Ask Dr. Z

I am a CIRCC coder for HIM. I enter the facility CPT codes for the Hybrid room. I enter these codes where the supplies and room time charge is entered. -HIM also has outpatient coders who would enter the CPT codes (only up to the 70,000 series) on a billing side, the side staff would not see. These coders do not code any CPT codes for IR/CV/EP/Hybrid cases; I code and enter them. -The OR billing staff enters their room time charge and says I should not double bill the patient by entering CPT codes; the OR says they “want the HIM outpt coders to enter them” instead on a side not seen. 1) Does it matter who enters the code? This creates a problem in HIM. To keep consistency I want to enter the codes, and the outpt coders want to enter their DX codes. 2) Is there double billing since there is no CPT code for room time? your Q&A #5257 reads “Since the operating room charges time for the surgical procedure performed, all surgical procedures are included in the OR time charge. I don't think that is correct. Please clarify.

We are still having debates on the compliant coding of the Rotarex device. According to the NCCI this should be atherectomy only (37225 see example) - in the beginning the Rotarex coding team told them to report code 37184 with 37225, and now they are telling them to code 37186 instead with 37225. I interpret the NCCI edit to clearly state if in same vessel as intervention only the atherectomy should be coded? Example: DX; multiple areas of atherosclerosis/significant stenosis: "A Rotarex device was then prepped per routine and advanced to the lesion over a 0.018" wire. Primary mechanical atherectomy and secondary mechanical thrombectomy were performed in multiple passes in the SFA and popliteal arteries." (Then they stented.) Am I correct in coding only the atherectomy and not to bill secondary thrombectomy with a modifier? Since the start of the use of the Rotarex and their suggested coding, I can get no one from Rotarex to respond to discuss their suggested coding with me.

Is it appropriate to report code 64445 if a sciatic nerve block is performed using a catheter, but the catheter is not specified as being indwelling or that the infusion was continuous?

For ICD-9, arterial stenosis was coded 447.1, which crosswalks to I77.1 for ICD-10. In the ICD-10 index, "Stenosis, artery NEC" indicates "see also Arteriosclerosis I77.1", which seems misleading since the Arteriosclerosis section appears to only have I70.XXX codes included. Is this a typo in the index? To confirm, extremity artery stenosis is coded as I70.XXX (as the index routes you to Arteriosclerosis, extremities when looking up Stenosis, artery, extremities)? If yes, what diagnosis term/condition is represented by I77.1?

"Using ultrasound guidance, left peritrochanteric collection was identified. A 5 French centesis catheter was inserted into the left peritrochanteric bursitis/collection. 10 cc of dark red-colored fluid aspirated and sent for analysis. FINDINGS: There is a complex septated collection overlying left peritrochanteric region, either represents hematoma, complicated seroma or bursitis."

Since catheter into peritrochanteric fluid collection, can we report code 20611 (US requirements met) though diagnosis not confirmed?

"TECHNIQUE/FINDINGS: A spot image of the existing nasojejunal tube was obtained. A Roadrunner wire was advanced, the old tube was removed, and a new weighted nasojejunal tube was placed. Postpyloric positioning was confirmed with Gastrografin injection." How is this procedure best reported? UPC 44799 + 76000 or 44500 + 74340?

We recently encountered an upgrade.

Old device: Manufacturer: St Jude Medical. Model: Assurity MRI 2272 Pacemaker

New device: Manufacturer: St Jude Medical. Model: Quadra Allure MP 3562.

St. Jude quadripolar left ventricular pacing lead.

The two old leads (RA and RV) were disconnected from the old PM device that was removed, cleaned, dried, and connected to the new device generator.

My question is, should this be coded with 33249 or 33229? I was confused when your coding tips said, "Report 33229 when existing system has multiple or more than two leads." In this case, the existing PM was a dual system. Our cath lab charged 33249, but medical records coded 33229.

Our physician did catheterization of bilateral internal jugular veins, bilateral sigmoid sinuses, bilateral transverse sinuses, torucla, right straight sinus, and left superior sagittal sinus with local venography and pressure measurements. I am getting: 36012 (x4), 75860, 75860-59, and 75870? Is this correct?

"Suprapubic catheter was injected with contrast. Catheter was occluded. Catheter was removed and a new catheter placed. Contrast injection demonstrated appropriate positioning in the bladder. Successful replacement of occluded pre-existing Foley catheter with a new 14 French catheter."  Would this be 51705 suprapubic catheter change or 51702 Foley change?

The patient is having a right shoulder joint injection for a subsequent MRI at an imaging center. Can the physician bill for all of the medications listed, specifically epinephrine, Marcaine, lidocaine, etc.?

"Medication supplies: 13 ml Omnipaque 180, 0.1 ml epinephrine, 5 ml lidocaine, 7 ml bupivacaine, 0.05 ml Gadavist. Discarded: 7 ml Omnipaque 180, 0.9 ml epinephrine, 2 ml lidocaine, 3 ml bupivacaine, 1.95 ml Gadavist.

Lidocaine 1% was used for local anesthetic. Under fluoroscopic guidance, a 27-gauge needle was placed into the right shoulder joint. A small amount of non-ionic contrast was injected into the joint to document intraarticular placement of the needle. A solution of gadolinium, saline, non-ionic contrast, Marcaine, and epinephrine was injected into the right shoulder joint."

If a patient comes in for an upgrade of a dual chamber pacemaker to a biventricular pacemaker with retention of the RA and RV leads (will be attached to new generator), insertion of a NEW additional RV lead and LV lead, how do you recommend coding this encounter? We are receiving conflicting information between coding as 33229 and 33225 or coding componently as 33233 (removal PM generator), 33207 (insertion new PM with new RV lead - prior RA and RV leads attached to new generator), and 33225 (insert LV lead). Can you please clarify with rationale?

Can an office visit and EKG be billed with a device check?

Would you code 76000 or 47531 x 2 with attempted modifiers for this case? "A scout image was obtained of the indwelling catheters. Fluoro time 1.4 minutes. Despite several attempts with multiple types of syringes and catheter tips, neither tube could be injected to obtain an adequate study. IR offered to exchange the tubes to perform the study, though this was declined."

Patient has a LUE brachiocephalic AV fistula but due to repeated issues with subclavian vein stenosis a bypass graft was inserted that went from the cephalic vein to the internal jugular vein. Since the subclavian vein is completely occluded, would the peripheral portion of the dialysis graft be from the brachial artery anastomosis to the internal jugular anastomosis with the central portion being the left internal jugular vein through the superior vena cava? Reason being they performed an angioplasty and stenting of the left innominate vein from the AV graft access (36908) and internal jugular angioplasty via the femoral vein access (37248). I know the CPT Codebook 2021 page 309 states if angioplasty or stenosis is performed via a non-AV graft access it is coded with normal CPT, but what if both the stenting of the innominate and angioplasty of the internal jugular were performed via the AV graft micropuncture? Would it be just 36907? Or would it be treated as a regular bypass graft with 37248?

My IR doctor did a diagnostic CT-guided aspiration of left thoracic fluid (32555), and then through a second puncture (same fluid collection) he placed a catheter under CT guidance and the catheter was secured to the skin and left in (32557). I'm confused because he's saying since 32555 was diagnostic and 32557 is therapeutic they can both be billed, plus 2 separate entry points. (I don't think that really counts.) There are no NCCI edits between 32555 and 32557, but I thought we could only bill one procedure per operative site. This was all one fluid collection even though two separate entry points. Can you please clarify for me (and my IR doctor) which is the correct way to bill this scenario?

"A venotomy was made in the basilic vein, and a 0.035 Bentson wire was placed. A 6 French sheath was then placed in the left basilic vein over the wire using Seldinger's technique. A venogram for the LUE was then performed. The LUE venogram revealed: widely patent SVC, left brachiocephalic, left SCV, left axillary, and left basilic veins."

This procedure was done after dissection of artery and vein, but before arteriotomy and venotomy for PTFE graft anastomosis. Can we bill 36830 with 36005 and 75820?

Is it appropriate to code IVUS (non-coronary) when the catheter remains in the aorta for diagnostic purposes prior to the endograft, and then again after one graft has been deployed, and then at the end after an additional graft is deployed and the procedure is complete? So this would be 37252 and 37253 (x2)?

Should 36228 be coded with 36223? "Selective catheterization, left common carotid artery, cerebral angiography with radiologic supervision and interpretation. Findings: The left common carotid artery fills normally. Both internal and external carotid arteries are patent. Intracranial segments of the internal carotid artery are patent. The posterior communicating artery is a moderate size vessel. There is filling of the left PCA but no reflux into the basilar artery. The anterior and middle cerebral arteries are patent. Capillary and venous phases are unremarkable."

Our practice is performing MR-guided focused ultrasound ablation to treat primary prostate cancer. I'm not getting an NCCI edit on the facility side with codes C9734 and 77022. However, the HCPCS reads "...with MR guidance", so it seems inappropriate to code for the 77022 in addition to the C9734. Should the two codes be reported with one another?

Can a physician bill an E&M code on a patient that was not seen face-to-face? When rounding on patients, there are times where the patient is off the floor having a test done. The physician documents a note and reviews labs, testing, and makes changes to medication. All aspects of the E&M note are completed, except for the physical exam. Would the physician be able to bill this service out on a time based manner?

What do we report for the hospital for the placement of a suprapubic catheter through an existing tract? Patient came in due to dislodged suprapubic catheter, and under fluoro the physician injected contrast to confirm the fistula and just used a catheter and wire to navigate through the existing tract back into the bladder. He then was able to place a new drainage tube into the bladder. My thoughts are to report just a simple catheter exchange (51705 and 75984), but I am not sure since the catheter was not actually still in the patient and I don't think a new insertion (51102) would be appropriate either.

Would SAVI scout placement that is a different date of service than a lumpectomy or lesion excision be separately reimbursed / separate co-pay for patient if performed, say, 2-3 days prior to the OR procedure? - Hospital Billing

Is this allowed?

e.g. 19281, then two days later, a 19125.

Can we bill an ILR extraction (33286) and implant (33285) in the same session?

The physician removed the pacemaker from the pocket with leads attached. He then revised the pocket and inserted the same pacemaker. Would unlisted code 33999 be correct?

I have a procedure that I am not sure how to code. It is supposed to be an upgrade from a dual PM to biventricular PM.

“Due to inability to place the lead, we pivoted to placing His-bundle lead. Medtronic 3830 lead placed with good His bundle recording and selective capture. All sheaths were slit and pre and post slit numbers remained consistent. The lead was then secured to the subpectoral floor using 0 ethibond suture x2. The His lead was placed in the new device header (RV port). The atrial and ventricular leads were removed and placed within the new device header. The RV lead was placed in the LV port (programmed RV-> LV 80 msec).“

The new lead was placed in the RV port, and the retained RV lead was place in the LV port. So would you bill 33207 and 33233?

There is an NCCI edit in place between J1644 and 36901-36909. It has been suggested that we use -59 modifier to override the edit when heparin is used during these procedures. My thought is the -59 or -X modifiers are not supported, and the heparin should be bundled in with the procedure. Do you agree, or is there a scenario where -59/-XS is supported here?

Our provider did aorto-bi-iliac graft (34705) and placed IBE on left side for common iliac aneurysm (34717). He also selected and embolized a largest terminal branch of left internal iliac artery with coils to avoid endo leak in future. As per CPT guidelines for 34707, 34708, 34717, and 34718, the treatment zone is defined as the portion of the iliac artery (common, internal, external iliac arteries) that contains the endograft. So if the embolization is done is in a branch of internal iliac artery that does not have the endograft, will that embolization be billable? Could you please advise whether 37242 is billable with 34717 in this case? Also he did angiogram in the mesenteric artery to find if it could be embolized to prevent endo-leak. Will that angiogram be billable with 75726? Do we need to consider that angiogram as diagnostic, or since it is done as a prophylactic measure will that not be billable? Please advise.

Can you please let me know if the below is sufficient documentation to support billing the tomosynthesis codes (77063):

3D and 2D synthesized bilateral CC views were taken

3D and 2D synthesized bilateral MLO views were taken

"ICE catheter was advanced to the right atrium, and we imaged the ASD and PFO. ASD measurements were performed. A wire was placed across the ASD into the left atrium. An 11 mm ASD septal occluder device was then deployed into the left atrium. It was pulled back to the ASD, and the right atrial disk was deployed. Imaging under ICE showed excellent closure of the ASD. We then placed a wire through the PFO and measured. We used an 18 mm PFO closure device. The left atrial disk was deployed and pulled back to the PFO. Next the right atrial disk was deployed. We took some time to make sure that this did not interfere with the ASD closure device. Once we were sure that we had good closure of both the ASD and PFO, each of these was released."

Code 93580 has an MUE of 1, but an adjudication indicator of 1, which I understand to mean it can be appealed. Is it appropriate to charge 93580 x 2 and appeal, since both a PFO and ASD were repaired? Or is this just considered one procedure and we should only charge 93580 x 1?

An abscess catheter was placed at "tip of the abscess drain was identified along the laminectomy site with successful drainage of the subcutaneous and deep fluid collections." It appears by looking imaging that the patient has several abscesses after her laminectomy. They aren't calling this a CSF collection, so I'm not sure how to really code/charge for this. When I queried the doc if this was a subcutaneous collection or deep, he said, "Deep at the laminectomy site."  What would I code for this? 10160?

"Patient with lateral tunnel fenestrated Fontan on warfarin who presented with hemoptysis. Prior to the procedure the patient underwent bronchoscopy. There were areas in the right upper lobe and left lower lobe that were suspicious for bleeding, but no true active bleeding was noted. Angiographically, there was mild aortopulmonary collateral burden bilaterally in the setting of tiny networks of collaterals. Collaterals from numerous vessels (right and left side) were occluded with coils and embolization particles."

Since no active bleeding was noted, but the reason for the embolization was hemoptysis, should this be reported with codes 37242 and 37242-51 (embolization for acquired arterial malformations) or with codes 37244 and 37244-51 (embolization for arterial or venous hemorrhage)?

A TTE with contrast (C8929) was performed. Lopressor was required to be administered afterwards to help regulate the heart rate. Would it be appropriate to charge for the Lopressor IVP (96374) because not all patients require Lopressor after the administration of the dobutamine?

Can you provide clarification on how to use 37184 and 37185? Should 37184-50 be used for each initial vessel (both the right and left pulmonary artery) and then 37185 would be used for the second or subsequent vessels entered (example if the right pulmonary artery was entered it would be 37184 and then catheter was moved into the lower lobe of right pulmonary and 37185 would be used)? Or 37184 is used for the initial vessel entered, say, the right pulmonary artery 37184 and then the left pulmonary artery would be 37185?

We have had several recent cases in which our IR physicians perform both US-guided percutaneous RF ablation of a hepatic mass as well as US-guided percutaneous alcohol ablation of a separate hepatic mass or nodule during the same session. Instruction #2 on page 556 of your 2021 Interventional Radiology Coding Reference states, "Report unlisted code 47399 for direct needle injection of alcohol for ablation of hepatic neoplasm." Since both RFA and alcohol ablation are being performed percutaneously on the same day, should we code only as 47399, along with a description that both RFA and alcohol ablation were used? Or should we use only 47382 since that code includes more than one tumor and RFA was performed? (We are aware that we can bill separately for the imaging/US.) See physician's impression below; the procedures were appropriately documented in detail.

IMPRESSION:

//Radiofrequency ablation of the 3.7 cm right hepatic mass.

//Ultrasound-guided alcohol ablation of a right hepatic 1.2 cm dysplastic nodule.

There is not a specific CPT code for MR lymphangiogram, so we typically see these come through billing as 71555/74185 (MRA chest and MRA abdomen and pelvis). Additionally, we see 76942 (US guidance) billed; this is being billed on the professional side only, as there is not a surgical code attached. We are wondering if this is appropriate and if it would also be appropriate to add 38790 for the injection/needle placement portion of the study.

In the 2020 ZHealth coding reference page 518 it says "16. Report code 49405 for sclerotherapy of renal, hepatic, or splenic cysts. Report code 10160 if the catheter is not indwelling. If sclerosis of a cyst is performed, add code 49185."

I attempted to report 10160+49185 for a renal cyst sclerotherapy without placement of an indwelling catheter. However, I was informed that 10160 is limited to "the skin, subcutaneous and accessory structures" and a renal cyst does not meet medical necessity to report 10160.

Can you please clarify how to correctly code for this procedure?

Patient sees Dr. A in office on 3/3. Tests are ordered. Based on results of test, patient advised in a telephone conversation to have a heart cath. Patient wanted to wait, called back, and was given an appointment for little over a month later. Patient saw Dr. B in the office on 4/6, consents signed, and H&P updated (as required by hospital) for the cath. Note says patient being seen for H/P update prior to cath. HPI and exam were done. Is this a billable visit?

Day 1 patient comes in for venogram for leg swelling. tPA is infused via the catheter for 10 minutes and thombectomy done. Thrombus is chronic and adherent, so they do multiple venoplasties. More thrombectomy thrombus is still there. No lysis catheter left in. Patient is in a lot of pain, and they discontinue the procedure. Doc states that no stent placed due to bacteremia. Adherent thrombus still present. Two days later: Angioplasty is done multiple times with multiple balloons. Then stent was placed. So, on day one, would it be a thrombolysis and thrombectomy? Or just a thrombectomy (37187)? On next procedure, would we be at a thrombectomy for the angioplasty, or would we not code a thrombectomy, as angioplasty is included in stent placement? The patient clearly still had thrombus present, and nowhere was it documented underlying stenosis. 37188 or 37187 since "ongoing thrombolysis" not done? Or just code the stent placement?

"TECHNIQUE: Using sterile technique and ultrasound guidance to access the vessel, patency was shown, and after anesthetizing the skin with lidocaine, the right common femoral artery was punctured successfully. A permanent image was created and stored. Using sterile technique and local anesthetic, a 6 French sheath was placed in the right common femoral vein via modified Seldinger technique. A 5 French long vertebral catheter was placed in the superior vena cava through a 6 French Benchmark catheter. We then advanced the catheter into the right vertebral vein. A venogram was performed. We then advanced a Headway Duo microcatheter over a Synchro Softip microguidewire to the C5-C6 radicular vein. A venogram was performed. The vein was then embolized using Onyx 34. A final x-ray and XperCT were performed." 

Can you please help with the coding? I came up with 76937, 36012 x 2, 76496 x 2, 61624, 75894, and 76377. This was done on an independent workstation under direct supervision and interpretation. If the spinal venograms were diagnostic, would they be reported with unlisted code 76496?

Our physician has handed in his billing and indicated a -52 modifier. I have looked through some old threads, and I am still on the fence if the documentation for not ablating the right side is sufficient or if we should append the -52 modifier.

"The right superior pulmonary vein was entered. Pacing from the circular mapping catheter at the level of the ostium did not capture the phrenic nerve. The right inferior pulmonary vein was then entered next. Pacing from the circular mapping catheter to the level of the ostium also did not capture the phrenic nerve."

Can you please confirm the accurate CPT code for injection at the A1 pulley for trigger finger? This is an example of the documentation, "bilateral trigger finger injections provided for both long fingers at A1 pulley." Would 20550 or 20551 be accurate?

We are unsure how to code this IR biopsy. Radiology wants 10005, auditing wants 20206, and coder wants 64795, maybe unlisted? What in your expert opinion would be an appropriate surgical CPT for this? "PROCEDURE: Ultrasound-guided core biopsy of left upper extremity solid nodule. PRE/postOP DX: Indeterminate nodule. Limited preliminary ultrasound was performed for procedural planning, demonstrating a 1.9 x 1.67 cm solid nodule in the musculature of the left upper extremity with internal flow. Left UE prepped and draped. 1% lidocaine administered under direct ultrasound guidance three 18 gauge core biopsies were obtained and sent for pathologic analysis. Pressure was held at the biopsy site and hemostasis was obtained. Path: TISSUES: A. Left arm; B. Flow cytometry. Left UE triceps lesion. Soft tissue, left UE nodule, core biopsy - Benign peripheral nerve sheath tumor, favor schwannoma."

Can you comment on the following scenario? A patient presents to a hospital outpatient imaging department for an MRI, and with a script for this MRI only. A screening form filled out by the patient establishes a positive history of metal-working. Would the outpatient imaging department need to obtain a script for the radiologic examination (eye, for detection of a foreign body - CPT 70030) from the original ordering (treating) provider, if performed?

Please advise on how to code this. Our surgeon did an open pulmonary vein dilatation using right angle.

"A right angle was passed into each of these left pulmonary veins. The left upper pulmonary vein did not reveal a tremendous amount of venous return. The left lower pulmonary vein on multiple dilatations with a right angle did appear to allow an increase in effluent into the left atrium. This was acceptable. The right atrium was then closed in two layers, and the patient was then placed back on cardiopulmonary bypass and rewarmed to 35 degrees Celsius."

Anthem is requiring a HCPCS on all 278 items for payment. What HCPCS is the best fit?

"The abdomen including the PEG were prepped and draped sterilely. I made transverse incision including the gastrocutaneous tract around 5 cm in length. This was carried down to subcutaneous tissue following the course of the PEG. The adjacent tissues were not inflamed or infected appearing. The PEG was partially within the stomach and within the abdominal wall along the tract, no evidence of perforation or communication into the abdomen. The PEG was then removed. The opening into the stomach was then closed using a 2-0 Vicryl suture in figure-of-eight fashion. Fascial was then closed using running 2-0 Vicryl suture transversely. Wound was irrigated and sutures were used to close the dermis. FINDINGS: PEG BUMPER WEDGED WITHIN THE GASTROCUTANEOUS TRACT, NO INFECTION. PROCEDURE: ABDOMINAL WALL EXPLORATION AND PEG REMOVAL." What CPT code would you recommend for this?

In this case would we be okay to report 35082, Ruptured AAA of Abdominal Aorta (8CM)- Procedures performed were - Open exploration of the abdomen, lysis of adhesions, pigtail cath of aorta w/AO Gram, bilateral fem sheaths (12 R 6LT) They clamp Aorta proximal and distal to ruptured aneurysm, ligate bleeding lumbars , incise the sac which has a hole in it, Drain the intramural thrombus, and then they suture the aortic sac with proline and close the abdomen. They placed the sheaths and the pigtail because they were considering doing an Endovascular approach (patient has prior endograft) but they did not attempt to place and EVAR. As they felt it would not suffice and patient was already ruptured . Thus I don’t think this would qualify for 34830. Since the open aneurysm repair codes are with or w/o graft insertion and all of the work described outside of placing a graft describes 35082. Would it be appropriate? Or would we instead report Ligation 37617. And exploratory lap? Or am I just way off all around?!

The provider performed right and left biplane pulmonary angiography and coronary angiography with left heart catheterization. Our cardio department submitted 93458 and 93568. However, it triggers an edit for missing base code. Code 93458 is not listed as a primary for 93568. Can we report 93568 without right heart catheterization?

Is there a code for a remote LVAD interrogation? I have seen 93297 suggested but wasn't sure that was correct.

A patient with ICD must have the device turned off during the MRI study and on back again. In order to do this, the provider (usually APP) from the cardiology team would turn off the device and turn it back on after the MRI. The APP would turn the device back on with settings aligned with previously documented settings.

Does the service fit programming or integration of the device?