Ask Dr. Z

Hi All,

Need to know if can charge 33992 on this case w/ Impella insertion.

*** the right groin was accessed using the modified seldinger technique. A 7fr french sheath was placed in the femoral artery. We then used a 4fr RIM catheter to go up and over and performed a femoral angiogram on the left iliac and femoral artery. Under fluroscopic guidance we obtained access on the left femoral artery and using the modifier seldinger technique placed a 6 fr sheath. and 14 fr sheath. ..... we then successfully delivered an impella cp in appropriate position with the outlet above the aortic valve and appropriate lv-ao waveforms confirmed on the implella console. we used a 7fr ebu 3.5 guide catheter ... engaged the left coronary artery and perfomed coronary angiogram in mulple views... instered to stent in LC and distal lm.

IMPRESSION:

Drainage catheter check demonstrates complete evacuation of the pelvic. The

drainage catheter was removed.

PROCEDURE SUMMARY:

- Drainage catheter check under CT guidance

- Drainage catheter removal

- Additional procedure(s): None

PROCEDURE DETAILS:

Pre-procedure

Consent: Informed consent for the procedure including risks, benefits and

alternatives was obtained and time-out was performed prior to the procedure.

Preparation: The site was prepared and draped using maximal sterile barrier

technique including cutaneous antisepsis.

Drainage catheter check and removal

The patient was positioned supine. Initial imaging was performed . The drainage

catheter was removed, and a sterile bandage was placed.

- Initial imaging findings: Complete resolution of the fluid collection.

Contrast

Contrast agent: None

Contrast volume (mL): 0

When there is no contrast listed i'm assuming we can't use 49424-49423, because these are contrast based codes. For this note I would code only for the CT Guidance, is this correct? 76380 or 77012

How do you code the removal of an abdominal pacemaker? What CPT code range?

Right femoral endarterectomy and thromboembolectomy with patch angioplasty. Is this reported with code 35141?

Can code 49424 be used when IV contrast is administered for CT abscess drainage catheter assessment instead of injection and imaging through the catheter? 

Are the CMS rules still the same regarding billing of codes 99152/99153 and "the physician must oversee the trained observer, and the trained observer can have no other duties during the procedure"?

"Patient presents with right carotid body tumor for resection. During dissection it was found that the vascular pedicle was densely adherent to the carotid bifurcation. While dissecting this free, the lumen of the bifurcation was entered. The vascular pedicle was isolated, ligated, and transected. The remainder of the tumor was dissected free from both ICA and ECA and posterior attachments and sent to pathology. The laceration to the carotid bulb and proximal ICA could not be readily accessed, therefore the right ICA was transected, eversion endarterectomy performed, distal end-point tacked, and re-anastomosed in bidirectional running fashion. Completion duplex was performed, and wound was closed. Findings: Right carotid body tumor 4x5x3.5 cm resected. This required eversion endarterectomy, as tumor was densely adherent to the carotid bifurcation." 

Are we able to bill for the endarterectomy (35301) in addition to the tumor resection (60600), or would this be considered inherent to the primary procedure given its (iatrogenic) nature and repair during the same operative session?

You have given previous advice to code the psoas muscle image-guided fluid collection to 49406. My research shows that the psoas muscle is not in the retroperitoneal space. Would this still be coded to 49406, and can you please explain why?

"Operative Report: Finally, attention is turned to placement of percutaneous drainage catheter from the left iliopsoas abscess. Under fluoroscopic guidance and utilizing bony landmarks, an 18 gauge Hawkins needle is directed from a posterior percutaneous approach into the abscess collection. Aspiration yields frank pus. A sample is sent to micrology for analysis. Exchange is then made over guidewire after utilization of fascial dilators for a 12 French multi-sidehole pigtail drainage catheter. Appropriate catheter positioning is again confirmed with aspiration of frank pus. The catheter is secured at skin insertion site with non-absorbable suture and placed to accordion drainage."

I would like confirmation on how to code stent placement on two coronary branches of left circumflex. If stent was placed in OM1 and OM2, will this be coded with 92928, 92928 or with 92928, 92929? Please advise.

Patient had an ICD lead fracture. The surgeon attempted to remove the RV lead, but when they "turned the stylet in a counterclock fashion in order to retract the active fixation screw of the ICD lead. The screw was retracting; however, it did not retract entirely. The lead was noted to be lodged well into the myocardium and could not be released with gentle traction." They then capped the lead and decided to implant a new RV lead. Would this be coded as 33216 and 33244-52 since there was an attempt to remove the lead initially?

A previous question in 2018 (ID 11764) asked about mitral valve replacement on an existing prosthetic valve. Your advice was to use either 0483T or 0484T depending on approach. Do you still recommend these codes? Some vendors and insurance carriers are now recommending unlisted code 33999. We cannot find any official coding updates that state 33999 is the correct code to be assigned.

From a RCFA access, the physician embolized R. sphenopalatine artery as an indirect embolization of the L. cavernous fistula. From a RCFV access, the physician embolized the R. cavernous sinus fistula.

Is this considered 1 or 2 operative fields?

I have a removal of the SICD lead (33272) with placement of a new SICD lead. PG was not replaced. Code 33216 is defined as transvenous. Would you recommend an unlisted code?

Patient with liver cancer. Surgical report states visceral and hepatic angiography with radioembolization using Y90 SIR spheres. They billed 37243 and 79445. Then following this Y90 treatment, they billed 78201 for static liver imaging and 78830 for SPECT, and they document as follows: "Post-procedure bremsstrahlung planar and SPECT acquired. PLANAR - radiotracer is seen through RT hepatic lobe. No significant extrahepatic radiotracer identified. SPECT - radiotracer is seen through RT hepatic lobe. No significant extrahepatic radiotracer identified."  My question is, should they really be billing for a bremsstrahlung since it seems just to be confirmatory, not diagnostic, OR should they report the 78800, which does look at the distribution of the agent? I always thought they should NOT bill for 78830 post Y90 therapy when not diagnostic in nature. 

If iFR is performed on two separate vessels during a cardiac cath, is each reported separately with 93799, 93799-XS?

"The patient was then positioned, prepared, and draped for a right robotic-assisted video thoracoscopy vs thoracotomy. Three port incisions were made in the lateral chest wall, adhesions between the superior segment of the right lower lobe and the chest wall. The rest of the chest was unremarkable. We began by removing the adhesions to the chest wall, which were inflamed. As we were taking down these superior segments, a lung abscess was unroofed. Purulent fluid was aspirated and sent for culture. There was a small connection about the size of a dime adjacent to the chest wall that also drained a small amount of purulent material, and this was also unroofed irrigated and debrided. A 28 French chest tubes was then placed posteriorly."

I was not able to locate a CPT code that encompasses everything that was completed. Would this be an unlisted code and compare it to 32604? Or is there a better CPT code to use that we are unable to locate?

"Patient has a right CFA access site. Catheter is placed in the aorta for an abdominal aortogram with bilateral iliac run-off (75630), then via the right CFA access a stent is placed in the right external iliac artery (37221) for occlusive disease."  Since the catheter was placed beyond the intervention site (and is the highest order non-selective code), can you report code 36200 for the catheter placement in the aorta with the right external iliac artery stenting procedure (37221) performed via the right CFA access site, or is 36200 bundled for this ipsilateral access/iliac artery intervention?

Which CPT code would you suggest for the lateral femoral cutaneous nerve block 64447 vs. 64450? 

The provider treated a Type C Lesion of the LAD that had 58mm of the lesion length treated with 3 stents (Prox LAD, Prox to Mid LAD and Mid LAD). In the Medicare LCD prior to 10/1/2022, they stated use of modifier 22 was justified only if 4 or more stents were placed in a single vessel. They did not address Lesion Type or Length. I had always been taught that a 22 modifier could be used when 3 or more stents are placed in a single vessel when factoring in lesion length and/or lesion type. Do you feel modifier 22 justified in this case? What recommendations/rule of thumb should be followed when considering Lesion Length and/or Type to justify modifier 22 use?

I am coding the below with 3D (73677), and I am clashing with others that code it as 76377 x’s. I’ve done extensive research trying to find documentation that 76377 is per field not per artery.

"Right vertebral artery intracranial circulation was obtained with 3D rotational angiography and cone beam head CT of the right vertebral artery intracranial circulation were obtained and processed on a separate workstation and saved to imaging system. The catheter was then withdrawn into innominate artery.

Left internal carotid artery was selectively catheterized over a glidewire. AP, lateral, transorbital oblique, and Schuller's projections of the left internal carotid artery intracranial circulation were obtained. 3D rotational angiography and cone beam head CT of the left internal carotid artery intracranial circulation was obtained and processed on a separate workstation and saved to imaging system."

Would the following documentation support billing 33641 as part of back bench work, if done off bypass?

"We examined the new heart on the backtable, and we prepared the donor heart. The left atrium was trimmed. The great vessels were separated, and the aorta and pulmonary artery were trimmed. The inter-atrial septum was examined, and there was a patent foramen ovale. We closed the patent foramen ovale with prolene sutures."

Would the donor heart need to be placed into the recipient and CPB initiated in order to separately report repairs? There is a CPT parenthetical for 33944: "(For repair or resection procedures on the donor heart, see 33300, 33310, 33320, 33390, 33463, 33464, 33510, 33641, 35216, 35276, 35685)."

When using the code 32555, does the ultrasound have to be in real-time? Example: Radiologist tech performs the ultrasound and marks the place for the provider. Once they are done with that, they leave and the provider enters and then performs the thoracentesis using the mark left by radiology. I am under the impression that image-guided is in real-time, but I wanted clarification on that.

Patient's PVC ablation was cancelled after infusion of epi and caffeine-sodium benzoate failed to induce a high enough burden of PVCs. Can we charge for the infusions? Epi was 31 minutes, and caffeine was 23 minutes. Patient was under anesthesia for nearly two hours. Only other service was the EKG. Procedure note says pharmacological stimulation study to induce PVCs.

When an ablation is performed for PVI and then isoproterenol administered for induction of "any inducible arrhythmias", is this adequate to support 93623? It was our understanding that documentation should indicate this was for other/new/non-pulmonary triggers arrhythmias in order to support it was not being performed to check for efficacy. We are being told that unless the doctor specifically states isoproterenol is being administered to check for efficacy, 93623 is a valid charge. This is backwards to your advice in Ask Dr. Z #15044, 14348, and 13587. Please clarify on the appropriate documentation to support 93623.

I have a report where a patient has afib and flutter. It states: "The CS catheter showed a left atrial flutter, and cardioversion resulted in ERAF." The next mention of atrial flutter in the report is after the PVI is done for the afib with this follow-up sentence: "The atrial flutter terminated on ablation of the RIPV." Would this qualify for 93655 as a separate mechanism? Any guidance is appreciated.

I am wondering if the below would be considered two graft placements or just one initial graft placement?

Would the below be coded as: 35571 only, 35571-22, or 35571, 35571-59?

Physician harvested the patient's saphenous vein and anastomosed it in an end to end fashion to the popliteal artery, then tunneled the graft to the anterior tibial artery and anastomosed in an end to side fashion completing the popliteal-anterior tibial bypass. The physician then thrombectomized the TP trunk and posterior tibial artery and soft sludge of thrombus was extruded. The physician then decided to take another section of the saphenous vein graft and attached one end to the mid-saphenous vein bypass and the other end to the tibial peroneal trunk.

Not sure if this would be considered a single graft placement, or a single graft placement where they turned it into a branched bypass graft, or if it would be considered two separate graft placements.

Thank you for your help.

During an ablation if the physician does documentation as stated can we charge 93622 and 93623?

The ablation catheter was positioned in the LV and pacing performed to prepare for pacing in the event of prolonged heart block during adenosine. Adenosine 12 mg was administered to assess if there was induction of new arrhythmia. Pacing was performed to attempt arrhythmia induction. Of note, entrance and exit block was demonstrated at the pulmonary veins.

"The surgeon performed an SFA to ATA bypass with harvested GSV. Following the bypass, the popliteal artery aneurysm was ligated. We proceeded with ligation of the distal extent of the popliteal aneurysm at the junction with the anterior tibial artery using 0-silk tie."  Are the correct codes 35566 and 37618?

My provider is reporting code 64450 for phenol injection with EMG guidance as 95874. I disagreed with his coding. Do we consider phenol injections as a nerve block or a nerve distraction method? Can we report EMG guidance (95874) with this service?

Our neurointerventional providers are performing transvenous embolization of the paraspinal veins to treat cerebral spinal fluid venous fistulae. Would this be considered CNS (61624) or non-CNS venous embo (37241)?

"LCC/LIC angiography showing 85% occlusion. Thrombectomy x 3 with no improvement. Decision to place stent. IMPRESSION: Successful left supraclinoid intracranial internal carotid artery stent placement after three passes with aspiration catheter and stent retriever demonstrated no improvement in the near occlusive supraclinoid left internal carotid artery filling defect. Findings suggest acutely ruptured supraclinoid carotid artery plaque causing the patient's stroke syndrome." 

Inpatient status. Billed to Medicare with 61635 but denied for modifier. No modifier used and none found that seem to be applicable. Medicare also not being helpful in helping us determine exactly what it is they want. Should this be billed as thrombectomy instead of stent placement? The dx codes are I63.432 and I67.2.

Are codes 37241, 36012 x 2, 76496 x 2, 75831 correct for the following?

"Ultrasound-guided access of the right internal jugular vein and right common femoral vein. Selective catheterization and venography from the left renal vein. Third order selection of the left gastrorenal shunt. Glide catheter was then removed over wire, and a 5 French Fogarty balloon catheter was placed. With the balloon inflated, diagnostic venography was then performed demonstrating large dilated varix. Plug-assisted retrograde venous obliteration of splenorenal shunt with GelFoam, STS, and lipiodol. Ultrasound-guided transsplenic access. Third order selection of the splenorenal shunt via the left coronary vein with subsequent diagnostic venography."

Can we code for the tibial/peroneal trunk IVUS if the popliteal artery, the tibial/peroneal trunk, the peroneal artery, and the posterior tibial artery are all evaluated with IVUS with diagnostic findings and measurements (for separate stenoses evaluation)? Would the tibial/peroneal trunk be considered an "additional non-coronary vessel" for coding purposes? The tibial/peroneal trunk is not necessarily a separate vessel as defined by the CPT Appendix L vessels, so I'm wondering if this section of vessel can be reported additionally with IVUS code when performed and appropriately documented?

Could you please clarify the use of code 93356 (myocardial strain imaging)? Our providers read echos in the hospital (inpatient/outpatient). They want to bill for code 93356 when they do the interpretation only. I do not see any -TC/-PC modifiers allowed. The way I read/interpret the description for this code is, it is to be used for the actual work in performing of the myocardial strain imaging. The review/interpretation of imaging would be bundled with 93306-26. What is your opinion?

This patient had a Whipple procedure for a pancreatic malignant tumor. The tumor involved the superior mesenteric vein. The doctors are saying that because the tumor encased the SMV, they should charge 35221 in addition to 48150 because after they excised the tumor, they resected and subsequently repaired the SMV. Is this correct, or is this a component of 48150? I hope you can help since 35221 is vascular even though 48150 is not.

I am trying to fully understand what page 361 (#13) and page 363 (#33) mean when it comes to the central veins. If a patient has a fistula thrombectomy (tPA injected and arterial plug pulled) and also a subclavian vein thrombectomy (no continous infusion is done), can the 36904 and the 37187 both be separately reported?

Patient presented for basilic vein transposition. Immediately post OP he developed a thrombus. Patient was returned to the operating room for open thrombectomy. Can both codes 36819 and 36831 be reported in this case?

Thoracic surgeon performed a laparoscopic plication of the left hemidiaphragm due to diaphragm paralysis. There is no CPT code available for a laparoscopic procedure. Which would be the appropriate unlisted code to use, 49329 or 39599?

There is some confusion with code 76885 (US infant hip physician or other healthcare professional). Do ultrasound techs fall under the definition of "other healthcare professional"?

Trabecular bone score using DXA. Software on the equipment generates an image and calculations. Radiologist interprets and reports. What is the correct CPT code to use? It does not seem to fit 77089 since the radiologist is not performing the calculation, and it does not seem to fit 77092 because the radiologist does not fit under the category of "other qualified healthcare professional".

Can we report code 36593 if the RN documents that one lumen of a two-lumen PICC was clogged? Chemo was given in lumen 1, but lumen 2 required Cathflo. Lumen 2 was not used during the encounter. Or in order to report code 36593, would the entire PICC need to be clogged?

"Patient underwent CT-guided biopsy of synovium of left temporal mandibular joint. Limited CT scan of neck was performed, and thickened synovium containing numerous calcifications within the left temporal mandibular joint was localized. A 19 gauge guiding needle was advanced to the periphery of the TMJ, and three cores were obtained with a 20 gauge Tru-Cut biopsy needle."  

Provider wants to use unlisted code 21299, but I want to make sure there is not a better code to use for this. If not, what CPT code would this be comparable to for the unlisted?

With the new guidance out indicating if an IFR is done use an unlisted code. If a RFR is done use 93571-52, but what about a DRF? Would that also be 93571-52?

"Procedures performed:

1) Bilateral common femoral endarterectomy with patch angioplasty.

2) Removal of obstructive stent over left profunda femoris artery necessitating additional 60 minutes of surgical time.

3) Heavy scarlike tissue around left common femoral artery necessitating additional 30 minutes of surgical time.

We then turned our attention to the left side. An arteriotomy using 11 blade and Potts scissors this was actually quite difficult as the stent was overriding so much and at the common femoral artery we were unable to actually identify the backwall of the common femoral artery. We were eventually able to get into the common femoral artery and had to remove the initial 2 cm of stent and an additional 1 cm of stent so that we would be able to close everything in the proximal superficial femoral artery. There was minimal blood flow able to get into the profunda femoris artery but we were able to remove all the plaquing as well as the stent that was causing the majority of the issue."

Is the stent removal included in code 35371?

Since recent change of iFR to unlisted we have several questions. Do you recommend using modifiers when done in different vascular families... since several iFRs can be performed on same date of service (i.e., LM, LD,  RC when MVD seen).   (Unlisted CPT doesn't allow modifiers in our editing system, but just wanted to verify.) Do you anticipate possible creation of CPT code for iFRs in future? Additionally we see the MUE of 1 but 3 MUE Adjudication Indicator for same date of service so can we charge for up to 3 on same date of service?

Would this be unlisted, or how would you code this? "Access to graft and right femoral. An 8 x 100 mm Gore Viabahn self-expanding covered stent was deployed from the patent lumen of the graft, across the occluded segment of the graft, across the extravascular track between the graft and the adjacent brachial vein, and into the axillary vein. The covered stent was post-dilated to 8 mm. Contrast was injected for completion access angiography of the dialysis circuit and central veins, demonstrating satisfactory bypass of the occluded graft and extravascular track between the graft and adjacent brachial vein without obstruction to antegrade flow."

Physician Billing -

When a patient is having a Nuclear Heart Scan - 78452 (Myocardial perfusion imaging, tomographic (SPECT) and the Resting Portion and Stress Portion are performed on (2) different dates of service.

How do we bill for the A9500 - Technetium Tc-99m sestamibi, diagnostic, per study dose.

Do we bill - A9500 X 1 for the date the rest portion was performed and bill A9500 X 1 on the date the stress portion was performed - Thus billing each dose on 2 different dates of service

or

Do we bill A9500 X 2 with the date of service in which the 2nd day of the study was performed?

Example: 11/01 - A9500 X 1

11/02 - 78452-26, A9500 X1

or

11/02 - 78452-26, A9500 X2

Can you bill code 93657 if performed prior to the PVI?

"The mitral isthmus was targeted for ablation between the mitral valve and the left pulmonary veins targeting an ablation index of 500 with an inter-lesion distance targeted as 4-6 mm. Mitral isthmus block was achieved. Pulmonary vein antral isolation was performed targeting an ablation index of 500 anterior and superior and ablation index of 400 posterior and inferior. Inter-lesion distance was targeted as 4-6 mm. Radiofrequency energy was delivered to a single loop encompassing the left pulmonary veins, right pulmonary veins, and posterior wall. Using the mapping catheter, additional radiofrequency lesions were delivered as needed to complete electrical isolation of the posterior wall and pulmonary veins."

I am at a loss for how to code the below procedure. Would we use unlisted code 37799? What would we compare that to for the insco?

"The patient right retroperitoneum was exposed. Tumor was already cut off the right retroperitoneum where it was stuck to the iliac artery. Here approximately 10 cm mass was stuck to the anterior wall of the iliac artery. With careful retraction and meticulous dissection the iliac artery was dissected exposed to as much as we can especially in the distal part and with the help of finger dissection created a plane in between the iliac artery and the mass. We continued dissection till we were able to lift of the tumor deposit of the iliac artery. This was circumferentially dissected. Mass itself was then removed of the iliac artery. Iliac artery was then examined and noted to be intact without any evidence of tear in the adventitia."

I've seen quite a few cases where a basilic vein transposition or cephalic vein transposition AVF requires an interposition graft due to vein not being quite long enough. I tend to just report the main code 36818 or 36819 and not code for the interposition graft, but is that the right thing to do?