Ask Dr. Z

Would T12-L1 interlaminar epidural steroid injections with imaging guidance be coded with 62321 for the cervical/thoracic? The transforaminal epidural of the T12-L1 does state for coding purposes to code to the cervical/thoracic level, but we can't locate a resource that the interlaminar also falls into this guidance.

I have a case where a TIPS procedure (initial insertion) was done with an ultrasound-guided paracentesis in the same setting. Can these two be billed together?

Would this be 49442-52 since it's done via ileostomy and not percutaneously?

"Right lower quadrant ileostomy and adjacent soft tissues were prepped and draped in standard sterile fashion. A scout radiograph was obtained. Contrast was injected through the efferent limb (inferiorly located) of the ileostomy to define the anatomy of the terminal ileum and ileocecal valve. Thereafter, with the aid of a 5 French angled catheter and 035 Glidewire, access was gained into the proximal ascending colon. Contrast injection confirmed appropriate positioning. IMPRESSION: Successful fluoroscopy-guided placement of ileocecal catheter via loop ileostomy using 5 French multi-sidehole pigtail catheter with pigtail loop at the level of the proximal ascending colon."

I have a patient who was taken to the cath lab, was sedated, and left femoral artery access was achieved. All the doctor documents after that is aortic pressures and arterial pressures. I am at a loss as to what to bill this as, because he did not do a cardiac cath or an aortagram, just the pressures. Is this billable, and if so what code(s) would I use?

When is it appropriate to use code 33235?

33234 - removal of electrode from a single chamber device

33235 - removal of one or both leads from a dual chamber device, or is this only used for removal of two leads?

After PVI 93656 is performed, most often my MD goes here next:

"The SVC was mapped and found to have significant fractionate potentials and spontaneous local ectopy. 40 watt lesions were used to isolate the SVC and elimination of CFAEs avoid phrenic nerve area......"

Would this be considered a 93657?

The physician performed thrombectomy on a patient with axillary-femoral graft. Physician accessed with two incisions. Would this be billed with a modifier -22? Would you bill 35875 x2? We want to be sure we cover the work for two incisions. Here is that part of the op report.

"A longitudinal incision made on the left abdomen overlying the distal axillary graft. Dissection to graft. Proximal and distal control obtained. Transverse graftotomy made. 5 French graft thrombectomy catheter passed proximally removing acute clot as well as well formed chronic clot (right limb). (Physician proceeded to remove clots and close)

A transverse incision made on the right lower abdomen overlying the distal femoral limb of graft. This site was not over the right anastomosis but rather 10 cm proximal. Dissection to graft. Proximal and distal control obtained. Transverse graftotomy made. 5 French Fogarty balloon catheter passed proximally removing acute clot as well as well formed chronic clot (left limb)." (Physician proceeded to remove clots and close.)

A scheduled external cardioversion was set to be performed. Patient was sedated, and then it was decided that patient's pacemaker would be used to terminate rhythm with success. I don't believe that 92960-73 would be appropriate in this scenario, as the procedure was not discontinued due to patient safety or extenuating circumstances. Is there a charge that would capture this? 93724?

If an incision is made over the common femoral and extends into the SFA with endarterectomies down into the profunda femoris, which code should be used, 35371 or 35372?

Patient seen for cyroablation of left iliac bone for metastases. Following cryoablation, provider completed a cementoplasy of the eroded iliac bone via trochars. Is it appropriate to bill a cementoplasty, and if so, what code would we use? I was looking at 27299 - with a possible like code as 22511?

If a congenital condition (i.e., ASD, PDA, etc.) has been surgically corrected, do we code a congenital or non-congenital echocardiogram for any follow-up visits? We are thinking a non-congenital echocardiogram if there are no residual issues being documented on the echo report. Also, if a congenital dx spontaneously closes (i.e., ASD, PDA, etc.), we them code as non-congenital echo, correct? Can you please clarify? 

The cardiologist indicates that he placed a lead in the RA and the LB for Afib and bradycardia, which I would coded as 33208. But his report says, "Boston Scientific dual chamber pacemaker that is MRI-conditional was placed. Excellent RA and LB pacing lead parameters. Large RA and septal RA lead location obtained. Patient tolerated the procedure well."

So, I'm not clear on what he is telling me. Are both leads in the atrium? Or, is he saying the RA is just large? He does indicate he has LB pacing parameters. Can I assume that the 33208 is the appropriate code?

HCPCS Level II codes effective April 1, 2021 included "C9776 - Intraoperative near-infrared fluorescence imaging of major extra-hepatic bile duct(s) (e.g., cystic duct, common bile duct and common hepatic duct) with intravenous administration of indocyanine green (icg) (list separately in addition to code for primary procedure)"

When a patient has a laparoscopic cholecystectomy with ICG fluorescent cholangiography how should this be coded? 47563 and C9776, 47562 and C9776, 47563 only or? I referenced the Dr. Z 10/11/2019 Q&A, however that was before the C9776 code was effective.

The physician removed the old DC ERI PM with difficulty from scar tissue and heavy calcification and replaced it with a new DC PM, which was then removed due to thick, heavy calcification of the atrial lead and the pocket. A smaller second new DC PM was then implanted. A pocket revision was done after old generator was removed and moved from an anterior posterior position in the pocket to superior lateral position, same pocket. How would you code this procedure, and can we bill for pocket revision?

Is it appropriate for the cardiologist to read the CT congenital heart and the radiologist to read the thorax CT and both bill for the reads from the same scan (75573-26, 71260-26)?

I have seen conflicting info on billing 93655 for a history of atrial flutter. Some guidance states it can be reported, while others state it cannot be reported. After PVI ablation, if a patient has a history of atrial flutter and ablation for atrial flutter is done, can 93655 be reported as an additional lesion?

I know that IVUS/OCT requires an interpretation of the findings. In your expert opinion, do you feel any of the below information is enough to be considered an interpretation to report 92978?

"An IVUS catheter was advanced for lesion characterization and vessel sizing. Next, a 3 x 38 mm DES was positioned across the lesion and deployed."

The clot was removed from the iliac, and the endarterectomy was performed in the iliofemoral. Here is info from the surgeon: “The clot was in the proximal vessel, and embolectomy was done with embolectomy catheter, which is a separate procedure from the endarterectomy.” Is it appropriate to bill both 34201 and 35355?

I need your opinion on new code 93319. Our facility performed echo congenital complete, color Doppler, Doppler complete, 3D echo rendering online. Code 93319 is a new code for 2022 and is bundling with color flow 93325. Is the appropriate coding for this procedure 93303, 93320, and 93319?

"Left Ventricle: Normal left ventricular size and mildly depressed systolic function. Mild or grade I (impaired relaxation pattern) left ventricular diastolic filling. Left ventricular ejection fraction by 3D analysis is 53%. Normal left ventricular wall thickness. Normal left ventricular mass (linear), 97 g/m²." 

Is this enough to support 93319?

How would you code this? Would you use code 20206 or 17999? It is my understanding that the abdominal wall is muscle and not fat; is that correct? So wouldn't you report code 20206 because the provider performed a core biopsy on a muscle?

"HISTORY: Amyloidosis, unspecified type (HCC). FINDINGS: The patient was brought to the ultrasound suite, and informed, written consent was obtained. Preliminary sonography was used identify anterior abdominal wall fat. Local lidocaine anesthesia was injected. An 18 gauge supercore biopsy needle was used to obtain four core samples. Three were placed in formalin and one in flow cytometry media. The needle was removed, and a sterile dressing was applied. No immediate complications. IMPRESSION: Technically successful ultrasound-guided biopsy anterior abdominal wall fat."

Can you give us more information on when to use the congenital heart cath codes? Are all hospitals required to use the congenital codes? For example, an echo is performed with findings suggestive of PLSVC with RV overload. Patient also had coronary CTA with CardioScore of 210. RHC was performed to assess pulmonary pressures given RV dilation. No coronaries were imaged, but pressures were obtained in the RA, RV, PA, and PCW positions. TD cardiac outputs were obtained. A PA and a PCW oxygen saturation were used to calculate Fick cardiac output. Saturations were obtained for full shunt run in the SVC, IVC, RA, RV, PA, pulmonary wedge positions. Can we code this as 93451, or should we use the congenital codes? I am not finding much information out there about these congenital codes.

Patient having a right femoral to tibial bypass. The saphenous vein is diseased, so the harvest is being done on the left for the right. This question has come up a few times. Is this inclusive or separately reported?

"Patient was brought to the cath lab for planned elective fluoroscopic evaluation of the mechanical mitral valve. Multiple fluoroscopic images/views were obtained to evaluate the opening and closing of the mechanical mitral valve bileaflets. Successful fluoroscopic evaluation of the mechanical mitral valve showing that both leaflets open and close appropriately." Can you advise what CPT code should be reported?

Question ID 16092 and earlier guidance seems to indicate that a synovial cyst aspiration is bundled into any spinal injection (transforaminal or medial facet). Procedures done in this instance were right L4/L5 facet synovial cyst aspiration (64999) and bilateral L3 (64635-50), L4 (64636-50) medial branch, and L5 (64636-50) dorsal ramus radiofrequency ablation. Would synovial cyst aspiration also be bundled into a dorsal ramus radiofrequency ablation since it was done at the same level as ablation?

Please let me know if code 64490 is correct in this case. If not, what code would you use?

"Procedure: Left side CT-guided C2 dorsal root ganglia block with steroid and anesthetics. Description: Needle tip at the left dorsal root ganglia C1-C2 level on left, contrast around the dorsal root ganglion,1 cc of mixture of celestone and Marcaine injected over 30 seconds."

When right carotid to subclavian bypass is performed along with right CEA, are both procedures billable for the same session, or is the CEA considered inflow/outflow and included in carotid to subclavian bypass?

Preoperative Diagnosis:

1. Symptomatic right ICA stenosis.

2. Right subclavian artery stenosis with right upper extremity claudication.

 Procedure(s):

1. Right carotid to subclavian artery bypass with 8 mm Hemashield (35606)

2. Right CEA with Xenosure reconstruction. (35301)

I'm new to IR coding and was told during procedure after ultrasound provider must mention vascular patency or we can't code it. Is this a separate ultrasound, or are they talking about ultrasound guidance? What CPT code are they talking about?

For interventional radiology procedures (e.g., 37243 tumor embolization), what is/are the proper revenue codes that can be used? Is revenue code 761 (treatment room) appropriate?

For PB coding, I have a provider who wants to bill a heart cath (93456)  and bilateral leg (iliac) angio (75716) that is being done for pre-TAVR - AO stenosis reasons. There is mild iliac stenosis, but he states they are okay to use for TAVR surgery. Patient did have CAD. Is code 75716 even billable in this case for the physician? It seems like if it is done for pre-op reasons or planning we should not be allowed to bill it. Your thoughts are appreciated.

As we know, as per definition a comprehensive EP study must include the following below, but in the CPT code for 93653 and 93656 it states "when necessary".

• Right atrial recording
• Right atrial pacing
• Right ventricular pacing
• Right ventricular recording
• Bundle of His recording

Since these codes are now bundling the ICE and 3D mapping, should we send a query to the MD if one of the elements are missing?  Do we also still have to have the pacing and recording documented in order to assign CPT code without -52/-74 modifiers?

What would be the appropriate CPT code for a transcarotid TAVR? Is it still 33999, or has there been any update to guidance in recent years?

What can you tell us about the coding of DynaCT imaging in a diagnostic cerebral angiography procedure? This topic has been a source of confusion for us in the IR coding area. If DynaCT is documented, would we report code 76380? May we report 3D reconstruction (e.g., 76377) with DynaCT if both procedures are documented? For a cerebral artery embolization, if DynaCT is used to confirm placement of the device, are we correct in thinking that this follow-up imaging may NOT be reported? What is DynaCTA, and how does its coding (in cerebral artery cases) differ from that of DynaCT?

For code 20611 it includes the ultrasound guidance. It states with permanent recording and reporting. So is this different from when we bill the ultrasound guidance separately? The description of 76942 does not include permanent recording and reporting. It seems to be more like 76937. My question is, does the documentation need to state images were obtained and retained to bill for code 20611? 

What is the correct ICD-10-CM code for presence of breast biopsy clip found on diagnostic mammography?

My doctors (co-surgeons) did bilateral iliofemoral endarterectomy then percutaneous stented bilateral common iliac arteries and angioplasty of bilateral external iliac arteries. He wants to bill 35355-50-62, 37221-50, and 37222-50. I don't agree. I believe this should be coded as 35355-50-62 and 37221-50-51. I feel any PTA in EIA is inflow, but he doesn't agree, as it was proximal EIA and endarterectomy was distal EIA and CFA. The other doctor I haven't seen yet, but he wants to bill 35355-62-50, 37221-80-50, 37222-50-80, so I think he is of the same opinion. Which of us is correct/wrong and why?

There is discussion about if the venous repair is billable for facility or pro fee. It centers around the "you break it, you buy it" rule that states that a surgeon cannot separately report (and receive compensation for treating) a complication during surgery if the complication occurs as a result of the surgery itself. What are your thoughts and rationale about this scenario? Patient had PPM generator and leads removed. Per report, "The leads exhibited calcification and significant lead-lead binding. The extraction process created a substantial tear in the axillary vein. This was managed by placing a 10 mm occlusion balloon via the femoral approach. After bleeding was controlled, the vein was repaired with 5-0 Prolene sutures over the inflated balloon." Is the axillary venous PTA billable? Is any of the vessel repair billable?

I'm looking for the RVUs for the fenestrated graft codes. Are these assigned?

We have been billing the new codes for lithotripsy done in the lower extremities (i.e., C9765). There are usually diagnostic aortogram and lower extremity angiograms done prior (same time) to the intervention with the lithotrispy balloon (C1725). We are receiving claim rejections looking for surgical codes. I can't tell if they are not recognizing the C9765 or if they want me to bill for catheter placement for the lithotripsy procedure. Do you have any feedback on whether to bill for catheters with these lower extremities litho cases? I haven't been able to find any information on this, other than a statement in one of your examples that catheter placements and S&I are bundled, but that example included codes 37228/37232, which do include catheters.

What is the correct code to report when a patient has an EP study performed that is discontinued due to no PVCs? The report indicates anesthesia is administered in preparation for groin access, but no PVCs were noted, so they did not proceed with venous access. IV isuprel was administered and titrated up to high-dose and stopped for washout phase. No PVCs were noted, and the decision was made not to pursue any invasive EP study.

I have a patient who came in for a TAVR. Patient the next day developed intermittent complete heart block and received dual chamber pacemaker. It was then noticed that the deployed valve had burned about 90 degrees. Pacemaker was placed. Cardiothoracic surgical team was notified. Patient was taken back to surgery after echo confirmed malposition of valve. Sternotomy was done, patient was placed on bypass, aortic valve was removed and replaced with new aortic valve, and the procedure was closed in standard fashion. Would code 33405 with modifier -22 be the best code for this procedure? If not, what should I report?

Our techs in Radiology take C-arm fluoro imaging in operating room to assist surgeon, then the radiologist dictates findings. Can Radiology charge one of these codes for the ERCP images (74330, 74328, 74329)? Also along those lines, could we also charge for cholangiogram, uretherogram, etc.  for images taken in the operating room then dictated by radiologist?

What documentation is required for reporting 93225 on the hospital side? Can we report 93225 with just an order as long as we have the subsequent report when the analysis is completed? Do we need a progress note/nurses note on the day of the connection?

Hepatic cyst aspiration using a catheter (catheter will not remain in place) with sclerosis of the hepatic cyst. We believe that the code for the sclerotherapy is 49185, but are unsure if an aspiration code can be billed. Or, if it can be billed, what is the appropriate code/codes?

Our physicians performed two venograms and used the IVUS catheter to navigate the right internal jugular vein and the left brachiocephalic vein. I coded as 36012-50, 37253, 37252, and 75860-26 x2. Is that correct?

"The patient was brought to the lab for possible ablation. Patient's PPM was checked comprehensively and programmed AAI 50 bpm. After observing the patient for over one hour, only two PVCs were observed, one of them non-clinical, which was insufficient to proceed with EP study. IV caffeine citrate was given over 3-5 minutes. After infusion, patient was observed for another 40 minutes without any PVC induction. Procedure was terminated given that no PVCs were observed. No groin access was obtained. No sedation given. Device was reprogrammed to AAIR 60 bpm."

I am at a loss as to how to code this. What would you suggest? The physician wants to report code 93286, but no other procedure was performed.

Our interventional cardiologist performed a left heart cath/FFR on a patient and then also performed a right subclavian venogram to evaluate the patency of the subclavian system prior to upgrading the PPM to AICD by another physician. Axillary vein, subclavian, as well as innominate vein into the SVC are all patent with focal stenosis. Can we charge for the 75820/36005 in this case or not, since typically we cannot bill for this when done at the time of the AICD insertion? 

What can be coded using the following documentation? Only 37197? I am having trouble deciphering.

"Procedure: Venogram of the right subclavian artery, venogram of the right internal jugular artery, central line placement in the right femoral vein, repositioning of the tip of the venous port.

5 French sheath was placed in the right femoral artery. I advanced an IM curved catheter, had difficulty advancing the catheter, and I did angiogram to the subclavian artery and to the superior vena cava. I was unable to visualize the internal jugular. Subsequently we did an injection through the port, and I was able to visualize the internal jugular artery. I repositioned the catheter advanced IM catheter up to the internal jugular then exchanged over a wire to multipurpose and I used a snare catheter was able to capture the tip of the port and then reposition it down to the superior vena cava."

During a CABG procedure, if the provider states that the NP/PA performs the endovascular vein harvest along with opening/closing, would the physician be able to bill code 33508 or only the PA? Our compliance department is stating the PA would code the parent codes along with 33508 and an -AS modifier, but not the surgeon because it was solely performed by the PA/NP.

Modifier -74 is used for outpatient procedures that have been discontinued after anesthesia. If the provider performs the FFR as they intended (without inducing stress with medication), would this be considered discontinued? There is a recent Coding Clinic for HCPCS published that recommends using an unlisted code for the facility side in these scenarios. I'm interested in your thoughts here. Part of the coding clinic has been quoted below.

Coding Clinic for HCPCS (Fourth Quarter 2021, page 11, effective date December 9, 2021):

"Assign CPT code, 93799, Unlisted cardiovascular service or procedure, for the intravascular Doppler flow reserve measurement (iFR) performed without the use of the pharmacologic stress agent...…. Modifier -52 is not appropriate for facility reporting when anesthesia is administered, and modifier -74 is not appropriate when a procedure is not discontinued. Therefore, the use of these modifiers with CPT code 93571 is not appropriate for facility reporting when the procedure is carried out as intended."

How would this be coded? 93922/52 or 93998?

Impression:

1. The ABI is falsely elevated bilaterally.

2. The TBI is abnormal bilaterally.

RIGHT LOWER EXTREMITY:Ankle pressures are falsely elevated. The ankle/brachial index is non compressible. The digital index is 0.55. Doppler waveforms are multiphasic in the dorsalis pedis artery and posterior tibial artery. 

LEFT LOWER EXTREMITY:Ankle pressures are falsely elevated. The ankle/brachial index is non compressible. The digital index is NC. Doppler waveforms are multiphasic in the posterior tibial artery and dorsalis pedis artery. 

RIGHT LEG

Brachial---156 mmHg

Ankle (PT)--->254 mmHg (NC)

Ankle (DP)--->254 mmHg (NC)

Digit---86 mmHg (0.55) 

LEFT LEG

Brachial---140 mmHg

Ankle (PT)--->254 mmHg (NC)

Ankle (DP)---206 mmHg (1.32)

Digit--->254 mmHg (NC)