Ask Dr. Z

My doctor did a CT-guided injection of methylene blue around a targeted right upper lobe lung nodule, then a CT-guided placement of a hook wire adjacent to the targeted right upper lung nodule (needle localization). Would this be 10035 for the needle localization and unlisted for injection? Or 32553 and unlisted?

When radiofrequency ablation is completed of the greater and lesser occipital nerves, do you report a code for each, or should only 64640 be reported once for RFA of both of these nerves (and not report 64450)?

Should G0269 be billed with heart catheterizations? The 2021 Chapter 11 NCCI Policy Manual states it may be billed, but everything else I read states no.

Per Chapter 11 - Placement of an occlusive device such as an angio seal or vascular plug into an arterial or venous access site after cardiac catheterization or other diagnostic or interventional procedure may be reported with HCPCs G0269.

The CPT book states closure device placement at the vascular site is inherent to the catheterization and is not separately reported.

Does CPT code 36410 include the use of fluoroscopy to demonstrate positioning of the catheter tip?

An alcohol septal ablation was performed same session as TAVR for septal debulking in order to give some room for a possible TMVR with a valve in MAC/Lampoon (off-label) at a later date. Is this billable? If so, what is your recommended CPT and ICD-10 coding? Severe global LVH causing small ventricular cavity, severe LF LG aortic stenosis, severe mitral regurgitation with severe MAC, and severe pulmonary hypertension.

We need some guidance, not sure if we should just report 33207 here? Or 33207/33225? Or unlisted? This was an initial implant with RA and RV ports plugged.

"The Seldinger technique was utilized to access the left axillary vein. A Wholey wire was positioned in the SVC. Due to recent tricuspid valve surgery for severe tricuspid regurgitation and concerns of recurrent tricuspid valve regurgitation if pacing lead is placed through the tricuspid valve, decision was made to place ventricular pacing lead in the coronary sinus. A 9 French peel-away sheath was advanced over the third guidewire. The CS was successfully cannulated using a Medtronic MB2 diagnostic catheter, deflectable QUAD catheter, and the Wholey wire. A venogram through the MB2 sheath showed a large size posterior lateral CS branch terminating at 3:30 o'clock on MA. A quadripolar, pace/sense lead was positioned in the lateral cardiac vein initially using a Choice PT wire. The RA and RV ports were plugged. Generator St Jude model PM3562 LV Lead St Jude 1458Q/86."

We do not bill the RHC when performing post-transplant surveillance caths unless there is a separate indication to support medical necessity of the RHC. However, I recently found out that the physicians are performing the right pulmonary capillary wedge pressure which should equal/represent the patient’s left heart filling pressures to assess for developing vasculopathy in the coronaries. In this case is the RHC billable along with the endomyocardial biopsies? We do bill 93458 when the physician is performing the LVEDP and coronary angiograms to assess for coronary vasculopathy. Is that correct? 

Can we bill the IVC venography (75825-26) with ASD closure when there is abnormal anatomy or would this be considered part of 93580 for placing the device?

"A 27 mm Gore Cardioform ASD Occluder was selected and prepared on the back table per the manufacturer's specifications. Through the right femoral sheath sheath, the device was attempted to be advanced, but could not track within the IVC to the right atrium. Therefore, we modified a Mullins sheath by cutting it to shorten it so a gore device would advance out the tip.

With the ice catheter positioned in the inferior vena cava, a hand injection was performed in the right common iliac vein through the femoral sheath. This again highlights the abnormal course of the inferior vena cava, running along the left side of the vertebral bodies before coursing rightward at the level of the liver.

Saved fluoroscopy demonstrates the initial attempted device deployment. This attempt demonstrates that the device pulls through from the left atrium into the right atrial side."

Is there a best practice from a documentation perspective for supporting that a provider performed supervision of a stress test only (93016)?

Can we bill for catheter placement and if so, would you code 36010 (svc to get to RA) and 36200 (aorta) to access LV?

"Access was obtained in the left femoral vein, and right femoral artery where 10F and 7F sheaths were placed using a modified Seldinger technique. Through the venous sheath, an ICE catheter was advanced into the RA. Initial images were obtained showing device in the LVOT. Prior to upsizing the arterial sheath, two Perclose sutures were prepared and delivered in the artery. The right femoral artery sheath was removed, and the vessel was dilated using a 14F dilator. We then upsized to a 14F D'Vill sheath in the right femoral artery. Using a 6F JR 3.5, and a 6F 6-10mm Ensnare, the device was captured in the LV. The sheath was advanced into the LV, and the Amplatzer device was pulled within the long sheath and removed. We performed final ICE which demonstrated mild AI, and mild MR. We decided not to replace the ASD device."

My physician performed a right anterior tibial artery atherectomy and angioplasty as well as a right posterior tibial artery angioplasty and stent. I reported code 37230 for the PTA stent/PTA and 37233 for the ATA atherectomy/PTA. The insurance (NY Empire Blue Shield) is denying the 37233 since it doesn't have a primary code assigned. Isn't 37230 the primary code? Am I assigning the incorrect codes for this procedure? Don't you assign the highest code first and then use the add-on code for the lesser procedure when the arteries are in the same territory?