RA and RV leads. Irrigated and packed pocket. I attached the same pacemaker to the lead and placed it on the skin and programmed to VVI at 60 paces per min."  

I'm thinking: 11042 pocket debride, 33216 new RV lead, 33233 removal generator (looks like used now as temp. external) and 33235 for removal two leads?

Would you add 93463 if a right heart catheterization was repeated in full after sublingual nitro spray?

I am looking for additional information on code 0503T. It appears there is only one diagnosis code allowed for medical necessity and that would be R93.1.  I looked in your book about this code (0503T),  and it does mention there is payment for this code under APC. Is that if it has the R93.1 only? I don't see a lot of information on the FFRct.

Patient had an active fixation lead that was attached to an external generator being used for temporary pacing. When the patient had a DC PPM implanted, the active fixation lead was "unscrewed" from the RV and removed from the patient. It was not used in the newly implanted DC PPM. So, 33208 is coded for DC PPM insertion. Can the active fixation lead removal be coded (33234)? Or is it considered bundled into the PPM insertion procedure?

Our RADS have new lumbar puncture templates. Is this enough to bill 62328? Or where it says "under imaging guidance,"should they state fluoroscopy was used?

"PROCEDURE DETAILS: Diagnostic lumbar puncture with fluoroscopic guidance. 

Total intra-service sedation time (minutes): Not applicable. Lumbar puncture: The patient was placed in prone position. Local anesthesia was administered. Under imaging guidance, a spinal needle was advanced into the subarachnoid space using a midline interspinous approach."

Shouldn't they state, "Under fluoroscopy, a spinal needle was advanced..."?

I am in a debate with my physician. He placed an EVAR (34705), then used a catheter to go between the EVAR graft and the blood vessel wall to access the AAA sac and deploy embolization coils. He thinks we should bill codes 34705 and 37242, while I think we should bill code 34705-22. His reason is the EVAR does not include embolization. My reason is I believe the AAA sac is in the treatment zone. He did not access the internal iliac, but used the common iliac to slide up the outside of the EVAR graft to access the sac. What do you think we should bill and why?

Patient with an aneurysm of non-functioning fistula that hasn't been used since 2018 due to clotting. Procedure was coded as 37799, but insurance is denying. Is this the correct coding, and if so, is there any suggested information that can be sent to help fight this claim?

"Longitudinal elliptical incision around the existing aneurysm down to the level of the elbow was made. I identified the brachial artery in the AV fistula aneurysmal anastomosis. I clamped just above the anastomosis on the fistula after dissecting around it to get complete control. After complete proximal control I extended the elliptical incision around the entire aneurysmal portion of the fistula. Using electrocautery I dissected the entire aneurysmal dilated fistula out all the way to the occluded area in the mid upper arm. I ligated this off with a silk tie and then excised the aneurysm in its entirety. I tied off the fistula just above the anastomosis with a 5-0 Prolene suture in a running horizontal mattress fashion followed by running locking outer layer."

I am question how to code this procedure for an intra-operative ICD lead and generator evaluation.

"Patient was taken to the EP lab with moderate sedation. The RV lead was inspected radiographically and physically. There was no obvious abnormality. The pin was inserted to the appropriate position past the electrodes. There was no change in the lead position radiographically. The interrogation intra-operatively at the time of surgery was within normal limits. Given this we took out each of the leads and re-inserted the leads in the header and re-secured the set screw, though this was also done previously. Interrogation of the device and leads revealed normalized function, as it was intra-operatively and post operatively previously."

I was thinking of code 93624 with a modifier -52 or option 93642 with modifier -52 since he did not induce or attempt induction of arrhythmia, or simply 93283 with the place of service as OP?

The procedure performed was diagnostic VATS LUL wedge resection for a nodule. Intra-operative pathology confirms clear margins. The final diagnosis is adenocarcinoma of the LUL.

Would this be coded as diagnostic 32608 because the intent of the procedure was to biopsy the nodule? Or would this be coded as therapeutic 32666 because the final diagnosis is adenocarcinoma of the LUL and intra-operative pathology confirmed the margins were clear?

I am not sure if this would be an aneurysm repair (35011) or a revision (36832). What are your thoughts?

"The skin over the left arm distal to the aneurysmal portion was instilled with lidocaine. The skin was cut with a 15 blade and deepened with electrocautery. The fistula near the arterial anastomosis at the antecubital crease was controlled with clamp. The fistula near the arterial anastomosis was ligated with 5-0 Prolene in double layers. The aneurysmal portion of the fistula including the overlying skin was resected sharply with scissors. The vein in the proximal arm was also ligated with 5-0 Prolene suture in double layers. Hemostasis was achieved. The incision was closed in layers with 3-0 PDS sutures, and the skin was now closed with 4-0 Nylon sutures and staples. A sterile, occlusive dressing was placed."