Ask Dr. Z

Cardiologist performs a left heart/right heart/coronary and left ventriculogram (93460-26). On the way out he does a right femoral artery (illiofemoral) angiogram. Documentation states, "The right femoral artery is normal. The puncture site is in the mid common femoral artery." Can we report code G0278 for this? If not, what scenario would we look for to use G0278?

What documentation elements are required for EKG? My providers are just signing the EKG strip. Do they also need to have a brief interpretation in the note to go along with the strip?

I am tying to figure out a code for an exploration/revision of LVAD outflow graft. I am having trouble pinpointing a code, and I was thinking that unlisted code 33999 comparable to code 36832 would work best. Any guidance is greatly appreciated.

"Incision was extended medially and laterally until all bend relief was exposed, then it was cut open. Pressurized yellow pasty substance escaped through the opening. LVAD flows gradually improved to 4.5 LPM as all of the space was cleared. The whole outflow graft was cut longitudinally, and the space debrided, cleaned, and irrigated with antibacterial solutions. The OFG fully expanded. Hemostasis was assured, and the incision was closed over a #10 JP with running absorbable sutures in layers."

When an ultrasound-guided breast biopsy is canceled after the ultrasound (being used for localization) due to no significant findings, what would be the appropriate code selection?

My EP physician did a loop recorder interrogation and loop recorder explant. Am I able to code for both the explant (33286) and the interrogation (93291 or 93285)?

"A standard time-out was performed using two distinct patient identifiers. At the onset of the study the patient's implantable loop recorder was interrogated, confirming the presence of multiple sinus pauses. The patient's chest was prepped and draped in the usual sterile fashion. Local anesthetic was injected. Using the scalpel blade, an incision was made over the left chest. The LuxDx monitor was subsequently explanted utilizing gentle traction. The incision was closed with Steri-Strips followed by topical skin adhesive."

I am confused on how this should be coded. My provider reported code 93621 (with ICE, 3D mapping, and 93623), but that's an add-on code. I just can't seem to figure it out. I would really appreciate your help!

"...The right groin was accessed x3 using the modified Seldinger technique. A 7 French, 10 French, and SL1 sheath were advanced into the vein without difficulty. A 10 pole EP catheter was placed in the coronary sinus through the 7 French sheath. ICE was advanced via the 10 French sheath to the right atrium. Complete survey of IC structures was performed, and ICE was used to guide ablation. A comprehensive electrophysiology study was performed with the catheters in place. Abbott mapping system was used to guide catheters and create 3D EA map. There were no inducible arrhythmias in baseline state. PES revealed no evidence of dual AVN physiology or AP connection. Isuprel was infused up to 10 mcg/min. No inducible arrhythmias with PES and burst pacing. No tachycardias were induced in the isoproterenol washout phase. Of note, sinus rhythm acceleration was only mild to 110 bpm with 10 mcg/min Isuprel." 

Now that IVUS must include a measurement and/or finding description, can you tell me if this is enough, or should I query the physician for more details? "Stent balloon was retracted, and an IVUS catheter was then placed and measured throughout the distal and mid stented regions with multiple measurements obtained. Successful IVUS-guided PCI of the mid left anterior descending artery with a drug-eluting stent resulting in excellent angiographic outcome and TIMI-3 flow." Most of our physicians have started including a vessel size from the IVUS, but sometimes they just say "IVUS-guided PCI", and I'm thinking we need more details. 

Our CT department wants to charge a CT scan of the abdomen post-px. Current charges are 50592, 76940, and 74170. The patient was in the CT suite for the ablation; however, both US and CT were used to confirm probe placement. The radiologist describes the ablation as US-guided followed by a post-px CT scan (three-phase).

"Under direct US visualization, a probe was advanced into the lesion. Appropriate needle position was confirmed by US imaging, permanent images obtained, as well as non-contrast CT correlation... Three-phase CT performed post ablation... demonstrates adequacy of the ablation zone with complete ablation... and no evidence of post-px complication. Multiple renal cysts are again noted. Incidental note is made of cholelithiasis."

There is no separate CT report, only what is documented in the ablation report. This sounds like CT guidance (77013). Should there be a separate charge for the CT scan of the abdomen? I think appropriate charges should be 50592 and 76940 or 77013. This is for the facility.

My EP physician does a semi-permanent pacemaker implant. He says he was told to bill 33216, but the lead is attached to an external generator. Wouldn't this be 33210 (temporary pacemaker)? Here is his note:

"Semi-permanent pacemaker implant, transvenous, right jugular vein, with right ventricular lead (33216). The patient was draped in a sterile fashion. Access to the right jugular vein was obtained using a modified Seldinger technique with US guidance. RV lead was placed in the RV with active fixation through sheath, tested with appropriate parameters with no phrenic nerve or diaphragmatic stimulation using 10 V pacing, secured with sleeve to skin with 0 sutures at venous entry site, and attached to external pacemaker generator. The lead was also secured to skin with sterile tapes and dressings in a routine way. Post procedure fluoroscope showed normal heart wall motion."

From a coding perspective, what would be the best way to describe the difference between trigger point injection codes and nerve block injections codes to my physicians?

During TAVR procedure we use modifier -62 for two surgeons. Now that Sentinel is a billable code for physicians, which physician should bill for the Sentinel? Modifier -62 does not apply. Can they both receive credit?

A duplex scan of the left and right radial arteries is done for pre-surgical mapping for CABG. The report documents measurements of proximal, mid, and distal radial artery on both right and left arm. Would this be billed as limited 93931 because only the radial artery is examined? Or would this be billed as complete since the radial artery is all that's wanted for a CABG so it is complete for the needed purpose?

If our provider performs an atherectomy in the right tibial/peroneal trunk and then another atherectomy in the right peroneal artery, can we report codes 37229 and 37233?

What would be the appropriate CPT codes for CT cystography performed for bladder evaluation? The codes I came up with are 51600 and 74430.

If a radiologist is sending CTA head images to AI software for stroke patients, is there an additional CPT/HCPS code that can be reported along with the CTA code? Is this something that only the technical can be coded?

Can a provider report congenital ECHO codes  (93303, 93304) for a patient with pre-transplant diagnosis of congenital heart disease? Currently we are reporting the non-congenital code (93306).

What elements are required to bill a radiology interpretation report for x-rays? These are done in house, and we report global. Our orthopedic doctors interpretations are "prosthesis looks good" header is left knee x-ray or "no acute fractures, changes" header bilateral shoulder x-rays. Are these billable based on documentation?

Is there a code for adductor myodesis done along with above knee amputation? I coded the amputation with 27590, but I don't know how to code the adductor myodesis.

Procedures:

1. Left above the knee amputation
2. Adductor myodesis

Operative report states: "We freed up the femur with a periosteal elevator and then we transected it with a hand held power saw. We then irrigated the wound, filled the bone edges, and also did an adductor myodesis. I drilled two holes in the medial aspect of the femur and using O Vicryl sutured the adductor muscle to the femur to keep it from going laterally."

How should we code for sentinel lymph node mapping using ICG dye when it is injected at the "3 o'clock and 9 o'clock" positions? Is this considered a bilateral injection, and would 38900-50 be appropriate?

Example Procedure: Robotic-assisted laparoscopic hysterectomy and bilateral salpingo-oophorectomy with bilateral pelvic lymph node mapping and bilateral obturator lymphadenectomy with sentinel lymph node removal. Operative report states: "The cervix was grasped with a tenaculum and injected with ICG dye at the 3 and 9 o'clock positions."

Is this reported with code 0644T? If not, what code(s) should be reported? "Catheter was advanced into SVC and sheath positioned into internal jugular vein. An Inari Triever 24 was introduced to evacuate a large thrombus from the right atrium, as well as a curved 20 Triever catheter to perform mechanical thrombectomy of the right ventricle. Aspirated blood was reintroduced through the sheath. A repeat cardiac echo was performed, as well as non-selective bilateral pulmonary arteriography, as the patient had no prior imaging of the pulmonary arteries and they could not be well seen by cardiac echo. Catheters were removed and hemostasis achieved with perclose device. A successful thrombectomy was achieved from the right atrium and right ventricle. Pulmonary arteriography shows no evidence of a saddle embolus, there is non occlusive embolus in the descending left pulmonary artery trunk as well as thrombus in the medial basilar segmental branch. Successful mechanical thrombectomy of right heart."

Is rev code 940 (Other Therapeutic Services) appropriate for code 96377 [application of on-body injector (includes cannula insertion) for timed subcutaneous injection] for outpatient hospital billing?

"After local administration of 1% buffered lidocaine. A 22 gauge needle was inserted within abdominal wall/left rectus muscle under ultrasound guidance. Injection of 5 cc of Marcaine 0.5% performed. The needle was removed and sterile dressing was applied. Impression: US-guided abdominal cutaneous nerve block."

When queried for muscle versus nerve block physician responded with this: "The cutaneous nerve is located within the abdominal wall. To block the nerve we have to insert the needle within the abdominal wall."

Please advise on the correct CPT code.

We performed CT-guided cryoablation nerve block of the 3rd, 4th, 5th, and 6th right intercostal nerves. Would this be reported as 0442T x 4?

"Left suture ligation of the proximal profunda femoris artery which was supplying the recurrent Sarcoma tumor in left proximal femur, consulted interoperatively. Common femoral was exposed by primary surgeon. I extended proximally to expose further SFA and distal CFA. Once CFA was exposed, I moved laterally to expose further the profunda. Several deep femoral crossing vein branches were ligated and transected. Once profunda was dissected, common femoral, SFA and profunda were clamped. At this point I transected the profunda at its origin. The profunda origin was then repaired with a prolene suture. Once completed, common femoral and SFA were flushed and the repair was completed. There was good pulse in distal SFA and foot. Afterward, the profunda stump was suture ligated with a Prolene suture and also ligated with a silk tie. Case turned back to primary surgeon for completion of tumor resection."

Code 37618 doesn't seem to quite fit since it's not related to post-traumatic or rupture. What are your thoughts?

How would you code an AFV graft created in the thigh with removal of infected PTFE graft in opposite thigh? Documentation: "Dissected out the GSV and clipped the distal vein above the knee then transected and pulled through toward the groin. In the mid thigh we created a curved tunnel medially and laterally from the groin towards the counterincision. We clamped the SFA and created arteriotomy. We then spatulated our GSV and performed an end-to-side proximal anastomosis. Next we turned our direction to the opposite thigh and infected PTFE graft and dissected around the old exposed PTFE site from that thigh and removed it from surgical bed." 

Are these two separate procedures? I understand arm graft creation, but not sure if thigh AFV is treated the same.

We have technologists in Radiology that have completed competency to use a portable ultrasound unit that rolls into the department to assist in venipuncture. There are no permanently recorded images and no dictation, but we are curious to see if we could use 76942 with a modifier or some CPT code for this?

"Utilizing local anesthesia and CT fluoroscopic guidance, a 22 gauge spinal needle was advanced to the posterior aspect of the ischial tuberosity just medial to the sciatic nerve. Small amount of dilute Omnipaque 300 injected to confirm positioning. Subsequently 40 mg of Depo-Medrol along with 3 cc of 1% lidocaine and 3 cc 0.5% ropivacaine injected."

Is this reported with 64450?

The patient had an MRA NOVA of the head and neck without contrast. What would be the appropriate code for an MRA NOVA of the head and MRA of the neck? Would it be appropriate to use codes 70544 (MRA head without contrast material), 70547 (MRA neck without contrast material), and 76498 (unlisted magnetic resonance procedure) for the NOVA portion of the procedure?

The doc performed a AAA stent graft placement with a cuff placement using a suprarenal bare stent. He used a distal piece with a proximal extension cuff to complete the system. However, the cuff placement is part of the intended procedure, and the renal artery(s) are not covered by graft material and only crossed by the bare metal fixation proximal component of the cuff. The doc wants to use 34709, but I do not feel that is correct; it's not an extension prosthesis in my mind. What are your thoughts?

How would you code this procedure? Would you code the placement and the removal of balloon pump? How would you code the cannulation of the left common femoral artery and the insertion of Impella?

"Procedure:

1. Balloon pump placement in the right common femoral artery and subsequent removal with pro glide in the right common femoral artery
2. Cannulation of the left common femoral artery with a 17 French arterial cannula for cardiopulmonary bypass
3. Direct aortic impella placement

After aortic and mitral valve replacement the cross clamp was removed from the aorta. The right heart started, but the left heart was completely akinetic. There was no movement of the left ventricle. A balloon pump was placed in the right common femoral artery, but then we made the decision to proceed to an Impella and the balloon pump was removed. A 8 mm graft was sewn to the distal ascending aorta and then tunneled up above the right clavicle and then an Impella was placed."

A diagnostic bilateral internal/external carotid and bilateral vertebral angiograms were performed. Decision was then made to perform an embolization. The physician then needs to reselect the vessels to perform the embolization. Our providers want to code the additional catheter selections for the embolization portion on top of billing the diagnostic angiograms. Would this be appropriate?

36224/36226/36227/61624/75894, the additional codes the MDs are looking to add are 36216-36218.

Can a left subclavian stent be billed with thrombectomy codes 34101 and 34111?

Please help determine correct code assignment in this biliary case. I am coming up with 47535, 47554, and 47555 since the cholangioplasty and lithotripsy were both done via the scope. Does 47555 include the work of 47554? 

"The indwelling biliary drain was exchanged over a wire for a sheath through which contrast injection was performed. A guidewire was then passed through the cystic duct, common bile duct, and into the duodenum. Following stone removal a new internal/external biliary drainage catheter was placed. Contrast injection was performed. An endoscope was passed through the sheath into the gallbladder. Several massive stones could be visualized. Despite several hours of laser lithotripsy only a portion of the largest gallstone was successfully removed. The endoscope was also passed into the common bile duct. Balloonplasty and stone removal was successful in eliminating the distal common bile duct stones. Additional lithotripsy was then performed of the gallstones; however, the endoscope malfunctioned and could no longer be used."

Our physician performed a lower extremity thrombectomy using the INARI system. He also placed two INARI discs in the IVC as a temporary filter. He removed the discs after the procedure. The physician wants to bill the placement/removal of discs WITH the thrombectomy: 37187 plus cath placement, 37191, and 37193. It has been my understanding that if temporary filter was placed/removed during a procedure then it is bundled. How would you bill this?

How would you code a stent to the internal carotid cavernous portion of the artery? Would you code to 37215 carotid stent, or would you code to 61635 intracranial stent where it is more towards the cranial area?

Can you help me with this CPT code please?

"Micropuncture stabs were then made in the skin and the identiffied varicose veins with thrombus were incised with a scalpel and then using the phlebectomy hoook and varicose vein was exposed and cut and then a large amount of thormbus approximately 10-15 cc was removed along with a portion of the variocse vein."

How would you code these ablations after achieved PVI, CPT/ DX (explain)? 

"Isopril was continued at a lower dose and burst atrial pacing induced atrial flutter once again with a cycle length of 230 ms. Entrainment again was in from the proximal and distal CS. 3D mapping confirmed mitral annular flutter. A mitral flutter radiofrequency ablation line was delivered from 10:00 on the mitral annulus across the septal left atrial wall connected to the right superior pulmonary vein. This terminated mitral annular flutter. Repeat pacing induced a second flutter with a cycle length of 220 ms. Entrainment was just out from the distal and proximal CS but in from the roof. 3D mapping confirmed roof flutter. A left atrial roofline connecting the superior veins terminated this flutter. Bidirectional block was demonstrated across both lines. Both flutters were noted to transiently degenerate into atrial fibrillation and felt to be in Afib trigger."

I’m confused with how to code this since the physician states PVs are still isolated from the previous ablation. Would the ablations performed at the roofline, posterior wall, CFAE, etc. all be reported then as 93653 and 93655 for each additional?

"Notably, pulmonary veins remained isolated from her ablation in 2016. The first plan was to isolate the posterior wall. A roof line extending from the left superior to the right superior vein was first performed. Next, an inferior line was created connecting the left & right inferior veins. During that process, posterior wall isolation was achieved. A second voltage map was then performed in order to assess for any additional areas of interest warranting ablation. During mapping of the left atrial floor by the right veins, an atrial tach was induced. After setting up for an activation map, she spontaneously terminated back to sinus. Voltage map was continued and areas of CFAEs were tagged on CARTO. Exit block was confirmed again in each of the four PV. Ablation was performed in these areas with near complete cessation of PACs."

Bilateral exchange nephrostomy drains and ureteral occlusion balloon catheters. The catheter with an occlusion (to divert flow from the bladder). I am thinking that the CPT codes are 50435 X 1 on each side. I also think the ureteral balloon occlusions for (urinary diversion, are an integral part of the nephrostomy) and that would already be included in the 50435 x 1 each side.

My co-workers and I are in a disagreement regarding diagnostics at the time of interventions. If there was no prior catheter-based angiography, but the pathology is known from MR or CT, wouldn’t it be appropriate to report the diagnostic angiography with the intervention? Must the provider state additional images were required necessitating the diagnostic angiography, or is it enough to go off the patient not having a prior catheter-based angiogram alone?

Code 37193 is specific to endovascular removal of an IVC filter. What code should be used if the removal converts to an open approach? Would we use the unlisted code?

Would a pericardial window done with a heart transplant be bundled? The report states: "We could not get a tube in the left pleural space from the anterolateral side since there were severe adhesions. We performed a posterior pericardial window and placed a drain through it in the left pleural space to drain the left pleura."

PROCEDURE:

• Redo sternotomy
• Explant aortic valve and root conduit
• Debridement subannular abscess cavity
• Pericardial patch of left ventricular outflow tract
• Aortic root replacement with 24 mm homograft with reimplantation of the left main and right coronary arteries
• Coronary artery bypass grafting x1 with greater saphenous to left anterior descending
• Right lower extremity endoscopic vein harvest greater saphenous

Am I correct to use the following codes: 33530 (redo), 33414 (LVOT pericardial patch), 33410 (aortic root replacement or is there another code I should use?), 33510 (CABG x 1), 33508 (endoscopic vein harvest)?

In prior responses in 2016 and 2018 when ask about reporting transcutaneous oxygen measurements without an ABI we were advised to use 99199. This also referenced a CPT Assistant article from 2012; however, there was a repeat of a similar question in CPT Assistant in 2014 and the response was to use 93998, which was effective 01/01/2012. It seems more logical if performing a non-invasive study to determine oxygenation that we would select an unlisted code related specifically to a non-invasive vascular study and not a generic unlisted code. Please advise on your current stance.

For Afib ablations, we have a physician who prefers to map the left atrium and perform cryo ablations of the veins with his patients in sinus rhythm. If a patient presents to the lab in atrial fibrillation, the physician will perform a cardioversion after gaining access and inserting all of the pacing catheters, just prior to getting transseptal access, with the thought that it is safer to cardiovert with pacing back up in place. Since the cardioversion is planned and performed prior to any catheter stimulation, would it be separately billable?

Patient with persistent Afib. PVI is performed, then ablation of the atrial roof and/or wall is performed after PVI. Does the physician specifically have to state the additional ablation is for persistent Afib in the body of the op note? For instance, can 93657 be reported (after PVI performed) based on a diagnosis of persistent Afib and this portion of the op note: “There also was recovery of conduction into the posterior left atrial wall. Left atrial posterior wall was isolated and this included roof line between the left and right superior pulmonary veins and inferior line between left and right inferior pulmonary veins with additional applications of radiofrequency energy along the posterior wall”? Secondly, to report 93657 x 2, does the op note need to indicate isolation in area ablated (roof) with continued conduction and subsequent ablation in other area (wall)? Or is it determined on how many areas ablated without a bearing on isolation?

Is MMA embolization through a facial artery considered intracranial or extracranial? Would code 61624 or 61626 be billed in this case?

"Patient with history of chronic aneurysmal degeneration of right radiocephalic fistula. Skin incision was made directly overlying the length of the fistula and was deepened to soft tissue taking care to protect the fistula. The fistula was circumferentially controlled and skeletonized throughout its course in the right upper arm taking care to preserve a segment in the forearm and upper arm shoulder region which could still be accessed for dialysis. The aneurysm was clamped and over a 24 French chest tube it was plicated using 5-0 Prolene in a running fashion. The chest tube was removed for completion and we flushed and backbled prior to completion. Stitches were placed as necessary. There is an excellent thrill. Skin flaps were then created. Then the fascia was tunneled on the lateral aspect of the arm. Skin closed with interrupted 2-0 nylon vertical mattress stitches. Wound was dressed with 4 x 4's Kerlix. There is excellent thrill at completion." 

Is this report coded 36832 or 37607? 

In our POS 11 our radiologists perform SIS with spectral Doppler and also perform 3D rendering of the uterus for better visualization of polyps, focal/diffuse abnormalities etc. We currently bill with codes 76831, 58340. We do not bill the spectral analysis, as this is included in 76831. However are we allowed to bill the 3D imaging 76376? If yes, what would be the documentation, and do we need a separate order and different dx for medical necessity?

What code would you use here? 35860 vs 23930?

Post-op Diagnosis

* Brachial sheath Hematoma [T14.8XXA]

Procedure(s):

Evacuation left upper extremity brachial sheath hematoma

The left upper extremity was prepped and draped in normal sterile surgical fashion. A preop checklist was completed. An incision was made above the elbow crease in the left upper extremity. Dissection was carried down through the skin and subcutaneous tissue. The fascia was opened and extended proximally and distally. There was old thrombus visualized. There was no active arterial hemorrhage. Small venous muscular bleeders were cauterized. FloSeal and Surgicel were left in the wound bed. The fascia was not closed. The skin was reapproximated using 3-0 Vicryl at the level of the dermis followed by 4-0 Monocryl. Skin glue and Steri-Strips were applied over top.