Ask Dr. Z

In the case where the existing drain was exchanged, and a second one was placed into the same abscess collection, would you code 49406, or 49423/75984, or both? It appears to be over the same access, just angled into a different area of the same collection.

"Under fluoroscopic guidance, the indwelling abscess drain was injected with contrast. Next, a Glidewire was advanced through the indwelling drain was removed. A 5 French sheath was then placed. Alongside the Glidewire a second wire was advanced and directed upward within the intra-abdominal abscess. The sheath was removed. A new 12 French biliary style abscess drain was placed in the inferior pocket. A new 10.2 French biliary style abscess drain was placed in the inferior aspect of the intra-abdominal abscess. Both drains were secured to the skin silk suture and a sterile dressing was applied"

Example 1: The baseline study was performed in roomair, demonstrating elevated @ 2/3 systemic PAp with PAm=39 mmHg and wedge=24 mmHg, simultaneous LVEDP=15 mmHg with LAm=23 mmHg. There was Qp/Qs=1.5/1 from his PFO with normal Rp=2.2. When his PFO was temporarily test occluded briefly, his LAm increased to nearly 43 mmHg with LVEDP=30 mmHg, demonstrating the importance of maintaining his PFO patentcy.

Nitric Study: He was placed in 100 % O2 with 40 ppm NO for 10 minutes. Repeat hemodynamic measurement was obtained, demonstrating reduction of her PAm = 28 mmHg with wedge=21 mmHg, simultaneous LA=22 mmHg with LVEDP=17 mmHg. His calculated Rp decreased to 1.3 woods unit.

Example 2: The patient was placed on 40PPM nitric oxide and 100% FIO2 and the sweep was repeated. Is this enough documentation for 93598?

Arteriogram revealed 100% occluded LSFA and LPOP artery. IVUS was performed in the LSFA, LPOP, LTP/P arteries. IVUS revealed 100% occluded LSFA and the proximal part of LPOP but the mid to distal part of the popliteal artery, TP/P arteries were widely patent. Provider wants to bill 37252 and 37253 x 3. If I have read your previous answer correctly I believe only one may be billed. Also, can you explain what you mean by pullback when it comes to IVUS? I understand that a guiding shot cannot be billed for, but in question ID 8925 it is stated routine pullback is one. If there are specific lesions being evaluated, then code per vessel. So, in my example would that be considered a pullback or evaluation? The arteriogram already confirmed the occlusion, so I want to say only one can be coded. Please provide clarification.

There has been confusion surrounding the 2020 MUE revision from one to two for add-on code 93657. A prior reference in CPT Assistant (July 2013, pages 7-9) states that 93657 can only be reported once per operative session. If there are two additional afib ablations performed (i.e., anterior roof and posterior wall), is it possible to bill two units of 93657 if they are performed in the same surgical session and by the same provider? If so, which modifier should be used on the second 93657? Or, should we bill one per operative session, only billing two if the patient has to return to the operating room for a repeat ablation with pulmonary vein isolation and an additional afib ablation on the same date of service but a separate surgical session?

How do you decide whom to bill for when you have two different providers billing the EMG (95718) and the WADA (95958)? We have a neuropsychologist performing the WADA test, another provider billing 36224, and another billing for the EMG 95718. We understand the EMG bundles into the 95958, so does this mean the provider that is doing the EMG gets nothing and we bill the WADA 95958 under the neuropsychologist?

Can you please provide any updated guidance on the newly published coding guideline from Coding Clinic for HCPCS, 4Q, 2021 for reporting iFR without administration of pharmacologic stress agent with CPT 93799, Unlisted cardiovascular service? Explanation provided indicates that reporting CPT 93571 with modifier -74 for hospital outpatient reporting is not appropriate use of the modifier. The guideline published in the 2021 Cardiovascular Reference directs the use of modifier -74 on CPT 93571 when performed without administration of a medication.

During dialysis graft angioplasty, we know that severity of stenosis has to be documented. For thrombectomy, does presence of thrombus alone allow for declot? Does it have to be "occlusive" thrombus? Does it have to be noted the thrombus is occluding the vessel ____ amount to support a declot? I've checked documentation from the NCCI Manual, SIR, CMS, and nothing conclusive is noted. Any input is much appreciated.

I'm trying to bill for a TEE done in the hospital setting and for the cardiology physician group that is a provider-based clinic. Is it appropriate to report 93313 for the hospital for the probe placement and 99314 for the physician who is present for the exam and does the interpretation? The same provider is doing the full procedure. Complicating matters, color flow, and spectral Dopplers were also done, which cannot be added on to 93313. Contrast was used, so for Medicare patients on the facility side C8925 would apply (even though that includes ALL components). Which is the correct way to report the hospital side? 93312, 93320, 93325 for non-Medicare and C8925, 93320, 93325 for Medicare? Or would it be 93313 for the hospital and 93314 for the physician?

For physician billing of lithotripsy in 2022, has there been a change in the CPT codes used? We have been using the angioplasty codes 37220-37235. But our MDs would like to know if we should be using the atherectomy codes instead of the angioplasty code for our cases in 2022.

Is any vein-to-vein bypass an unlisted code, or can we use the regular bypass codes? For example, an external iliac vein to superficial femoral vein bypass with an ePTFE graft. Would that be 35665 or 37799?

Do you agree that the following is charged 64640-RT x 3, 64624-52 for facility billing?

"Right knee iOvera cryoneurolysis. Treatment of the anterior femoral cutaneous, medial branch of the anterior femoral cutaneous, and infrapatellar branches of the saphenous nerve were treated. Subsequently the superolateral and inferomedial deep genicular nerves were also treated."

I am a bit confused regarding the revised 2022 CPT updates for code 93653, which now bundles 93613 and 93621. CPT 2022 revised parenthetical states, "Do not report 93653 with 93613, 93621." However, I have seen in other portals where 93613 and 93621 may be reported separately with 93653.

The patient was positioned supine. Initial imaging was performed. Under ultrasound guidance, the needle was advanced and positioned adjacent to the left phrenic nerve. 4 mL of Lidocaine and 125 mg of Solu-Medrol were injected at the target. The needle was removed and a sterile bandage was applied.

Is the phrenic nerve a peripheral nerve? If so, would you code the above IR procedure with 64450 and 76942-26?

Or, code it with 64999 and 76942-26 according to information I found online that CPT code 64410 was deleted at the end of 2019 and to instructed to use unlisted CPT code 64999 for phrenic nerve block injection along with guidance CPT code.

As always, thank you for your assistance! I hope to see you either in person or online for your May 2022 seminar!

Physician performed endovascular aortic aneurysm repair using Alto device. There is a right renal artery stent placement as well as femoral endarterectomy. In Alto device instructions, it states the main body includes a proximal suprarenal stent. They also placed the iliac limbs. Would this be coded with 34705? Would the renal stent be coded separately? Can the femoral endarterectomy be coded separately?

"The affected veins were located in the medial proximal, medial mid, and medial distal leg of the left lower extremity. The affected veins were punctured with a needle, and trapped blood was manually expressed from the veins. Gauze dressing was applied to the treatment area, and compression dressing was applied. Then, ultrasound was used to identify varicose veins at the medial, lateral, and posterior thigh; lateral calf; and medial leg below knee. Ultrasound guidance was used, and foam STS was injected into pathological veins in multiple locations feeding areas of concern in the leg."  Are we able to report code 10160 along with 76942 and 36471 as long as in separate veins?

Is there anything besides unlisted code that we can use for the following scenario? I cannot find a code for vein excision. "The patient had a coil in his forearm causing pain. Physician excised vein with coil intact."

Would the following support billing 37228-53 and 37232-53 (since the arteries were entered, but there was nothing able to be completed)?

"I then entered the posterior tibial artery with selective posterior tibial angiography. I was able to cross the lesion distally to the ankle mortise however there is no distal reconstitution that I could revascularize to. No further intervention performed on the posterior tib. I then did the same thing on the anterior tib. Entered the vessel. Performed angiography tertiary, and traversed the lesion down to the ankle mortise however there is no distal reconstitution that would allow for outflow revascularization. No intervention was performed."

I have been told that a true CTO develops with time that it has been closed > 3 months of blockage to be able to use C9607 or 92943. On the OP if it just state CTO intervention(does not state how long blockage has been or collaterals) & one access site used the CPT that was reported was C9601 because I have been told to qualify CPT 92943 or C9607 you need to have 2 access sites so the CTO can be approached both antegrade and retrograde. A second access site that enabled to use the collaterals. If the OP only states CTO and just one access site is used can CPT C9607 or 92943 still be used or C9600 (which does not state CTO).

I am new to cardiology and want to understand when it is appropriate for me to code heart failure. The provider assesses: chronic hypotension, most likely secondary to her end-stage cardiomyopathy, severe left ventricular dysfunction, and refers the patient for a heart failure transplant. Elsewhere in the note he states, "She is New York Heart Association Class II-III at baseline." Is this sufficient for me to code heart failure?

I'm a little confused by the new rules for 2022. My physician always does his EP study with his ablations. What can I bill for that EP study? According to the new education, codes 93621 and 93613 are no longer allowed if an ablation is billed. I think we need a webinar to address all the scenarios for EP. 

I was hoping you could help with how to code in the the tibial/peroneal area when shockwave lithoplasty is involved. Patient had diseases and stenosis in all three vessels. Angioplasty was performed of the posterior tibial artery and peroneal artery followed by shockwave lithoplasty of a particularly stubborn anterior tibial artery stenosis. Can we bill C9772 with 37228 and 37232 on the hospital side?

Our IR coded prostate artery embolization using CPT code 37243 and ICD-10 codes N40.1 and R31.0. The payer, Humana Medicare, paid the claim initially and then recouped the money. They forwarded a LEVEL 2 MEDICAL RECORD REVIEW DISPUTE DETERMINATION letter stating INTERNAL CODER TEAM found that CPT 37243 was not supported because "the records did not contain documentation of a prostatic or other pelvic tumor, any organ ischemia, or infarction". The letter further stated that the PAE procedure "is better represented by a different CPT code, and 37242 is suggested". Please advise as to your opinion regarding this determination.

Looking at the parenthetical notes for CPT codes 93656 and 93662 there seems to be a contradiction.

Under 93662 (ICE) the parenthetical note states to use in conjunction with 93656 ablation code. But when looking at the parenthetical note for 93656 it states DO NOT report with 93662.

For 2022, can ICE be coded along with 93656?

Would you report code 38505 (superficial lymph node biopsy) for a cardiophrenic lymph node biopsy, or would you report code 49180?

"Patient came to department as a code stroke. The cervical carotid artery was occluded at its origin without any antegrade flow intracranially. The catheter was repositioned into the left cervical internal carotid artery under roadmap guidance. The balloon was placed at the proximal cervical ICA and was inflated to its nominal pressure. Repeat angio demonstrated good antegrade flow within the left cervical ICA. At this point the microcatheter was inserted into the aspiration catheter and advanced to the occluded left MCA branch. The aspiration catheter was placed on continuous suction, and clot was removed." Is it appropriate to charge for carotid angioplasty in the ICA during mechanical thrombectomy (codes 61645 and 37246)?

"Attention was then turned to the right groin. Under ultrasound guidance, access to the right common femoral vein was obtained. A sheath was placed. Next, a 20 mm Abre stent was deployed in the infrarenal inferior vena cava. Next, in a kissing, double-barrel fashion, two 14 mm Abre stents were deployed extending from the inferior vena cava into both common iliac veins. Post-deployment angioplasty was then performed with 14 mm balloons. Next, two 14 mm Abre stents were deployed extending from both common iliac veins to both external iliac veins. Post-deployment angioplasty was then performed with 14 mm balloons. Completion bilateral lower extremity ascending venography was then performed." 

No mention of catheter placement is made in this report. Can we assume catheter placement and code it? Or does it need to be documented? I have always been taught that if it isn't documented it didn't happen, but the IR coders tend to infer the cath placement.

Can you explain when you would use the atherosclerosis of coronary artery bypass graft(s)? Would you use this once the patient has a CABG or when they have had it but then stenosis develops?

There is the Table of Elements of Cardiac Ablation Codes in CPT 2022 Professional Edition book. We are not clear if 93623 applies to the "induction or attempted induction of arrhythmia with right atrial pacing and recording". If the answer is yes, we can no longer code 93623 for SVT, VT, and AF ablation.

Is genicular artery embolization covered by Medicare for osteoarthritis - related knee pain, inflammation? While I was trying to find reimbursement information I see there is an Interventional Clinical Trial - G190316-NCT04379700. It is a Category B. The study start date is 12/01/2020, and estimated study completion date is June 2023. Could you please explain when this procedure would be considered for reimbursement by Medicare?

Coding help please. Do you agree with CPT code 36200, and is the documentation suffice?

INDICATION: Dyspnea on exertion and Severe aortic stenosis undergoing evaluation for aortic valve replacement

PROCEDURAL DETAILS: Radial artery was cannulated with a 6 French hydrophilic-coated sheath. Intrarterial verapamil, nitroglycerin and IV heparin was given. A Nonselective angiogram the left cusp with multipurpose A2 5 French catheter followed by nonselective angiography of the left cussed with a 5 French angled pigtail catheter. At the conclusion of the procedure, the sheath was removed, and radial compression band was used for patent hemostasis of the right radial artery.

COMPLICATIONS: No complications during the procedure.

RESULTS:

Hemodynamics: Ao Pressure: 121/63

Coronary Angiogram:

LM findings: Normal

LAD findings: Proximal:luminal irregularities with prominent first septal perforator.

No evidence of anomalous coronary left cusp

LCX findings: Luminal irregularities.

"Stenting of the restrictive atrial sepal communication was next performed. We attempted to upsize the 5F short sheath in the right femoral vein to a 7F Mullins sheath. However, resistance was encountered with advancing the Mullins sheath a short distance into the body. A hand injection of contrast through the sheath into the RFV showed significant upstream stenosis of the right external/internal iliac veins. 3 mm x 2 cm Evercross balloon was advanced into the Mullins sheath, and inflated a total of 3 times across the right external/internal iliac veins and then repeated w/4 mm x 2 cm balloon due to difficulty passing sheath. Following angioplasty, and over this wire, the 7F Mullins sheath was able to be advanced past the area of stenosis to the RA. Genesis stent was positioned across the atrial septum."

Can intervention of iliac stenosis be billed with TIS (33745) when being treated to advance a shunt?

I am in need of some guidance coding critical care performed during cath lab procedures. For example, in an op report for a stent placement for a patient with an acute MI, the op report would say, "Spent 70 minutes of critical care time stabilizing patient with acute MI." Would I be able to report code 99291 in addition to 92941? In what cases, if any, is it okay to bill for critical care that is performed during a procedure, or is it considered bundled?

If a surgeon performs cardiac lead extraction in a patient with a capped ICD lead and dual chamber pacemaker leads, can we bill for both pacemaker lead extraction (33235) and ICD lead extraction (33244)? I don't see an NCCI edit to stop the pairing, but it seems like we should only bill for the ICD lead extraction.

I need your advice on this case I'm auditing. The procedure was left bundle pacing upgrade from DDD pacemaker. "The existing LV lead was removed, and multiple attempts were made to place an LV lead but not successful. At this point the procedure was converted to place a left bundle branch lead. The pacing lead was positioned and deployed in the midseptum. The lead was sutured in place, the pocket was flushed with antibiotic containing solution, and the new CRT-P was connected to the leads." There was new CRT-P implanted, RV His bundle implanted, old battery removed, CS lead removed, and leads reconnected RA and RV. Do we report codes 33207, 33225, and 33233? I don't believe 33225 needs to be coded since there is no LV lead implanted. Is this correct? Do we also code for the removal of CS lead?

A cardiothoracic surgeon is requesting digital waveforms and pressures when also performing bilateral radial artery mappings prior to CABG. The assessment of the RA is for possible use as a conduit for CABG vs. saphenous vein or other grafts.

The digit-brachial index (DBI) is the upper extremity equivalent of the lower extremity ankle-brachial index. Is it appropriate then to report both 93930 (duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study) -and- an ABI (93922 limited -or- 93923 complete) when pressure measurements and waveforms are obtained of the digits when measured and documented both with and without radial artery compression maneuvers?

I'm being told to append a -24 modifier to the E&M code for a patient in a global period. Patient had an AVG placed and is admitted for a complication during the global period (e.g., for thrombus or stenosis). My surgeon does a consultation and decides to take the patient back to the OR. Can I append the -24 modifier to the E&M code? I have been using modifier -57, and my claims are getting denied. Is this E&M part of the global package? Most of his procedures are open (e.g., revision with or without thrombectomy). Codes 36832 and 36833 will start a new global period. Please advise on the proper use of the E&M modifiers.

Are you familiar with a SESAME procedure? Our MD is doing this and describes a percutaneous septal myotomy procedure for severe hypertrophic obstructive cardiomyopathy where he will puncture the septal knuckle and then snare within the LV and use an insulated electrosurgical energy to perform myotomy. This laceration is effectively the same as the original Morrow procedure and has been performed 11 times at Emory and many more times in an animal model with the NIH. Do you have any information on this? We are only coming up with unlisted 33999.

Can we charge for spot ablations? Would this be reported with codes 93656 and 93657?

"Wide, extra ostial pulmonary vein antral isolation was performed with power cutoffs of 25 watts when ablating on the posterior wall and 30/35 watts when ablating elsewhere. The right phrenic nerve was marked by high output pacing after reversing the paralytic agent, and ablation was predominantly performed without paralytic agents. There was no evidence of right phrenic nerve paralysis during or after the procedure.

Spot-ablation was performed on the posterior wall of the left atrium between an anterior roofline and an inferior floor line. The patient was then cardioverted to sinus rhythm. After cardioversion, entrance and exit block were demonstrated using differential pacing maneuvers. There was loss of voltage in the left atrium within the ablated area. Partial carinal ablation was required bilaterally. Wide, extra ostial pulmonary vein antral isolation, bilateral carina lesion, LA roof line creation, and RA CTI line ablation."

Code 36556 is the correct code to use for a cooling catheter placed in the cath lab during a cardiac cath. When 36556 is used in IR to report CVC placement, the physician must document where the tip of the catheter resides. Does this also hold true for documentation in the cath lab? Most of the time the physicians only state that the ICY/cooling catheter is placed via the femoral vein or in the femoral vein. No documentation of where the tip ends. When documentation is lacking, should this be coded as a midline catheter (36140), or is it still okay to report with 36556? This is for facility coding if that makes a difference.

I have a note for an 84-year-old male patient who has a known AAA. He has had an ultrasound to check to see if this has grown. Code 76706 was billed, but the payer denied it saying the diagnosis is inconsistent with the procedure. The code definition states screening, but in the CPT Codebook this is the only ultrasound code I found for AAA. Can you advise of something more appropriate, or do you feel this is correct?

I have a diagnosis question. The patient comes in for a follow-up TEE after having a Watchman implanted. If the TEE shows appendage closure, the patient will be maintained on antiplatelet therapy per the H&P. The indication on the TEE report says "Watchman Follow-up". Should the primary diagnosis be Z09, Encounter for follow-up after completed treatment for conditions other than malignant neoplasm; Z48.812, Encounter for surgical aftercare following surgery on the circulatory system (which is the diagnosis the encoder comes up with if you choose condition requires additional treatment); or the atrial fibrillation code followed by Z95.818, Presence of other cardiac implants and grafts?

Simple question here from a relatively green coder:

What is the correct diagnosis code to use when patient presents with symptoms for myocardial perfusion stress test and the report findings indicate ischemia with one of the below phrases:

"ischemia in 1% of myocardium"

"small area of partially reversible defect in x wall(s), consistent w/ ischemia"

"region of ischemia"

I use I25.6, silent myocardial ischemia if the ordering diagnoses do not include symptoms but what if chest pain (or other symptoms) is the ordering diagnosis? What is the correct ICD-10 CM code to capture the ischemia then?

I25.5...I would think the cardiomyopathy part must be stated by a provider....?

I24.9 and I25.9....I don't know the duration as this is from a diagnostic test report.

CAD...These images only show "areas" of perfusion, right? Not specific vessels.

R94.39.....?

Thanks!

Is it allowed to report codes 93286/93287 with a cardioversion (92960)?

Does the physician need to document that he/she personally supervised the service in order to bill code 93016?

I am wondering if 47554 bundles with 47556. Per CPT hierarchy it should. However, the two CPT codes don't edit in our coding software, making it seem like they could be stand-alone codes. Please advise.

In a brachial artery to jugular vein AVG, would angioplasty documented as venous outflow be considered central or peripheral for coding purposes?

One of our vascular surgeons sent us a recommendation from Boston Scientific to report codes 37211 and 37252 when using EKOS in an artery.

Per the recommendation:

“Ultrasonic fragmentation using EKOS” can be used in the dictation for clarity.

The specialist further clarified that 37252 can also be used together with 37211.

Is this appropriate, as the 37211 descriptor states "any method", and isn't the EKOS catheter usage just another method ? Or is the use of "ultrasonic fragmentation using EKOS" sufficient to allow for the 37252 billing?

Can you please provide your interpretation of 3M's guidance that "separate diagnostic heart cath requires a separately written report"? This is seen in the coding CPT pathway under PTCA and guidance for charging the diagnostic angiogram at the same time as the intervention. I interpret this as CPT believes there should be clear documentation that the physician is performing a true diagnostic study and then determining that intervention is needed. Does this Nosology Help Message state there has to be two different/separate physical reports? 

We have had a scenario come up a couple times where an interventionalist and a cardiothoracic surgeon perform a TAVR, but need a vascular surgeon to come in and perform the access portion of the procedure for an open approach. We have been using unlisted code 37799 for this work by the vascular surgeon, since we're already billing the TAVR as a co-surgery for the interventional cardiologist and the CT surgeon. Would you agree with this?

What is the correct CPT code for repositioning of suprapubic catheter? Per the operative report: "The suprapubic tube balloon was deflated, and it was pulled back until it was no longer in the fistula and it was in the bladder."