Ask Dr. Z

“Is it okay to report codes 93653, 93621, 93623, and 93642 together even though code 93621 is an add-on procedure without a base code?” Per NCCI, code 93642 is a component of 93653. Only 93653 will be reimbursed. No modifiers are allowed to unbundle. One of our providers doesn’t agree, stating that it's not related to the EP study at all, but rather a totally unrelated procedure indicated to evaluate whether the archaic defibrillator hardware still works, just coordinated at the same time to avoid giving her anesthesia twice. Would you agree that in these cases code 93642 is appealable?

Can code 34716 be reported when performing a TAVR? STS guidance states graft conduit creation is included in TAVR codes, but our surgeons do not agree. No definitive coding guidance exists.

Per the surgeon: "Our primary approach is to surgically place a conduit onto the axillary artery. This is not covered by code 33363. That is covered by code 34716. Not used for just bypass but also for delivery of endovascular prostheses (a.k.a., a TAVR valve)."

OP report example: "Side biter was placed, followed by arteriotomy and placement of an 8 mm graft in an end-to-side fashion. Graft was flushed with heparin and distal clamp placed. This allowed placement of a 6 French sheath into the graft. An AL1 diagnostic catheter and straight TSF guidewire were then used to advance across the stenotic aortic valve and placed into the LV. The LV catheter was then placed. This allowed passage of the 14 French delivery sheath under fluoroscopy into the arch. No BAV was performed due to pre-existing AI. The Edwards S3 23mm TAVR delivery system was advanced over the wire and across the aortic valve."

Would I use code 32669 whether robotic trisegmentectomy of the left upper lobe was one or three segments?

Patient had stenosis in common femoral artery. MD performed angioplasty, and follow-up angiogram demonstrated dissection. Would you code for the intended procedure, which was angioplasty in the common femoral artery, or would you code for the stent placement for the non-occlusive dissection?

Is code 62323 or 96450 appropriate for this type of intrathecal drug?

"Patient with Niemann Pick disease. The patient's skin was prepped and draped in the usual sterile manner. 1% lidocaine without epinephrine was used for local anesthesia. Using CT guidance, a 22 gauge 3 1/2 inch spinal needle was inserted into the thecal sac at the L5-S1 level with spontaneous return of clear cerebrospinal fluid. 10 of CSF were removed. The prepared syringe of intrathecal 2-hydroxypropyl-beta-cyclodextran 10 cc solution was attached to the spinal needle for intrathecal administration by Dr. X. The stylet was placed back into the spinal needle and the needle and stylet removed from the patient."

I know Medicare states to date the professional interpretation of test with the date that the test was interpreted. Does this also apply to all insurance companies or just Medicare and Medicare Advantage plans?

Please advise as to what CPT codes would be appropriate. Does the response in question ID 15139 apply to this case?

The patient's identity, planned procedure, and laterality were confirmed. The skin overlying the lateral right hip was prepped and draped in usual sterile fashion. The skin and subcutaneous tissues were anesthetized with 1% lidocaine solution. Under ultrasound guidance, a 20-gauge spinal needle was advanced near the greater trochanter and the deeper soft tissues were anesthetized using 0.25% bupivacaine solution. Subsequently, percutaneous needling (tenotomy) was performed by gently fenestrating the distal gluteus medius and minimus tendons using the 20-gauge spinal needle. Once the fibrosis/scar tissue was released and the tendons were adequately softened, the needle was removed.

IMPRESSION:

1. Right gluteus medius and minimus insertional tendinopathy.

2. Uncomplicated ultrasound-guided percutaneous needle tenotomy of the right gluteus minimus and medius tendon insertions.

Indication was Afib and Aflutter. "PVI was completed and exit block confirmed for each vein. After PVI, isuprel was started and burst pacing was performed from the CS catheter. Patient was induced for Aflutter, and subsequently an activation map, Ripple map, and coherent map were performed that showed an area of slow zone conduction in the septum of the left atrium; areas were targeted with ablation. Aflutter organized with proximal to distal activation in the CS catheter. Multiple areas in the septum were targeted for complex fractionation. A few areas of complex fractionation noted in the posterior wall as well. These were targeted as well. The catheters were taken to the right atrium, and ablation of the CTI was performed. The flutter was terminated during the ablation in the CTI." One coder thinks this should be coded as 93656, 93655 x 2, and 93623, while the other coder thinks it is 93656, 93657 x 2, 93655, and 93623. What is the correct coding please? Second question, is CAFE always coded as 93657?

Can you please help with the coding for this procedure? We are trying to determine if 35820 would apply for this scenario or maybe 32999 (unlisted VATS procedure). Thank you. 

"Earlier this same day, the patient had a VATS with wedge resection. The patient came back to the OR for post-op bleeding. After general anesthesia, the previous port site was opened. A 10 mm port was placed into the chest, and a 30-degree scope was passed into the chest. There was a large hematoma that was present. This was irrigated copiously and completely evacuated. The second port site was opened. All port sites were then systemically examined. All three port sites were generally oozing. The posterior port site seemed to be the culprit; however, no arterial bleeding was identified. Two 36 French chest tubes were brought through the port sites and directed up anteriorly and posteriorly to the apex. The port site was closed." 

Can code 93319 be billed with 93320 when completed during a transesophageal echo? It does not conflict in my NCCI edit checks like 93325 does. What is the rationale behind this?

Code 35121 is an open procedure, and code 37236 is for occlusive disease. Would I use an unlisted code?

"It was determined to repair the common hepatic artery aneurysm with placement of covered stent graft, as there was proximal and distal landing zone identified. The guidewire was exchanged to a 0.014 inch run-through wire. Next, a Gore Viabahn stent graft 6 mm x 25 mm was advanced and deployed distally in the common hepatic artery, and this was then expanded with a 5 mm balloon. Next, a Gore Viabahn 7 mm x 25 mm stent graft was advanced and deployed in the proximal common hepatic artery, allowing for adequate overlap, and the stent grafts were then angioplastied with a 6 mm balloon. Completion angiogram revealed excellent positioning of the stent grafts with adequate repair of the common hepatic artery aneurysm."

Can we append modifiers -52 or -53 to code 93356? If so, what would be the best practice for documentation?

Due to infection, lead #1 went through the TV and cannot be resected any further than where it enters the subclavian vein. Lead #2 could not be resected further than where it enters the chest. Both leads were divided and capped. The note then describes that the pocket incision was opened, and dissection down to the leads occurred. The leads were pulled back into this pocket and then were dissected down underneath the subpectoralis area for complete resection, and once the leads were completely resected all the areas were inspected and closed. This sounds like only part of the leads were removed. Can code 33235 be billed in this situation?

May we report codes 93656/93655 for the following?

"Cryoballoon ablation with PVAI, RF ablation CTI. Four femoral venipunctures/sheaths placed. ICE cath to right atrium, low normal EF/trace pericardial effusion noted. Ablation catheter to right atrium, 3D map created. CS cath advanced to CS. Baseline conduction taken. RF of CTI delivered. Bidirectional block confirmed. Ablation catheter removed. ICE-guided transseptal puncture, trace pericardial effusion noted. Cryoballoon advanced to left atrium. 3D map created. Pulmonary veins identified. Voltage mapping. Four pulmonary veins targeted with cryoablation. Entrance and exit block documented. Comprehensive EP study with R/L atrial pacing/recording and His bundle recording. AH and HV intervals noted to be 120 ms and 54 ms respectively. ICE noted baseline trace pericardial effusion. All catheters removed."

In 2015 patient had a re-do right femoral endarterectomy and now is having fem-pop bypass with vein (35556). Can we also report code 35700 for the re-do groin for bypass now with prior right femoral endarterectomy from 2015?

Steroid injection of the breast: Can 19030 be reported for this with US guidance? My inclination is to report 96372 or 19499 with 76942, but there is no clear direction in the CPT Codebook.

MD input provided of procedure:

"Assess sonographic area of granulomatous mastitis, draw up the steroid mixture smaller area: 2 mL steroid mixed with bupivacaine larger area: 4 mL steroid mixed with bupivacaine to fill 10 mL syringe skin and subcutaneous anesthesia with 1% lidocaine inject steroid/bupivacaine mixture into the area of GM."

This practice will be reporting primarily for pain in the breast/injection with US guidance. Any information you can provide is appreciated. I did see another response for a similar question so understand if this does not get a separate response.

Our hospital IR department performed a contrast injection under fluoroscopy into the vaginal vault via a Foley catheter in a patient with Crohn's disease and a known rectovaginal fistula. Upon injection there was no gross evidence of fistulous communication to the rectum. The Foley catheter was removed. What should be reported?

I need clarification about the empiric CTI. Can you provide me good example documentation that will indicate empiric CTI was performed? And what is the difference between the CTI ablation 93655 and the empiric CTI? I'm searching online, but I cannot find a good scenario or example of operative report that says empiric CTI was performed. If the patient had PVI ablation performed and then another for atrial flutter typical, do we report code 93656 for the atrial fib and then 93655 for atrial flutter? The location is right atrium CTI.

What code would I use when an infected AVG is removed along with removal of a stent in the basilic vein during the same surgical session?

Primary doctor planned an anterior cervical discectomy with decompression of spinal cord, arthrodesis, and structural allograft. Due to history of neck irradiation, for throat cancer, there was significant scarring. My vascular doctor was called in and asked to expose and mobilize the internal jugular, common carotid, and the vagus nerve. Numerous adhesions and scar tissue were found. Multiple vessel loops were utilized for mobilization. I'm not certain what codes would be appropriate.

I wanted to bring up the fact that nowhere in the CPT Codebook does it say that you can't bill 33268 with 33261. The new guidelines say: "(Do not report 33268 in conjunction with 33254, 33255, 33256, 33257, 33258, 33259, 33265, 33266, 33420, 33422, 33425, 33426, 33427, 33430)." I see nothing about 33261; however, I'm getting an edit when trying to code these together. Do you know if this is an error with Medicare NCCI guidelines? I also don't see that you can't bill them together per your 2022 books. It would make sense that these codes are unbundled due to 33261 being an ablation. Thoughts?

"A lead was advanced to the sheath to the right ventricular septum. A His and left bundle potential was identified throughout the procedure. Pacing along these areas did temporarily show a narrow complex QRS. Unfortunately is growing into these areas with the lead did not provide adequate stabilization of the lead. Numerous areas all along the septum were attempted for adequate lead stabilization and unfortunately a position was not able to be identified. After numerous failed attempts of placing the lead in a stable position where it would cause a narrow QRS complex the procedure was aborted. A biventricular device was attached to the existing leads. The left ventricular port was capped. The pocket was flushed and the device was then placed into the pocket. It was closed in a three-layer technique and the dermal layer was sealed with dermal adhesive. The patient was sent to the post procedure care unit in stable condition. (Leads in RA and RV)"

Would this case be reported with code 33264? Or with 33249-74 and 33241?

Would this scenario be reported with codes 33533, 33510, 33518, and 33508-XU?

"The provider harvested the saphenous vein endoscopically. A segment of reverse saphenous vein was then anastomosed to the obtuse marginal with 7-0 Prolene suture in an end-to-side fashion. There was a small segment of visual saphenous vein that was of adequate caliber. This was anastomosed to the LAD at this level in an end-to-side fashion. The obtuse marginal proximal was then performed of the ascending aorta with a 6-0 Prolene suture in an end-to-side fashion. There was only a small segment of saphenous vein that was anastomosed to the LAD, and so, therefore, this was taken off of that vein graft in an end-to-side manner in a vein-to-vein anastomosis. The mammary artery was then anastomosed to the saphenous vein that goes to the LAD, approximately 1 cm from the anastomosis, with 7-0 Prolene suture in an end-to-side manner."

History documents prior ruptured abdominal aortic aneurysm repair in 2001. Now with a left common iliac artery pseudoaneurysm. Do you agree that although the current encounter report documents that after internal iliac artery embolization, two overlapping iliac limb prostheses were deployed within the prior left iliac limb and extended to the native external iliac artery; code 34707 instead of 34710 should be used since the current encounter is for treatment of a different aneurysm 20 years later although in the previously placed bifurcated device for the prior ruptured AAA repair?

Is there a charge that can be used for CT departments when CT images are taken for use in rad therapy treatment planning? Since rad therapy simulation is charged in the same DOS, is the hospital not able to charge for CT imaging?

I code for a hospital outpatient facility. When a physician performs core needle biopsies of two inguinal lymph nodes on the right side, can we bill code 38505 twice? If not, please explain.

Should I use open codes, or are TEVAR codes 33880, 34715, 34716, 75956, 37252, 37253, plus cath and redo code correct? 

"We began with the right axillary cutdown.We also identified the first and second rib to allow a channel for a bypass graft to connect from the ascending aorta to the axillary artery. Aortic arch as a means to confirm were in the true lumen for future placement of her frozen elephant trunk Next we performed a redo sternotomy and entered the right and left pleura. We then performed performed an extensive adhesiolysis over about a 1 hour periodWe do not separate the subclavian artery as it appeared to be very distal and difficult to access from the chest. We sewed an 8 millimeters graft onto the left carotid artery first. We then identified the IVUS catheter and the aortic arch and placed an Amplatz wire through there. We removed the IVUS catheter advanced our TEVAR graft through the Amplatz wire and under direct vision deployed our TEVAR. The TEVAR was placed covering the left subclavian artery and covering part of the carotid artery between zone 1 zone 2."

Which code should we use for the procedure below? Is unlisted code 64999 appropriate for this?

"The skin was anesthetized with 1% local lidocaine anesthetic. Using serial CT guidance, a 22 gauge 5 cm radiofrequency ablation needle with 5 mm uninsulated tip was advanced to the left C2 dorsal root ganglion. Sensory testing was performed at 50 Hertz up to 2 volts. Appropriate position was confirmed, and thermal radiofrequency ablation was performed for 90 seconds at 80 degrees Celsius. A mixture of 1:1 dexamethasone (10 mg/mL) and Bupivacaine (0.5%) was combined. This steroid: anesthetic mixture was instilled using a total of 1 mL. The needle was removed, and a sterile dressing applied."

Pt. has previously placed plug/drain (MIC G-Tube) in intestinal fistula. We used 20500/76080..not same DOS. IR Dr. tends to it during placement of central line. Bill for this? It was not ordered........Given ongoing leakage from RUQ drain (MIC G-Tube), site assessment performed w/US. Small amount of extraluminal air was thought to remain. Balloon was inflated with addt'l1 ml. sterile water for total of 6 ml. Retention disc was gently tightened to skin surface and remaining prolene suture removed. Site was cleansed & clean dressing applied. There were no signs of skin breakdown or infxn.

NM THYROID THERAPY PLANNING - do we use 78012, 78018, 78830, and 77300?

"TECHNIQUE: Following the oral administration of 1 mCi I-131 sodium iodide, whole-body dosimetry counts were obtained at 1,4,24, 48 and 72 hours for a full body dosimetry calculation. At 24HR post administration, quantitative thyroid uptake measurements were performed to quantify remnant thyroid tissue. Additionally, thyroid carcinoma metastases imaging was obtained at 24HR, and included whole body and spot view images of the neck and chest.

SPECT/CT imaging of the skull base through the lungs was also performed at 24HR. The non-diagnostic/non-contrast CT was obtained to provide attenuation correction and anatomic localization only. Source data was utilized to generate reconstructions in the axial, coronal and sagittal planes. Tomographic images and 3-D maximum intensity projections were generated. Basic radiation dosimetry calculations and image findings will provide guidance for additional surgery, altering the prescribed I-131 therapy, determining the maximum tolerated therapeutic activity, or for avoiding unnecessary I-131 therapy if no disease evidence."

Since we have two separate accesses, should we code this as 37224, 37220, and 35371? Or only report code 35371?

"The physician completes right SFA and right EIA angioplasty through an ultrasound-guided left common femoral access. After the SFA/EIA procedure is completed, the physician makes a right groin incision, exposes right femoral artery, dissects 3 cm of the PFA and SFA, clamps the CFA/SFA/PFA, and opens the atriotomy. The physician then completes a common femoral endarterectomy/profundoplasty and extends the arteriotomy down the SFA for 2 cm. He pulls plaque from EIA and then uses 6-0 prolenes at the distal profunda endarterectomy and origin of SFA and then places patch."

Is there a code for temporary wire reposition?

How do you code an arterial bypass involving the anastomosis of the iliac artery and mesenteric artery? Code 35633 is for other than a vein; however, in our case a vein was used. Procedure described as being performed was "right common iliac artery to superior mesenteric artery bypass graft with a segment of the femoral vein harvested from the right lower extremity". Patient had a postoperative diagnosis of mesenteric arterial ischemia with occluded superior mesenteric artery bypass graft. Should this be an unlisted code?

Provider performed pseudoaneurysm repair in the left SFA and also had endarterectomy in the common femoral for occlusive disease. Can we report both or just one?

When is it appropriate to append a -59 or -X modifier to 32609 when performed in conjunction with 32608? For example: "Patient is status post a lung transplant. He has nodules on his skin, and there is a concern for a post-transplant lymphoproliferative disorder. Endobronchial attempts failed, referred for surgical resections for definitive diagnosis. Two biopsies of the right lower lobe of the lung were taken via thoracoscopy and sent to path. There was a dark area on the pleural surface that appeared to be old blood, and this was biopsied."

Are the lung and pleura considered different structures, and are we able to append a -59/-X modifier? Or, since both biopsies are done on the right lower lobe, are they considered bundled?

For the stent graft of the popliteal to mid SFA with exclusion of popliteal, I use 37236-RT. How do you code open exposure right femoral 2/2 large antegraded femoral sheath? I am looking at 34812, but I do not have the primary code. I am wondering if 37236 is the correct code to use. Please help.

"Patient arrived in atrial flutter. An ablation line was created from the right sup PV to the antral mitral valve annulus with shift of a flutter at 330 msec. Ablation from the left sup PV and the anterior mitral valve annulus terminated the atrial flutter. We noted a different (concentric) atrial flutter. Ablation from the LSPV to the RSPV resulted in termination of this atrial flutter. Conclusion: Successful ablation of three different left atrial flutters." 

Would this only be reported as 93653 since the atrial flutter ablation was all in the PVs, or would we also report code 93655 for the "different (concentric)" atrial flutter ablation?

Correct coding for wedge resection of blebs 32655 or 32666, 32656? 

"Procedure details: the patient was brought to the operating room and placed supine on the table. General anesthesia was induced and patient intubated with double lumen tube. Perioperative antibiotics were given. Bilateral lower extremity sequential compression devices were placed before induction. He was then placed in left lateral decubitus position. He was prepped and draped in usual fashion. 3 thoracoscopic ports were placed and the chest explored. He had blebs visible in RUL apex. This area was resected with purple load stapler. The superior segment of the RLL also had irregularity of the edge, thus this area wedge resected as well with purple loads. Pleurectomy was then performed from the 6th rib cephalad, sparing the apex where the subclavian vessels lie. The remainder of the pleura was scratched with a bovey scratch pad. A 28F chest tube was placed apically, and a 24F blake placed at the base. Patient was awakened from anesthesia and taken to recovery in good condition. There were no apparent complications."

I am not sure what code to use since debridement was done on the fibrinous exudate.

Procedure:

1. Washout of chest wall wound involving the right sternoclavicular joint

2. Debridement of fibrinous exudate overlying the clavicle and sternal notch

The patient was brought into the operating room and placed on the operating table. The old wound vac was removed and I started by copiously irrigating the wound with 3 liters of sterile saline using the pulse lavage. There were some areas of fibrinous exudate overlying the right clavicular head and sternal notch, which I sharply debrided with scissors back to healthy tissue. I then replaced the durable wound vac sponge measuring approximately 20 x 13 x 2cm.

What is the correct CPT for ESWL of pancreas? Our physicians are recommending 43265, but there is no support of the ERCP portion being done during the encounter. The procedure report states: "Extracorporeal shock-wave lithotripsy was performed using the Dornier Delta II. Began with a power of 1 at 60 shocks/minute with a total of 4000 shocks. There was successful partial fragmentation of the pancreatic duct stone."

What is the correct CPT code for venous sampling by catheter?

How would you code this procedure? The provider reported 93660 and 93623, but 93623 is an add-on code, and 93660 is not a primary procedure for 93623.

"The patient was brought the lab in the fasting state after informed consent was obtained. The groins were prepped and draped in a sterile manner. Anesthesia was provided by anesthesia consult. Please see separate documentation report. Continuous twelve-lead electrocardiogram was employed. Continuous hemodynamic monitoring was also employed. Despite isuprel infusion to increase baseline HR >20%, isuprel washout, infusion of calclium gluconate, infusion of IV caffeine and >45minutes of observation awake and under anesthesia, NO PVCs WERE NOTED. Hemodynamics remained stable throughout the procedure."

Please help. I'm really hoping this isn't an unlisted code and that there is a CPT code that accurately represents the below procedure, but every one I come across involves graft stent placement. Code 33877 would be perfect, I think, except for the no graft placement issue. Is there a code I'm missing, or is this unlisted code 37799?

"Patient had percutaneous endovascular repair of dissecting descending thoracic aorta, which came off just below the pre-existing stent graft placed five years prior for descending thoracic aorta traumatic injury. They successfully excluded the aneurysm, but one week later CT scan showed persistence of large aneurysm, which was causing mass effect on esophagus and left heart. Patient was taken to OR for open exposure of the aneurysm and repair with decompression of aneurysm sac. Cardiologist performed left posterolateral thoracotomy. Vascular surgeon opened aneurysm sac and removed the thrombus. TEE showed sac was totally decompressed, and sac was closed over the previously placed stent graft and aortic wall repaired with suture."

Would you report code 33745-52 or 37246 for balloon dilation of a pre-existing stent in the LPA for in-stent restenosis in a congenital heart cath patient?

I was inquiring on how you would recommend billing for his bundle lead? It was billed as 33208. This is the first time I have seen this. 

"Procedure: An approximate 2-inch incision was made in the left chest wall, and using a combination of blunt and sharp dissection, the pacemaker pocket was fashioned down to the pre pectoral fascia. Using standard Seldinger technique, two guidewires were placed into the left axillary vein and confirmed by fluoroscopic imaging. Over these guidewires, standard peel-away sheaths were advanced into the left axillary vein. Through these peel-away sheaths, standard pacemaker leads were positioned (Table 1) under fluoroscopic guidance.

Table 1:

Location Company Model # Serial # Date of Implant

RA Medtronic XXX XXX October 7, 2022

His bundle Medtronic XXX XXX October 7, 2022"

A His lead was placed instead of a left ventricular lead in the coronary sinus (there was not a suitable vein). The His lead was attached to the interventricular septum, the RA lead was placed in the right atrial appendage, and the RV lead was placed in the RV low septum. All leads were cleaned and attached to the biventricular PPM generator. (The His lead was plugged into the LV port.) What should be coded for a His lead placed in this manner? I understand code 33225 would not be suitable, as it is not a coronary sinus lead placement.

Patient is in the OR for a CABG. Saphenous vein is harvested, open technique, but the vein is not usable. The doctor speaks with cardiologist and concludes that the patient is high risk and could easily have PCI to the occluded vessels, which is better for the patient and closes the thigh incisions. How would you bill for this to give the provider credit?

If physician documents 100% occlusion calcified mid - left circ would you consider coding this as CTO (C9607)? No previous heart cath or any other non invasive procedure done before. Patient only diagnosis history of HTN and hyperlipidemia. Please advise.

"Reason for exam: CT fluoroscopy epidural block injection for right lumbar radiculopathy. CT was obtained, and images were used for localization of the right L4-5 neural foramen. Procedure: After infusion of subcutaneous xylocaine, a 22 gauge spinal needle was inserted into the patient's back at approximately the L4-5 level. Under CT fluoroscopy, the needle was then advanced so that the tip abuts against the exiting right L4 nerve root. With the needle tip in this location, a solution composing of 80 mg of Depo-Medrol and 4 cc of 0.25 % Sensorcaine was injected through the needle. The needle was then removed."

Code 62323 is charged by the rad department. It seems like a nerve block injection, and I would want to code it as 64479. Please advise.

We have been following the instruction that 75774 only applies to subselective ARTERIAL studies; however, CPT Assistant (Septmeber 2022) states, “If venography is performed in a main vessel and then a selective venogram is performed, report code 75774 in addition to the venography code for the initial vessel.” Can you please clarify from the AMA that 75774 can be used for both arterial and venous studies?