Ask Dr. Z

In regards to coronary and peripheral interventions, can you please clarify if the Penumbra thrombectomy (Indigo, CAT RX, Lightning) is aspiration thrombectomy or mechanical thrombectomy? Q&A #7672 (peripheral/venous) seems to contradict questions #14498, #12605, and #12649. I know the reps market this as mechanical thrombectomy. 

Prior to a Y90 treatment, the doctor places a Hyperform balloon catheter to occlude the GDA during treatment. The balloon is removed after the injection of the Y90. Can I code for catheter position of the occlusion balloon?

I believe this is a revision of AV fistula (36832) with perhaps a -22 modifier appended; however, the surgeon wants to use 35011 and 36830. What are your thoughts?

"Indication for Surgery: Left forearm cephalic vein aneurysm, ESRD, degenerated left forearm AV fistula aneurysm. Surgical Procedure: Excision of aneurysmal left forearm cephalic vein, placement of a left forearm PTFE AV graft. Procedure: A long elliptical was incision made along forearm cephalic vein that was aneurysmal; it incorporated the degenerated overlying skin as a long skin paddle. Cephalic vein was dissected free, clamped, and divided. Aneurysmal segment of cephalic vein was handed off as specimen. I then anesthetized a lateral curvilinear tunnel and passed a PTFE graft through the tunnel and created a beveled end-to-end anastomosis between the graft and the inflow cephalic vein at the wrist. The graft had a strong inflow pulse. Excess graft was trimmed and created an end-to-end anastomosis to the outflow cephalic vein at the proximal forearm. Graft had a strong thrill."

The description for code 93657 is as follows: "Additional linear or focal intracardiac catheter ablation of the left or right atrium for treatment of atrial fibrillation remaining after completion of pulmonary vein isolation (List separately in addition to code for primary procedure)".

Is it absolutely imperative that the provider explicitly document that atrial fibrillation remained or complex fractionated atrial electrograms were present following pulmonary venous isolation in order to report this CPT code? Or is documented ablation of the atrial wall itself sufficient enough to support 93657, devoid of mention of remaining Afib/CFAEs?

A dual chamber pacemaker generator was removed and replaced with a new dual chamber generator. The two leads were reused. Later in the day the patient returned, and the RV lead was explanted and a new RV lead inserted. We charged 33228 for first procedure and 33216, 33234 for the second. But we received a Charge Correction for these CPTs stating they could not be charged same day. Coder suggestion 33207, 33233, 33235? Do you agree?

Is it appropriate to code 93654 and 93655 when there are "2 separate PVC sites and mechanisms targeted"? Specifically these two? "Focal PVC ablation with two PVC sites targeted. First morphology: an epicardial LV outflow tract focus targeted from the distal branches of the coronary sinus. Second mechanism/morphology was an endocardial site located just inferior to the aortic valve at the aorto mitral continuity. Both sites ablated. Both PVCs eradicated." The discrete mechanism confuses me at times when trying to be certain they are separate. Any tips?

Would we use CPT code 37248 for the recanalization of the femoral vein performed here?

"We performed high pressure angioplasty up to 15 ATMs with a very tight waist that  resolved at full inflation. We performed three additional angioplasties up to 10 ATMs with no other waists noted. The balloon was deflated and removed and I performed a hand injection angiogram through the long sheath which showed further improvement in the patency of the femoral vein, although there was still an area of stenosis near the femoral head. We carefully prepared and de-aired a 7 mm Dorado balloon. This was advanced over the wire into the area of stenosis and multiple angioplasties performed. In the area of tough stenosis there was a waist seen that completely resolved at full inflation. The balloon was deflated and removed and I performed a hand injection angiogram through the long sheath which showed further improvement in the patency of the vessel."

Patient came in for an EPS with arrhythmia induction and was confirmed to have VT. After EP study doctor placed a single chamber defibrillator. Insurance is denying placement of defibrillator. They paid the EPS but not the defibrillator. I coded it with 33249/I25.5, I50.22 and with 93620-26,51/I47.2. How would you have coded this?

Patient has had previous MIs with one stent and EF of 40%

"Patient scheduled for TAVR procedure. Cutdown was done on the right groin to expose the right femoral artery. The artery was very calcified, and there was no soft spot. Dissection was extended upwards and downwards to expose the common femoral artery as it went up more to the proximal to the inguinal ligament and all the way retroperitoneal to the external iliac artery. The artery was calcified throughout, and no access could be obtained. Both surgeons at this point agreed they could not proceed, and the incision was closed in layers of vicryl and monocryl. The decision to follow up with a subclavian percutaneous approach was made, and TAVR successfully placed at a later date."

Since 34812 is now an add-on code, would 33362-53 be appropriate? We are unable to bill anything but the incision and closure, as no angiography/catheterization procedure was performed.

If an IVR procedure is done in the OR department, should the case be billed by CPT procedure codes or OR time charges? What is appropriate?

Do you agree with 61645 and 61624 for the following scenario?

"Patient with: 1) Flow limiting dissection at right ICA petrous segment. 2) Clot at MCA m2/3rd.

Vessel reconstruction was performed with pipeline flow diverter, post flow diversion, right common carotid confirmed proper position, post procedure tici 3. Aspiration technique performed. MCA angio demonstrated technically successful mechanical thrombectomy."

When the MD accesses the brachial artery in a brachiocephalic fistula, is this always reported with 36140-XS? Or is the perianastomosis brachial artery included in 3690X? Example: "Real-time ultrasound guidance was used to access the brachial artery in retrograde fashion. Fistulogram was performed. Based on the findings, angioplasty of the cephalic vein was performed."

A patient had an atrial fibrillation ablation, 3D mapping, and ICE, which was coded to 93656, 93613, and 93662. We use an Endcoder, which is also including code 76376. I have never used that code before with the ablation. Is 76376 appropriate to use with the ablation? Below is the documentation of the 3D mapping from the operative report. 

"Standard ablation mapping: The coronary sinus and pulmonary veins, left atrium, and left atrial appendage were mapped from a transseptal approach with circumferential mapping. Mapping was performed during atrial fibrillation, atrial pacing, and left atrial pacing. DC cardioversion was performed to restore normal sinus rhythm to allow accurate activation mapping during atrial pacing.

Intracardiac 3D mapping: The coronary sinus and pulmonary veins, left atrium, and left atrial appendage were mapped from a transseptal approach with point-by-point voltage and activation mapping using a Rhythmia device. Mapping was performed during sinus rhythm, atrial fibrillation, and coronary sinus pacing."

Can a hospital report both IVUS and iFR in the RCA when performed during the same setting with a LHC and DES? Would 93458-59, 92978-RC, 93571-74RC, and C9600-RC be appropriate? Guidelines state use up to one initial and four additional, but these are different devices so may we have two initials on the same vessel? There are no NCCI edits. We understand IVUS and OCT performed in the same vascular territory can only be reported once.

A physician outside our group was placing a transvenous pacemaker and asked one of our physicians to help by creating the right internal jugular access, which was done with ultrasound guidance. Is there anything I could (or should) bill?

Our provider performed angioplasty to proximal to mid 1st septal perforator and 2nd septal perforator. Do we also code this with 92920?

"Wire placement was performed with a Runthrough NS Extra Floppy 300 cm guidewire, which was advanced through the vessel beyond the lesion. Angioplasty was performed with a RX Emerge 2.0 mm x 15 mm balloon at 4 ATM. Balloon used to block flow into LAD for possible alcohol septal ablation procedure. Injection of echo contrast through balloon shaft under TEE showed brisk contrast filling of the RV chamber as well as contrast staining of the RV side of the septum and moderator band. We decided against alcohol injection given these findings and the procedure was stopped. Final angiogram with the wire and balloon removed showed patent LAD and septal perforators without evidence of acute vessel closure, dissection or perforation."

Can I report codes 36831 and 36907 as well as direct repair of aneurysm if provider amends to which artery?

"We confirmed it almost completely thrombosed. We identified both anastomosis as well as area non aneurysmal areas where we can obtain control. We then made small transverse incision over AVF in medial arm just distal to arterial anastomosis and obtained circumferential control. We did the same just proximal to venous anastomosis. Patient was heparinized. We then made longitudinal fistulotomy over both aneurysms. We encountered large amount of occlusive thrombus and removed it. We used Fogarty catheter (# 4) to remove additional thrombus from venous segment. Next, we placed 11 French sheath into distal AVF and performed fistulogram. We identified stenosis at venous anastomosis and treated it with POBA (6, 8, and 10 mm). We performed central venogram and identified moderate stenosis in SCV that we treated with POBA (8 and 10 mm). We then performed aneurysmorrhaphy (excised redundant tissue and primary repair w 4-0 Prolene running suture). We then excised redundant thin skin as well."

I have a patient who had a pacemaker pocket revision due to discomfort. No infection, relocation not done except for a slight move within the same pocket; I&D was not done. What code would be appropriate in this scenario?

"Blunt and Bovie dissection was carried out down to the level of the existing generator. The generator was removed from the pocket. Leads were dissected free of scar tissue. Dissection of the pocket was carried out in a superior medial direction extending over top of the transpectoral lead insertion position. The leads were coiled under the device in a more favorable anatomic location. The device was tacked to the prepectoral fascia as superior medially as could be obtained, just medial to the lead insertion positions. The pocket was irrigated with 180 cc of antibiotic irrigant solution on once again examined for bleeding. Both leads were pulled tested and remained fixed in place in the header. The wound was closed using a standard 3-layer closure technique."

My doctors are doing lithotripsy angioplasty. I am coding them as angioplasty, but they think there should be a new code for physicians to use to bill for this procedure (just like the atherectomy has one). Please clear this up for me.

When is it appropriate to bill codes 76377 for 3D and 93612 for ventricular pacing when performed during rotational angiography along with pulmonary artery angioplasty (92997)?

"Example: Patient presents for a diagnostic cardiac cath and possible intervention on the conduit. Complete right heart and retrograde left heart cath was performed. 6 French Berman angiographic cath was placed in the right ventricle. A 4 French pacing cath was inserted in the LFV sheath and placed in the right ventricle. Right ventricular pacing was performed at 180/min with breath hold, and rotational angiography was performed. Rendering and post-processing of the rotational images was performed. After post-processing, the image was used for overlay on the fluoroscopy. Angioplasty was then performed within the RV-PA conduit and the right pulmonary artery. There was adequate arborization bilaterally. Post angiography demonstrated adequate relief of the stenosis. Improved angiographic appearance of the RPA post balloon angioplasty with no evidence of vascular injury."

I'm unsure if I should code any of the work that was done prior to the incision being made. Would you code and modify with reduced services 37197, 75820, 36005 or ONLY code 10120? Thank you for your help! DIAGNOSTIC VENOGRAPHY OF THE RIGHT CEPHALIC VEIN WAS PERFORMED THROUGH THE 4 FRENCH SHEATH. THE RIGHT CEPHALIC VEIN IS PATENT. A 1 CM LINEAR FOREIGN BODY PARALLEL WITH THE CEPHALIC VEIN IS PRESENT. FOREIGN BODY RETRIEVAL UNDER FLUOROSCOPIC GUIDANCE, ATTEMPTS TO SNARE THE FOREIGN BODY WITH 2 MM AND 4 MM LOOP SNARES WERE UNSUCCESSFUL. ATTEMPTS TO DISPLACE THE FOREIGN BODY WITH A 4 MM BALLOON UNDER FLUOROSCOPY WERE ALSO UNSUCCESSFUL. UNDER FLUOROSCOPIC GUIDANCE, A 5 MM INCISION WAS MADE OVER THE SITE OF THE FOREIGN BODY. WITH MINIMAL DISSECTION, THE FOREIGN BODY WAS ABLE TO BE REMOVED. A MAGNIFICATION VIEW SINGLE SHOT X-RAY WAS PERFORMED DEMONSTRATING SUCCESSFUL RETRIEVAL.

When performing a duplex scan of arterial inflow and venous outflow for preoperative vessel assessment prior to creation of hemodialysis access (93985/93986), if you were to perform a duplex scan on the entire radial and ulnar artery as well as the palmar arch, would you be able to bill for the additional studies (e.g.,  93930/ 93931)?

In know code 93930 is a column 2 code for 93985, but you may use an NCCI-associated modifier to override the edit under appropriate circumstances, so I just wanted to check whether the use of a modifier would be appropriate.

When angioplasty is performed in the posterior tibial/ lateral plantar and dorsalis pedis arteries, would we code 37228 and 37232, or only 37228?

These insertions were performed on the same DOS. Patient was released from the cath lab and was brought back 5 hours later. See documentation below. How would we code the second insertion, 33990?

"The Impella is seen to have migrated to the arch of the aorta. Despite multiple attempts, we were not able to prolapse the Impella CP across the patient's aortic valve. Our next plan was to use a snare through JR4 guide and use it to snare the tip of the Impella pigtail and push it across the aortic valve. However, we noted that there is spasm in the radial artery and did not resolve with nitroglycerin. Hence, we decided to proceed with Impella removal and insertion of new device."

Code 35102 allows a -50 modifier. If both iliacs are involved and bypassed, would you use a -50 modifier? If not, is there a case where you would use a -50 modifier? A Carrier is insisting on an anatomic modifier; however, -LT or -RT does not feel correct because both sides were equally involved and the -50 would modify the price, so I wanted to see your thoughts.

We have a patient who previously had a breast biopsy and biopsy clip placed. Now the clip needs to be removed. Should we use 10120 for this procedure?

My doctor is wanting to do loop recorder implants and removals in the office instead of the hospital. He is planning on purchasing the devices from St. Jude. How do I find out if this is okay to do in the office and figure out cost?

My provider is documenting limited findings for stress tests performed in the hospital setting. His documentation will at times only have "normal". Must the provider document all of the following: starting and ending hemodynamics, arrhythmias, symptoms ST segment changes, and functional capacity? Can you please tell me what are the minimal requirements that the provider must document to support 93018?

Please advise how to code for an epicardial echo. I’m baffled because the procedure has been around since the 1970s, and in 2007 ASE published an article on the growing importance of them, so epicardial echos are well-established yet I cannot find any mention of it in CPT or your reference books.

The case: A baby is in the OR for surgery to correct ASD. Before closing the chest, a pediatric cardiologist (not a surgeon) performs a limited epicardial echocardiogram with spectral and color flow Doppler. How do we report this service appropriately? Unlisted, 93799? Or is there a better code? I do not believe 76998 is appropriate here because it is not for guidance; it is done at the end of case to evaluate function after surgery. Or does that count as guidance?

If we must use unlisted, how does the work compare to TEE? Not sure how to go about pricing it, we didn’t have to place a probe down a throat so that seems like less work, but carefully probing over the surface of the heart might be more work? I don’t know.

Our surgeon performed a basilic vein resection due to thrombophlebitis with an extensive arm debridement. We cannot locate a code for the resection. Can you suggest one?

Is it appropriate to submit CPT code 71250 for CT of the sternoclavicular joints? Would a -52 modifier need to be appended?

I read where even though no catheter used CT and MR angiograms are considered catheter based. If a patient has a CT angiogram at 800 and it shows Active contrast extravasation in the pyelocalyceal system in the midpole of the LEFT kidney. Later that day the patient is taken to IVU and has a left renal angiogram, segmental left renal angiogram and embolization. The doctor notes in his dictation the left renal hemorrhage noted on CT angiogram. In this case I don't believe the angiogram done by IVU would be billable because the hemorrhage was seen on the CT angiogram. Is that correct? What if CT angiogram done on a Monday for lower extremity but atherectomy done on Wednesday, would the angiograms done in the IVU at that time be billable? The doctor gives detailed findings of each angiogram done. It seems to me that the CT angiogram showed the problem and unless there is a change in the patient condition the angiograms done in IVU prior to the intervention would not be billable. What if IVU angiograms done a month after CT angiogram? Thank you

"Patient has AF and atrial flutter. After completion of successful PVI, the physician performs a typical atrial flutter ablation. Three-dimensional mapping and conventional catheter mapping were performed using this ablation catheter and the left atrial coronary sinus decapolar catheter. Multiple radiofrequency lesions were administered, resulting in gradual slowing of the atrial flutter with eventual termination. The ablation catheter was then placed in the lower lateral right atrial wall, and pacing was performed from the coronary sinus catheter from coronary sinus. Conduction times across the caval tricuspid isthmus were noted to be [135] ms in both directions confirming a bidirectional block across the isthmus."

We were going to bill 93656 for the PVI and 93655 for the atrial flutter ablation, but the physician is thinking we should bill an additional 93655 for the CTI. Would you please review and see if we should add the additional code?

Would we code anything for profunda jump graft in addition to CPT code 35646?

"Procedure(s): Aorto to left iliac and right femoral bypass 18 x 9 and ligation of right femoral artery aneurysm, profunda bypass with 6 mm graft, profunda endarterectomy.

Dissection included dissecting out the femoral artery aneurysm, which was ligated, profunda bypass with a 6 mm graft. Aorta endarterectomy and stent removal were performed, and then an 18 x 9 Dacron graft was sewn into side. I then turned my attention to tunneling the right limb of the graft through the inguinal canal, and my assistant started the anastomosis to the common femoral after ligating proximal femoral aneurysm forming endarterectomy at the SFA and profunda and was performing common femoral anastomosis along with his profunda jump graft, I performed the left limb to the proximal common iliac artery end-to-side anastomosis."

When a patient has an anomalous origin of the coronary arteries and you perform a CT with contrast, would you report code 75573 or 75574?

Patient underwent TEVAR with coverage of the take-off for the left SCA using TX2 Cook endograft (33880) with Petticoat Cook graft in the perivisceral aorta to infrarenal aorta (tube graft) with bilateral iliac limbs using VBX stent grafts as follow: "Next, to treat the abdominal aorta, we advanced a Cook Petticoat Bare endograft and deployed it an aorto-aortic tube graft across the perivisceral aorta to the infrarenal aorta above the aortic bifurcation. This was done using a 36mm/36mm x 180 mm Petticoat Cook Bare endograft. Next, we advanced VBX stent graft 11 mm x 79 mm in bilateral common iliac arteries, which were deployed successfully with about 2 cm into the distal aorta. They were post-dilated with a 16 mm x 4 cm balloon for distal seal with excellent results." For the Petticoat and bilateral iliac stents, do we report 34705? Or 34701, 37236-50?

Please help! I have a case where the patient was diagnosed with MINCA (MI with normal coronaries). I have no clue whether to code it as ACS or NSTEMI or something completely different. 

Patient presents for planned atherectomy about one week after percutaneous angio. Spider distal protection device was placed. Injection of contrast revealed string sign. SilverHawk device is advanced, “which went though the lesion very easily. For this reason, I decided against initiating the procedure with atherectomy and instead I proceeded with mechanical thrombolysis to remove any soft material or thrombus that may be present... The AngioJet device was then used through the SAME popliteal lesion removing a significant amount of thrombus.” After another injection of contrast, SilverHawk is used for atherectomy in the same vessel. Would you code this thrombectomy as primary 37184 because an AngioJet was used for a significant amount of thrombus? Or, would you code it as secondary 37186 because it was unanticipated and removal of clot was needed before the planned atherectomy?

Procedures: 1) Hemodialysis access, autogenous fistula, branchiocephalic, left antercubital crease. 2) Ligation of large accessory branch via small separate incision, left extremity.

The surgeon performed creation of arteriovenous fistula. Also performed closure commenced after making a small separate stab incision, closing an obviously large and a clearly visible cutaneous tributary.

Is code 36821 (arteriovenous creation) included with ligation (37607) when both are done at the same encounter via two different incisions? Or do we code both separately?

Patient was undergoing transcarotid TAVR, which will be billed with unlisted CPT 33999. Intraoperatively, there was an LV apical perforation requiring emergent sternotomy and primary repair with pledgeted sutures and then a superimposed patch with Dermabond impregnated valve bovine pericardial patch overlay. Is the sternotomy with LV repair separately reportable?

I have noticed that the -50 modifier is allowed on open aneurysm repair involving iliacs. Does that mean if a patient has a AAA and also an aneurysm in both iliacs that the 35102 should be coded with a -50 modifier? I always thought that the 35102 is a bifurcated graft, therefore you only code once if the repair also involves the iliacs.

Per the NCD for carotid stenting it states: "The degree of carotid artery stenosis shall be measured by duplex Doppler ultrasound or carotid artery angiography and recorded in the patient's medical records. If the stenosis is measured by ultrasound prior to the procedure, then the degree of stenosis must be confirmed by angiography at the start of the procedure. If the stenosis is determined to be < 70% by angiography, then CAS should not proceed." Does confirmation by angiography include CTA or just catheter placed angiogram?

For professional services, what should the date of service be on claims for remote device checks? CMS released an article "Guidance on Coding and Billing Date of Service on Professional Claims" that outlines rules for cardiovascular monitoring services that outlined: "When the service includes a physician review and/or interpretation and report, the date of service is the date the physician completes that activity." However, the company we have partnered with for remote device interrogations has stated that on the CMS 1500 claim form for physician services we have to use the date on their reports so that it will show every 30/90 days for reimbursement. What is your opinion on the correct date of service for reporting remote device checks for professional services? Ex: CPT code 93294.

Please answer this, as we are getting mixed messages from your older answers (Oct.  1, 2013).

REPORT READS:

"Vessels selected: 1) Celiac artery. 2) Right hepatic artery. 3) Segment 5/8 hepatic artery.

Cath into celiac with angiogram then to RHA with angiogram done. This catheter was then advanced into segment 5/8 with angio and y-90 embolization done."

Is it correct to code 36247 for RHA and 36248 for the Segment 5/8 (this is based off your answer from Oct 1 2013)? Or is it just 36248 since the segment 5/8 normally is off the RHA?

What is normal anatomy for SEGMENTAL arteries off the LHA and RHA and does documentation have to state the segmental arteries came off the RHA or LHA?

What is the proper CPT code for a TTE, 2D, M-Mode, complete, with spectral/Doppler, with contrast for non-Medicare patients?

Would it be appropriate to bill 33508-59 twice: once for the surgeon and once for the assistant who is a PA or NP? We have been billing for both and now starting to see denials. Should we just be billing 33508 for the assistant with 59-AS?

If a patient has a guillotine amputation (27882) of the lower extremity, would it be appropriate to use the secondary closure CPT code (27884) as the book suggests, or would it be more appropriate to use the re-amputation code (27886)? This question has arisen due to the description of the re-amputation states that bone is resected, and this is not in the description of the secondary closure. If the guillotine is at the ankle, would it be more appropriate to bill a straight below-knee amputation code (27880)?

Patient was undergoing a fem-pop bypass with a 6 mm Gore-Tex graft. Following completion of the proximal anastomosis, the physician went down to the below-knee popliteal space and took the GSV and sewed it on as a patch, then made an arteriotomy in the vein patch and sewed the distal end of the Gore-Tex to the vein patch. Is this still coded using 35656, or would there be a different or additional code added for the vein patch?

Are the studies only combined if ordered as an acute abdomen series? Or do they require separate technical scans and medical necessity?

Sometimes our providers insert a VAD, which has no global period, but then delay chest closure, which does have a 90-day global period. When they come back to see the patient the follow-up is focused on the VAD and reason for the VAD and not the chest closure itself. Is it appropriate to append modifier -24 to the E&M in this situation?