Ask Dr. Z

My physician did an aorto-bi-femoral bypass with aortic thromboendarterectomy, left common femoral endarterectomy with eversion endarterectomy of the profunda femoris, and endarterectomy of the proximal superficial femoral with tacking of the intima of the SFA and patch angioplasty of the CFA and SFA. It is my understanding that the thromboendarterectomy (both aortic and femoral) would be included in the bypass coding. He disagrees and says he does more work than just establishing inflow/outflow. Also, he wants to code for the profunda and superficial endarterectomy in addition to the CFA endarterectomy. I was under the impression that if it was one arteriotomy and one patch angioplasty you would use only one code (CFA, 35371). From what I can tell from his op note, only one arteriotomy was made and one patch angioplasty used. I guess my question is, when would it be appropriate to code separately for the endarterectomy with bypass and when would it be appropriate to code for more than just the CFA endarterectomy when the profunda and SFA are done as well?

We have physicians dictating that a coronary mechanical thrombectomy was performed using a Penumbra Cat Rx catheter. The department wishes to charge 92973 for the procedure. Would this be an appropriate charge? Or is the Penumbra Cat Rx catheter considered an aspiration catheter and the procedure is inherent?

Do radiologists need to wait for the path report results to dictate and bill code 76098 with an localization procedure?

Is the follow-up angiogram (75710) billable following PTFE graft aneurysm repair of the popliteal artery (35151)?

Our doctors are both billing for a bilateral lung transplant (32854-62), but the operative notes state that each did one lung, right and left. The specialties are the same. Is this sufficient to establish the medical necessity of a co-surgeon?

We are not sure if we can use 77001 for x-ray spot radiographic guidance. MDs are performing insertions and removals of tunneled catheters, ports under spot film x-ray radiographic guidance. They are not documenting fluoroscopic guidance, and there is an image saved after such procedures. Same goes with lumbar punctures.

Can we report code 37225 with the C9764 (Shockwave) in the ASC setting?

"Tag was deployed with x-ray guidance in right breast. Patient taken to operating room, and the tag was identified using Hologic reader. Dissection proceeded deep to the capsule, to the fascia of the pectoralis musculature. A 2 cm area of breast was excised with the Hologic capsule and sent for mammogram. Mammography of the surgical specimen verified tag and calcifications were biopsied."

I am questioning the tag deployment with x-ray guidance. I am thinking of reporting 19301 for the lumpectomy and 76098 for radiological examination of specimen. What are your thoughts?

Old answers (ID:14602 & 3515) to this question state to use 93799. However, the 2022 Z ref book pg 176 says that since non-cong. heart cath codes are in the parentheticals as not reportable with 93581 that may indicate the use of 93581 for percutaneous VSD closure of a post MI VSD. in this case should we code the heart cath and unlisted for the closure or just the closure that bundles the heart cath? Case: H/O MI; treated with PCI (3 stents); noted to have a ventricular septal rupture the next day and went into CHF.S/P surgical patch closure of the VSR/VSD. Pre: Moderate to large residual VSR/VSD at the superior margin of the previously placed VSD patch, minimal diameter 13-16mm. Right and left heart cath performed, LV angio done. 18mm occluder device placed. Post:Small residual shunt through the VSD device, no additional VSR/VSD is noted.

Coding to be used in IR for placement of a surgical marker in the thoracic spine. Patient is bariatric and needs the marker to be placed in IR prior to surgery. What would be the correct coding for this procedure in IR? It will be a separate encounter from the surgical procedure.

During a CABG procedure the atrial appendage is cannulated and then oversewn/ligated at the end of the procedure. Can code 33268 be billed in this case, or is this considered closure and therefore included in procedure?

"Tachy therapies were disabled before the surgery, and pacing was turned to VVI 40 mode. Parameters were returned to original values at the end of the procedure." This verbiage is often used in reports I'm reviewing, and I wanted to know if I am correct in not reporting 93286/93287. The CPT guidelines state there should be a report regarding certain elements of the device in addition to the adjustment that is done peri-operatively. There is usually some version of this in the reports I see. 

Ablation SVT substrate incl comp EP study (93653); ablation of add’l arrhythmia substrate x4 (+93655); left atrial/coronary sinus recording w/ pacing (incl in 93653); Med infusion w/ prog stim (+93623); 3D map (incl in 93653); intracardiac echo (+93662). During the procedure, another MD performs/bills a congenital RHC – Abnormal native connections, which found dilated coronary sinus with venous anatomy demonstrated for potential future procedure (93594).

Question: EP wants to bill 36012 for coronary sinus venogram stating that “venogram is not related at all to the EP study or ablation; it is formal diagnostic imaging to evaluate options for future defibrillator upgrade and should be billable other than the fact there aren't great codes for it.” Based on the documentation, it appears he performed the CSV during the RHC. What is the appropriate code for the CSV, if any?

I am inquiring to see if there have been any updates in regards to coding for an iFR and DFR. Should we still be coding 93571-52?

Can we get clarification on when/when not to use 0715T when a coronary lithotripsy is performed? The CPT Codebook states the following: "Use 0715T in conjunction with 92920, 92924, 92928, 92933, 92937, 92941, 92943, 92975."  It looks like it can be used for angioplasty, atherectomy, or stent placement. Can we also use it with drug-eluting stent placement?

Right CFA was treated with lithotripsy, and right SFA was treated with stent. Should this be coded C9764 and 37226 or just C9765?

Code C1898 is described as "lead, pacemaker" and is being billed/coded when using Tendril lead insertions with defibrillators per Abbott vendor C-Codes Coding Guide. Is C1898 limited to pacemaker leads and incorrect for defibrillator leads? Should C1896 or C1895 be used for these Tendril defibrillator leads instead of C1898 regardless of vendor guide?

"Hepatic infusion pump was accessed under fluoroscopic guidance. MAA infusion was given via hepatic pump. Diagnostic angiogram demonstrated existing hepatic arterial infusion pump within the appropriate position, contrast filling into the hepatic artery." Will this be reported with unlisted vascular injection code 36299?

A port was placed (36561), and once this procedure was completed, the patient started having arm pain and shortness of breath. Because of this, a rhythm strip was done. The rhythm strip demonstrated a new onset of complex tachycardia. The evaluation of the rhythm strip was located at the bottom of the port placement report. It is my understanding you can't code for rhythm strips that are done during the procedure. However, can you code for it once the procedure is completed? Also, if the interpretation of the rhythm is located on the same report as the procedure, can 93040 (rhythm ECG, 1-3 leads, with interpretation and report) be coded?

I know the vertebral body mass would be coded with 20225 and 77012. I’m not sure what code to use for the epidural space mass biopsy. Do I even get to code for both biopsies since they were done at the same level?

"CT probe was used to guide and select a percutaneous entry site for biopsy of portion of the right lateral aspect of the T9 vertebral body that is involved with tumor. This is the inferior aspect of the vertebral body. I also used CT guidance to select a percutaneous entry site for biopsy of the mass involving the right epidural space at T9. A 19 gauge outer cannula co-axial system was advanced into the epidural mass at T9, and multi core specimens were obtained. I removed the co-axial system. A co-axial system was then advanced into the inferior aspect of the vertebral body at T9, targeting the right lateral mid body. Multi core specimens were obtained. Successful biopsy of a mass involving the right epidural space at T9 and a successful biopsy of the mass involving the right T9 vertebral body."

What codes would we use to capture everything done during a pediatric cloacagram? These are performed for surgical planning and include a distal colostogram (74270?) performed by hand injection of Cysto-Conray via Foley catheter in mucus fistula. There is also a vaginogram via catheter placed in common opening. Also, they perform 3D cone beam CT acquisition of the contrast filled bladder, vagina, and distal colon with image post processing performed on a separate workstation. These are the codes we have so far: 51600, 74455, 74270, 76377, and 76380. Would you agree with these?

It looks like the update to billing iFRs has changed so that 93799 should be billed as opposed to 93571-52. Would this same process apply to the RFRs since they are similar, or would the recommendation still be to bill RFRs as 93571-52?

My providers always have this statement for 93623, and I am confused on if it's billable or not. This is done after the ablation. Usually with a PVI for Afib when no atrial flutter is ablated.

"Patient was then started on 5 mcg/min of IV Isuprel. Rapid atrial pacing protocols were then employed down to cycle length 250 ms but failed to induce any sustained typical atrial flutter. The Isuprel drip was then discontinued."

Is the 93623 billable in this case?

"The baseline rhythm was atrial flutter. A 3-D shell representing the left atrium and pulmonary veins was completed with FAM mapping. Octaray catheter was used to map each PV. There is noted partial reconnection of the left superior pulmonary vein by the ridge. Activation mapping of the atrial flutter demonstrated early meets late around the roof/ridge. A 3.5-mm irrigated tip ablation catheter was advanced into the left atrium. All 4 pulmonary veins were isolated with wide-area circumferential ablation. After reisolation of pulmonary veins along with roofline, there is noted ongoing atrial flutter therefore further ablation was performed to complete posterior box isolation with roofline and floor line. Due to ongoing atrial flutter, ablation was then performed in the mitral isthmus to create a line from the left inferior pulmonary vein to the mitral annulus which led to termination to sinus rhythm."

Provider coded 93656, 93657, 93655. Should this be 93653, 93655 x 2, and 93662-26 due to no Afib?

Does it matter how a patient is exercised when reporting 93464 during a heart cath? The report I am currently reviewing documents, "With lower extremity exercise, left ventricular end-diastolic pressure remained fixed at 28 mmHg." That is the only place exercise is mentioned. Is this sufficient to bill for 93464?

If the surgeon treated multiple atrial flutters ablation with clear documentation, do I need to apply modifier -XU/-59 to 93655 for each ablation?

In this case would the posterior wall isolation be coded as a second arrhythmia as dictated (93657), or is it part of the PVI (93656)? 

"...showed full isolation...of the pulmonary veins. Then he mapped the posterior wall and found patchy scar and ablated."

Procedure: Ablation of arrhythmia - Pulmonary Vein Isolation procedure

Ablation of second arrhythmia focus - posterior wall isolation

Important portion of procedure pertinent to my question on selective catheter placement: "The wire was advanced centrally. The catheter was advanced into the abdominal aorta. The celiac artery was selected. The 5 French catheter was advanced to the proper hepatic artery. A microcatheter was inserted through the 5 French catheter. The right hepatic artery was selected. The posterior division of the right hepatic artery was selected inadvertently in an attempt to select the middle hepatic artery. The subsequent arteriogram at confirmed access of the posterior division. There was no tumoral enhancement on delayed imaging. The microcatheter was retracted. The segment 8 branch of the middle hepatic artery was selected. (embolization then performed)."

The provider coded this as 36245, 36246, 36247, and 36248. I believe it should be 36245, 36247, and 36248. Which of us is correct? Also, the provider performed a post embolization nuclear medicine study (78201) three hours later to check on the middle hepatic artery. Is that a billable test?

How would you report the following scenario for CT surgeon, IC, and vascular surgeon? The CT surgeon and the IC performed the TAVR through percutaneous femoral approach. Afterward, according to vascular op note, the patient had lack of pulses and signals in bilateral groins, so the vascular surgeon was called into the room. The vascular surgeon prepped the patient and made incisions into both groins, exposed the CFAs, removed previous Proglides, and performed bilateral CFA endarterectomies (35371-50), stented the left EIA (37221), and performed separate arteriotomy for endarterectomy of left SFA with patch (35302). For the TAVR, would you use the femoral exposure code 33362 for CT surgeon and IC? For the vascular surgeon, since both femorals were exposed, would you use modifier -52 for 35371-RT (TAVR side), 35371-LT, 37221, and 35302? Not sure how to code vascular part when they did the femoral exposure with other procedures after the TAVR. These were all done in one session but with different anesthesia.

We would like guidance coding pericapsular nerve group (PENG) post-op pain blocks that meet criteria for coding separately from surgical anesthesia. Per National Library of Medicine (NIH), PENG block is a regional analgesia technique to reduce pain after total hip arthroplasties while sparing motor function. Technique involves the deposition of local anesthetic in the fascial plane between the psoas muscle and superior pubic ramus. This is an interfascial plane block aiming to block articular branches supplied by femoral, obturator, and accessory obturator nerves as an alternative to other regional nerve blocks such as femoral nerve block or iliac fascia nerve block.

Since no nerve is specifically named in the descriptor, would we code a PENG block to 64450? Or, considering PENG is an interfascial plane block, should we report code 64999 similar to an IPACK block?

https://www.ncbi.nlm.nih.gov/b...

CPTA, Jun 20 p14: iPack block, correct reporting

Coding Clinic for HCPCS 4Q 2019 p10: iPack nerve block

CPTA Jul 22 p13: Nerve block clarification

Is it appropriate to bill for both open brachial and open femoral artery exposure (34834-RT and 34812-RT) when they are used to perform a body-floss technique to deploy a fenestrated aortic endograft (34848)?

For the following, do we use the 48999, 49423, and 74984?

"Patient has peripancreatic necrosis and has a drainage and catheter placed. Now they are changing out the catheter and debriding necrotic tissue under fluoro and endoscopic guidance. PROCEDURE: Contrast was injected through both catheters to opacify the collection. Visualized using fluoro. Catheters removed over guidewires; 30 French X-Force sheaths placed with safety wires. Rigid nephroscope advanced through both sheaths to visualize the cavity. Cavity was debrided with forceps and stone retrieval baskets through both sheaths. 22 French drainage catheters were advanced through the sheaths and used to vigorously lavage the cavity with saline, removing copious solid debris. Sheaths were removed, and two new 22 French drainage catheters were placed and sutured. Catheters were connected to bag drainage. Successful fluoroscopically and endoscopically guided percutaneous debridement and lavage of peripancreatic collection."

Code 33286 states "removal". If the provider inactivates the ILR, but does not remove, can we report code 33286? I don't believe we should; however, I'm unable to find any guidance. "Linq has been inactivated." Please advise.

37213 - ... continued treatment on subsequent day during course of thrombolytic therapy, including follow-up catheter contrast injection, position change, or exchange, when performed.

Would this include 75710 of the same extremity that the catheter is in? Is that what contrast injection stands for?

What is the appropriate way to code the following? Breast or lymph node biopsy?

"36-year-old with biopsy proven right breast upper outer quadrant malig presents for US-guided biopsy of enlarged lymph node ant to malig, as seen on MRI, and for axillary tail lymph node as requested by referring physician. Informed consent was signed. After sterile prep and 1% lido the lymph node in the outer right breast 9:00 pos was initially localized for biopsy. Four passes were made through the lymph node. All samples sent to path for analysis. Hanger shaped clip was deployed. Subsequently right axillary tail lymph node was localized for biopsy. AGAIN using sterile tech and 1% lido a 16 gauge Bard needle was utilized for biopsy. Two passes were made through the lymph node. Samples sent to path for analysis. Twirl shaped clip was deployed. Successful US-guided biopsy of lymph node outer right breast @ 9:00 pos and also right axillary tail lymph node, both negative for atypia/malignancy."

"The left radial to perforator arteriovenous fistula is patent.  There is early filling of the brachial vein. selection of the AV anastomosis and drug coated balloon angioplasty of the AV anastomosis and the perforator vein was done, Volume flows demonstrated adequate flow in the perforator vein and decreased insufficient flow in the cephalic vein.  Decision was made to coil the brachial veins-multiple Nester coils were deployed in brachial vein. Decision was to band the distal basilic vein.  0.018 wire was advanced into the basilic vein.  Over the wire, 2 mm balloon was inflated. silk suture used to band basilic vein."

Would this px be revision? 36832- angioplasty of the arteriovenous anastomosis, coiling of the brachial vein, and banding of the basilic vein were done.

Site: Left face cystic-appearing collection of material in the vicinity of the mandible.

Needle: 20 gauge and 18 gauge needles.

Samples: 2 passes.

Specimen: Approximately 10 mL of thick whitish fluid.

Specimens were sent both for cytology as well as microbiology.

Impression: Ultrasound-guided aspiration of a cystic mass-like collection of material in the left face near the mandible. Aspirated fluid was sent for cytologic and microbiologic analysis

Non-GYN Diagnosis - Result:

A. Left facial mass, fine needle aspiration:

- Atypical squamous cells and numerous acute inflammatory cells present.

There is hesitation to report FNA code 10005 for this, as a fine needle wasn't used and therefore CPT 10160 is suggested; however, this isn't an aspiration of an abscess, hematoma, bulla, or cyst. Should it be reported with code 20206 when it's not collected with a fine size needle?

Should I report code 35301 -53, or just the neck exploration with node excision?

"Dissection carried down through subq tissue and platysma to the level of the internal jugular vein with cautery. Facial vein was then identified and ligated with 2-0 silk ties proximally and distally along with medium clips; vein was transected with Metzenbaum scissors. Large reactive lymph node was noted overlying the ICA and mobilized and transected. It were passed off the field to be sent to path. Additional smaller veins were ligated distally with 3-0 silk and small clips. Internal jugular was then reflected laterally. Common carotid was then visualized & dissected circumferentially; red vessel loop was used to encircle. The internal, external, and the superior thyroid arteries identified and controlled with vessel loops. After dissection of the ICA, it was palpated gently and lesion was noted to be high. Maneuvers for more distal exposure were performed such as mobilizing the hypoglossal nerve, taking down part digastric muscle & ligating associated veins. Lesion still to high, proc aborted." 

Our facility is beginning to perform ablations as part of a study called the Admire study in conjunction with BioSense Webster. I am hearing conflicting information on how to report these procedures. Would it be correct to code these as 93656, or would an unlisted CPT code be more appropriate? We'd appreciate any guidance as we begin to navigate through these. 

Our physician performed open thrombectomy of the mesenteric vein. I am planning to code as unlisted (37799), but we need to submit a fee. What is a comparable procedure to use for pricing?

How would the following be coded? With 62329?

"IR FLUORO NEEDLE/LUMBAR/OPENING PRESSURE. Procedure: Patient was placed left lateral decubitus on the interventional table. Under fluoroscopy, a left paramedian approach to the L4-5 interlaminar space was selected and the overlying skin anesthetized with several mL of 1% lidocaine. A 20 gauge Sprotte needle was advanced under fluoroscopic vision into the thecal sac with return of clear CSF. The opening pressure was measured at 15 cm water. 12 mL of CSF was collected in four aliquots and sent to the clinical laboratory for testing per the referring physician's specifications. The needle was removed and a bandage placed. The patient tolerated the procedure well without immediate complication. Fluoro Time: 1.3 minutes Findings: Stored fluoroscopic images show the needle positioned with its tip in the spinal canal at the level of L4-5. Impression: Successful lumbar puncture for CSF analysis, as detailed above. [Opening pressure: 15 cm water.]"

No permanent image saved noted. How would you code the following?

"US GUIDANCE MAJOR JOINT ASPIRATION AND/OR INJECTION. Procedure: The risks and benefits of the procedure including infection, bleeding and technical failure were discussed with the patient, who agreed to proceed. The patient was positioned supine on the ultrasound table. Time out was performed. The right hip joint was localized using live ultrasound guidance, and the location on the skin for needle insertion was marked. Pre-procedural scanning demonstrated dysplastic appearing right femoral head. The region was prepped and draped using sterile technique. Approximately 5 cc of lidocaine was injected for local anesthesia. A 23 gauge spinal needle was inserted into the right hip joint utilizing live ultrasound guidance. 2 cc of 6 mg/cc betamethasone and 2 cc of 0.5% Ropivacaine was injected. Pre-procedural pain level was 4/10 and post-procedural pain level was 0/10. IMPRESSION: Successful ultrasound guided anesthetic and steroid injection of the right hip joint."

"Moderate sedation was provided by nursing under cardiac monitoring during 44 minutes. Versed 1.5 mg IV, Fentanyl 100 mcg IV, Levaquin 500 mg IV. Description: Maximal sterile barrier and technique were utilized. Time out performed. Patient prone. Lidocaine 1% was delivered around the existing left PCN. Antegrade nephrostogram was performed. Large pelvis stones. Non dilated ureter and good contrast flow to bladder. The PCN was cut and wired. Exchange with a 8F x 23 sheath. The wire was manipulated to pass around the UPJ large stone down to the ureter, into the bladder. Antegrade nephrostogram confirmed appropriate position. The sheath was sutured and bandage was applied on the looped wire. No complications. Impression: Pre-op PCNL as above."

Would above be considered a conversion, and would you use 50434?

Is code 32561 appropriate for this case? If not, what code do you suggest?

"TITLE: Insertion of 4 mg tPA into left clogged pleural catheter.

DIAGNOSIS: Metastatic breast cancer with mets and malignant pleural effusions.

INDICATION: Worsening shortness of breath.

PROCEDURE IN DETAIL: The procedure was done in the clinic room, and radiographs reviewed prior to procedure. Patient was placed in the sitting position. The left hemithorax revealed aerated lung with moderate collection of pleural fluid confirmed by personal ultrasound done in the examining room. The pleural cath was visualized in the pocket of pleural fluid. Site uncovered, no evidence of erythema, fluctulence, or tenderness. Pleural cath was connected to the 5-in-1 adapter. 10 ml normal saline was flushed with mild resistance, followed by insertion of 4 mg tPA in 5 ml sterile water. The pleural cath was again flushed with 10 cc of saline without significant resistance. No complications.

DISPOSITION: Patient remained in stable condition and will drain IPC at home in two hours."

How would you code this? The office wants 37607 (ligation of angioaccess of AV fistula), but the description of that code says of a created AV Fistula, and on this surgery it is not surgically created. Would this be unlisted code?

DX: Acquired AV fistula, not surgically created (HCC) [I77.0]

Procedure(s):

LIGATION, AV FISTULA RIGHT WRIST - Wound Class: Clean

An incision was made over the left radial artery. We traced up and down the artery and found a connection between the radial artery and radial vein. This led to multiple branches. We went around the fistula and all the branches as well using a right angle and tied it off with a 4-0 silk. The fistula was also tied off with 2 4-0 silk sutures. We were unable to palpate the thrill and she had an excellent radial pulse. Satisfied with this we irrigated the wound and closed it in multiple layers.

We have a patient who underwent a repair of a thoracoabdominal aneurysm. Two physicians were co-surgeons, then a third came in and did the closure, although it is not said why. Is this billable, and if so, would this be just an intermediate closure of trunk wound? The doctor thinks it is 49900, but I disagree since it was on the same day as the repair and not with any evisceration or dehiscence.

I have a physician who would like to plasty AV graft mild stenosis and wants to bill for it. Rad states that this is his medical necessity: “A mild grade stenosis is present which could become severe and cause further complications if not treated at this time. For this reason, I believe it is medically necessary to treat the stenosis with angioplasty.” I am telling rad this is prophylactic and cannot be billed. Am I correct? Should he just be doing US until he does have a 50%> stenosis? 

What catheter and imaging codes would you use for the following? Code 36226 doesn't seem appropriate since the catheter wasn't in the vertebral artery, and code 75710 doesn't apply since there are no findings for the subclavian.

"Through the sheath, a 4 French catheter was navigated over a guidewire into the following vessels: right common carotid artery, right internal carotid artery, right subclavian artery (adjacent to the right vertebral artery origin), and left common carotid artery.

Right subclavian artery: There is a stent seen in the right vertebral artery origin with no evidence of residual or recurrent stenosis within the stent or narrowing within the remainder of the right vertebral artery. The basilar artery and its branches are well visualized and normal in appearance. There is no posterior circulation, vascular anomaly, or stenosis."

I work on the hospital side, but I'm interested in how both the hospital and the physician side should code for this. My doctors are performing something that looks very similar to an Angiovac, except this device is called a Alphavac, and guidance from the manufacture for this device is saying this should be billed out as 37187.

"Procedure detail: AlphaVac vacuum-assisted debulking of the right atrial mass/thrombus. Technique: Under fluoroscopic guidance in the angiolab, a 25 French Alphavac multi-purpose mechanical aspiration cannula was advanced into the right atrium where the cannula was angled to engage the mobile mass/thrombus and approximately 90% decrease in the size of the mass/thrombus was confirmed on intracardiac echo."

Should we bill 36013 and 37187 (not sure if I can bill for the intracardiac echo here), or should I bill for 0644T? 

Would you consider this a bridging lesion and only code as C9600-LD (hospital coding)?

"Distal LM on IVUS was an eccentric calcific plaque 60-65% extended into the ostial LAD. LAD is heavily calcified throughout the proximal to mid segment with diffuse 80% stenosis in the mid segment; proximal vessel has diffuse 50-60% stenosis. Procedure: We deployed a 3.0 x 38 mm stent from the proximal to mid LAD was post dilated with a 3.0 non-compliant balloon in the distal segment and 4.0 non-compliant balloon in the proximal segment. We performed IVUS. There was residual disease in the ostial LAD extending into the LM. We treated that with an overlapping 3.5 x 8 Xience drug-eluting stent from the ostial LAD into the distal LM."