Ask Dr. Z

If a patient is being treated with intervention in the right tibial vessels for a CTO, and the patient is then brought back in one week to intervene on the right femoral/popliteal, does this require modifier -58 for the second procedure? Or bill "normally"?

On a first account, the patient has pre Y-90 mapping arteriography. On a second account, the patient has the Y-90 treatment with arteriography. On this second account, would the arteriography be considered guidance and not coded separately since it was just performed a few days earlier on this first account if no changes have happened in the meantime?

We are have difficulty determining the correct CPT code(s) to use for this right iliac aneurysm repair. Could you help us decipher if this is a stent, stent graft, endograft, embolization, other? What CPT codes are assigned?

"Left common femoral access. Anterior and posterior divisions of the internal iliac artery were cannulated and then embolized with 8 mm and 12 mm Amplatzer plugs respectively. A 12 French Gore dry seal sheath was introduced and advanced into the right iliac system. A pigtail catheter was used for measurements, and a 18mm x 11 1/2 cm Gore iliac extender was used to occlude the origin of the internal iliac artery extending from the distal external iliac artery to the proximal common iliac artery. It was post-dilated with a balloon. Completion angiogram demonstrated no filling of the internal iliac artery aneurysm. The Amplatzer plugs placed in the anterior and posterior divisions were noted to be occlusive."

If the physician orders an MRI of the brain for cancer treatment planning, one of our insurance plans suggests we bill with the unlisted code 76498 instead of the site-specific code. I'm not sure I agree, and I can't find any specific guidelines from CMS or the AMA on this. Should we use code 70552 with a -52 modifier or the unlisted code 76498?

How do I code for an open approach for Impella insertion? Should I use the unlisted code or use what the device rep states (33975)? I don't feel an open Impella should be coded as an extracorporeal LVAD.

Patient with brachiocephalic AVF has a crushed stent in the subclavian vein, which is causing issue with outflow. The physician performed a bypass of the subclavian vein by placing a PTFE graft from the cephalic vein at the level of the shoulder to the internal jugular vein. The AV fistula venous anastomosis was not recreated or altered in any way. Would the below be considered a revision of the AV fistula (36832) or a vein-to-vein bypass (37799)? 

"The dorsal surface of the cephalic vein was incised with a #15 blade scalpel, and this was extended proximally and distally with Potts scissors. The 8 mm PTFE graft was spatulated. We performed an end-to-side anastomosis with 5-0 prolene suture. We turned our attention to the distal anastomosis within the internal jugular vein. Again, a #15 blade scalpel was used to incise the skin. The jugular vein was exposed and skeletonized. A venotomy was performed to construct an end-to-side anastomosis. The bypass graft was again spatulated in order to fit the venotomy."

Is it appropriate to report the contrast separately (Q9967) in addition to CPT 49450?

When a patient comes in for a PVI ablation, and additional ablative lines are performed after PVI, does the physician need to state that the patient remained in Afib in order to report 93657?

In regards to CFAE ablation after PVI, CPT Assistant, September 2019, seems to say that the physician does not have to document that the patient remained in Afib in order to report 93657. Is that correct?

We want to make sure we are clear in what needs to be documented in order to capture 93657.

"Pre and Post Diagnosis: Severe right foot diabetic infection with abscess and osteomyelitis. Procedure: Transmetatarsal amputation of right third toe; transmetatarsal amputation right second toe; partial resection right first metatarsal. Description: Using a 15 blade scalpel, the base of the right second toe was incised all the way to heathy bone. The toe was amputated and using a ronguer debrided all the way to healthy bone. This involved resection of the metatarsal head of the second toe."

He also resected metatarsal head of previously amputated right first toe. He amputated and resected metatarsal head of right third toe in the same manner as he did the second toe.

Can you please advise if this is coded as two 28805's with a 28122 for the resection of the right first metatarsal head, or do you code as 28820 for the toe amputations with a 11044 bone debridement?

Please let me know if more information is needed for you to be able to answer us appropriately.

Do TCAR procedures need to be in registry? Unable to find if Z00.6 is a requirement.

"MD identified aneurysmal segment of greater saphenous vein. He dissected proximally and distally, then using silk ties he ligated the proximal saphenous vein near the junction. He ligated the greater saphenous on the causal side of the aneurysmal vein segment. He advanced radiofrequency ablation catheter to the proximal thigh until the tip hit the end of the ligated vein at the distal end of the incision by direct palpation, then infiltrated tumescent solution around the vein from the catheter tip to the sheath insertion site. He performed radiofrequency ablation on the vein. Each segment was doubly ablated."

We are coming up with 37700 for ligation and 36475 for radiofrequency ablation. Is the aneurysm resection included with the ligation?

When coding a diverticulectomy via a VATS approach, would you code this as 43135 or unlisted? I thought about 43180, but that didn't seem correct either.

How would you bill an epicardial pacemaker system insertion with open insertion of LV and RV leads?

"The bipolar epicardial steroid-eluting leads were then placed on the lateral wall of the LV, and each lead was secured with 4-0 prolene suture... As the heart was reperfusing, an RV epicardial steroid-eluting lead was then placed on the diaphragmatic surface of the RV and on the anterior surface of the RV and secured with 4-0 prolene. Both leads were brought out through the intercostal space. A left subclavian pocket was fashioned, to which the leads were brought and eventually hooked to the bipolar pacemaker."

CPT instructions are to bill for bilateral 34713 on two separate lines utilizing -RT/-LT modifier; however, the MUE is 1 with a MAI of 2. So how exactly are we supposed to bill for bilateral 34713? Is this an error in CPT? Done with 34848 FEVAR.

If an Impella CP is placed in the LV from the RT CFA and an Impella RP is placed in the main PA from the RT CFV, are both CPT codes 33990 and 33995 to be reported together? There is an edit with this code pair. Should modifier XS or 59 to be appended to one of the codes?

If ultrasound guidance was used to perform a left breast wire localization, and then US guidance was used to perform a right breast cyst aspiration, what are the hospitals charges? Would I report 19285 for the left breast and 19000 and 76942 for the right? Since US guidance is included in the left breast wire localization, I was unsure if it can be reported on the right side separately if an aspiration is performed.

Can we report intravascular ultrasound codes 37252 and 37253 with new lithotripsy codes C9764-C9775? They are not on the list of primary codes. As I understand, catheter placement is bundled into lithotripsy code, so we are not reporting it. There is a recent diagnostic angiogram, and we are not able to code for it either.

We have surgeons who use the incision wound vac system on surgical wound incisions placed during the surgical encounter (disposable). There are no wound measurements noted due to the incision is already closed when the vac is placed. Our question is when the wound vac is placed on a closed surgical wound, is this bundled with the surgical procedure? Some have NCCI edits that do bundle the vac; some do not. Would that be inclusive to the surgery, or is there an additional code that should be reported? Since this is closed and there are no measurements of an open wound, does this support 97607?

"The CS catheter was inserted through the access & placed in the coronary sinus. Standardized diagnostic EP testing was performed with atrial pacing & recording, ventricular pacing & recording, and His recording with attempted induction of arrhythmia: Next we started decremental pacing starting at 600 msec from CS 7-8. AV block was obtained at 430 msec. Next we started decremental pacing from the RV catheter starting at 700 msec. VA block was obtained at 580 msec with VA prolongation during pacing. Next we paced from CS 7-8 with extrastimuli: AV block was obtained at 650/350 msec. No echo beats or AH jumpe were obtained during pacing. Next, we started isuprel 2 mcg with gradual increase to 5 then 10 mcg. We repeated the same pacing protocols without being able to induce any SVT."

How would this study be coded? I also have a question regarding the CVC lines placed for study. Our HIM codes them. Can they be charged?

"Incision made in the 8th intercostal space and camera inserted. Additional ports placed and robot docked. ID area of concern on chest wall. Cautery used to completely excise nodule. Not adherent to bone and freely dissected away. Mass removed in Endo Catch bag." I can't find any VATS codes that meet this, but if it goes to unlisted does it go to the MS section since that is where the chest wall procedures are or to the VATS unlisted section?

When a patient has an echo 2D complete and a TEE performed the same day, do the results of one take precedence over the other?

Can you confirm the below terms all represent 3D? If any do not or are questionable will you please outline those?

• Quantitative Analysis
• Segmental volumes & surgical planning
• Rotational reconstructions
• Surface shaded rendering
• 3D Volume Slab
• Volumetric Rendering Technique (VRT)
• Minimum Intensity Projection (MinIP)
• Maximum Intensity Projections (MIPS) or (MIP)
• Shaded Surface Display (SSD)
• Spiral Acquisition

Do leadless pacemakers still need to be in registry? My cath lab team is now telling me they are not aware of them being in a registry, but I was unable to find where this requirement has been lifted.

We see cardiology cath reports for RHC and LHC where no CAD is found, and the only abnormal diagnosis given in the cath reports is "elevated bilateral filling pressure" or "elevated LVEDP". The patient has no heart failure in the HP, and came in for DOE or abnormal stress test with chest pain. What ICD is best for the diagnosis of "elevated filling pressures" diagnosis off the cath report? Also, if there is CAD found in the cath and the details read "moderately calcified", can we code the CAD and I25.84 for calcified lesion? If not, what documentation is needed for ICD I25.84?

Is this reported with 37765, even with the use of the Trivex system?

"I had her stand up, and the areas of the varicosities in her left anterior/medial thigh and anterior/medial calf were marked. After adequate induction of anesthesia, she was prepped and draped in the usual sterile fashion in prone position. Time out was performed.

Using 11 blade, stab incisions through the skin were made. Tumescent was injected with the transilluminated powered phlebectomy device and using the Trivex blade, phlebectomies of the left anterior/medial thigh and anterior/medial calf. She tolerated all this well. This required 11 stab incisions for completing the phlebectomy.

Using rolling technique, the tumescent solution was expressed out of the stab incisions. After that, Steri strips were applied followed by sterile wrap dressing with Kerlix, an ACE bandage, and coban."

Some of my claims came back denied for -50 modifier. Per CPT Codebook, if bilateral procedures are performed at the same session, should be appended 50 modifier. The insurance paid for one and denied the other. Am I using the wrong modifier? Or should I just billed two units?

ex: 34713

34713-50

37609

37609-50

Our IR physician performed electrocautery to remove pericatheter granulation tissue around a cholecystotomy tube. Code 17250 is for chemical cauterization only. The electrocautery codes I'm finding are for lesions. Any advice what code to use in this instance? 

I'm still confused on the use of modifier -50 and -RT/-LT for spine injections. Revisiting quest ID #13686, is it appropriate to code 64493-50, 64494-RT, 64494-LT, 64495-RT, 64495-LT for 3 level bilateral lumbar facet injection (Medicare patient)? Can you comment specifically on using -RT/-LT with 64494-64495 and also reporting 64495 twice? CPT is contradicting, "Do not report more than once p/day" .... "Report twice for bilateral".  I've been checking for updates but haven't found any. Are there any updates that you know of?

Can insertion and removal of IABP be billed on a different day? And do I need a modifier?

Can I report 93655 for SVC isolation after PVI for Afib? "The LSPV, LIPV, RSPV, and RIPV were circumferentially encircled as a pair. Isuprel was initiated and titrated pu to 20 mcg/min with the Pentaray on the posterior wall. No pulmonary vein triggers were seen. There were some right atrial premature beats. These could be SVC in origin, decision was made to isolate the SVC. The sheaths were withdrawn into the right atrium and the Pentaray catheter was used to perform a geometric map of the SVC-RA junction. High-output pacing around this region demonstrated phrenic nerve capture along the posterolateral SVC-RA junction. Using the ablation catheter and avoiding areas of phrenic nerve capture radiofrequency ablation lesions were delivered while the Pentaray catheter was advanced into the SVC. Isolation of the SVC was successfully obtained."

Do you still recommend unlisted code 33999 for this CHD case?

"A 4 French x 80 cm Abbott/Amplatzer TorqVue LP delivery catheter was advanced with the aid of a wire via the RFA to the DAO to the AAO and into the LV. An LV angiogram was performed. An angled Penumbra/Lantern microcatheter and Whisper wire were advanced via the TorqVue delivery catheter to the LV. With gentle probing the pouch of the aneurysm was entered with the Whisper and Lantern. The TorqVue was advanced over the Whisper and Lantern into the LV pseudoaneurysm. The Whisper and Lantern were removed. The duct occluder 2 was advanced via the TorqVue catheter. The device distal disc was deployed into the pouch of the pseudoaneurysm, the middle waist was deployed across the LV free wall, and the proximal disc was deployed on the on the endocardial LV wall side of the defect. An LV angiogram and TEE images demonstrated good position and no change in mitral regurgitation. The device was released. A repeat LV angiogram was performed. An ABG and ACT were repeated. All catheters and right groin sheaths were removed."

When TAVRs are done that do not require an incision (e.g., 33361), two interventional cardiologists do the procedure and the CVT surgeon is simply present. He states this in his dictation: "Description of Procedure: The patient was taken to the hybrid operating room and placed upon the table in the supine position. Monitoring lines and catheters were placed and then general endotracheal anesthesia formed. Details of the operative procedure will be dictated separately by the interventional cardiologists. I did not participate in the technical aspects of the procedure but was present for the entire procedure in the hybrid lab and available for any emergency or other technical assistance."

**As he never takes part in the procedure in any way can he bill as co-surgeon? When there's an incision to be made this is not an issue, he participates and his dictation reflects as much. He's been told that CMS requires him to be present even if he isn't participating so that there is still a CVT surgeon on the operating team.

If a retrograde left external iliac endarterectomy is completed through the same incision as a left common femoral endarterectomy (or any other femoral), would this be coded as 35355 or 35351 and 35371?

We have provider-based clinics, and the cardiologists are billing the same as the hospital, which is they are both billing 93350-26, 93016, and 93018. It was my understanding that if the full complete service was performed by the same provider that the 93351 should be billed. The POS is 22. I am in Compliance, and it is my responsibility to educate them correctly. Please assist me in the correct way to bill for physicians and hospital when it is provider-based?

Our provider group is contracted out to provide cardiology services for a detention center. If the detention center uses an automated remote monitor (i.e., Merlin On-Demand, Carelink Express, Latitude Consult), and the results are routed to us to collect, assess, and give to provider. Can we use 93296 (technical)? Can the provider use 93294/93295/93298 as part of their services rendered?

We plan on working towards fixed quarterly monitoring periods for billing purposes. The “scheduled” 91-day reports could fall anywhere within the 91-day window. Monitoring requirements, as we understand it, for billing include a minimum of 30 days' monitoring, and at least one report within the 91-day period.

For CIED remote monitoring and codes 93294/93295/93298, does the date of service (DOS) for the professional codes have to be on the same date as the DOS for the technical 93296? Is there a window of time that they must both occur in?

Our physician performed FFR in the 1st diagonal and in the left circumflex. May this be reported as 93571-LD and 93572-LC because it was performed in two separate coronary distributions? Or should FFR not be reported for the 1st diagonal because it is not a major coronary artery?

I am finding mixed information on how to code for the image-guided placement of a fiducial wire into a neck mass prior to surgical intervention. Would I report code 10035 or unlisted code 21899?

Is there a CPT code for RVAD implantation through open-heart surgery?

Patient presented with progressive chest discomfort. He was found to have an NSTEMI in the ER and dynamic EKG changes indicated of ischemia. He was brought emergently to the cardiac catheterization lab. Coronary angiography was significant for 99% mid RCA lesion. Would this documentation meet the criteria for I25.10-I25.9 heart disease of native coronary artery? Is there a particular percentage stenosed that qualify for these codes?

Patient had a TAVR via femoral access (33361-62). Complications arose during the same session, and it was converted to open procedure. The newly placed valve was removed, and a 21 mm Edwards bioprosthetic aortic valve was placed (via sternotomy)(33405). Should both codes be billed? And, if so, should a modifier be appended to 33361 (maybe -53)? Or should 33405 be reported alone perhaps with a -22 modifier?

Can a limited echo be reported the same day as TAVR (33361) by the same physician performing the TAVR?

I perform TAVR, and occasionally we do coronary angiography as part of standard work-up at the same setting to avoid a separate visit for the patient. I am being told that both this and ultrasound access are bundled with the TAVR. Is this correct since we would most commonly do these as separate, distinct procedures?

My provider wants to do a left renal vein venography with pressure measurements via right groin. This is for pelvic congestion syndrome. I am wondering if there is a code for a special catheter for these pressure measurements. The codes that I would use (36011, 75831) do not say anything about pressure measurements. I just want to know if I should be using a different CPT code besides the basic catheter.

How would you code for a facility when an intravascular ultrasound of a coronary artery is performed by one physician and then another physician performs the cardiac cath? We’ve reviewed CPT Assistant, December 2013 (page 18, Frequently Asked Questions), with add-on code 92978 and wondered if the guidance for to use the unlisted CPT code 93799 more for the professional side of billing or should be used both for professional and facility billing?

Our physician performed HawkOne atherectomy and Penumbra thrombectomy in the same SFA artery. In one case the thrombectomy was performed first in the other it was performed after the atherectomy. He states, "occlusion likely composed of thrombus and thrombectomy performed to minimize risk of distal embolization". Can the thrombectomy be coded if he didn't state there was actual thrombus retrieved? If we query the physician and he states there was thrombus retrieved how do we determine if this is a primary or secondary arterial thrombectomy? Medicare has denied billing a secondary thrombectomy 37186 with atherectomy 37225 even with an unbundling modifier for a separate device used. We would really appreciate your opinion on how you would code these cases.

Your reference book defines “multi-lead device” for PPM/ICD implant/revisions as biventricular, and states a multi-lead device does not need an atrial lead (pg. 546/560). CPT clearly defines "multi-lead" as leads in three heart chambers. CPT Assistant, 12/2013, clarified: “When a LV lead is implanted, the system is referred to as a multiple lead system.” But CPT further clarified their guidelines in 2015 and continues to reiterate their definition of multi-lead for 33206-33249, 33264 as a device “with pacing/sensing function in 3 or more chambers of the heart”. Please clarify if/when it is appropriate to report multi-lead codes (33229, 33264, 33221, 33231, and 93281, 93284) for devices that only have RV/LV leads? Is it correct that we code dual chamber biventricular devices as “multi-lead” when it comes to device revision codes, but they are considered “dual chamber” for programming evaluation codes? So we could conceivably report 33229 for a multi-lead PPM generator change in a patient with LV/RV lead, but would subsequently report 99280 for dual chamber programming evaluation on the exact same system?

Would it be appropriate to report code 77012 in addition to 64530 for a CT-guided celiac plexus block? The CPT code description for 64530 says "with or without radiological monitoring".

We had a patient with a chyle leak. Our radiologist performed a bilateral pelvic and abdominal lymphangiogram – percutaneous transabdominal access into the cisterna chyle, catheterization of the thoracic duct, and thoracic duct lymphangiogram and embolization. We coded 37244, 38790-50, 38794, 75807. We are questioning whether an unlisted code is needed for the thoracic duct lymphangiogram? 

Procedure: Left L3-4 and right L5-S1 therapeutic transforaminal epidural steroid injection. How should this be coded: 64483-LT and 64484-RT? Or 64483-50?