Ask Dr. Z

1) Vein graft to marginal branch of circumflex

2) Vein graft to 1st diagonal of LAD

3) Vein graft to RC

4) Vein segment going to the marginal branch was anastomosed end-to side fashion to the graft going to the diagonal.

5) Artery to LAD

The #4 section has me question if this would be three vein grafts (33519) or four (33521)? It sounds like he connected the #1 and #2 grafts.

What CPT code can I use to capture a left bundle lead with biventricular ICD generator upgrade, not a bundle of His lead? Code 33264 can be used to capture the generator change. Dual ICD generator upgrade with existing RA/RV leads and implant of LB lead with new biventricular ICD generator.

"The prior RA and RV leads were tested and found to have adequate capture and sensing function. A new lead was placed, the left axillary vein was accessed using the seldinger technique. Through a 7 French sheath and using a C315HIS preformed catheter a Medtronic 3830 lead was advanced to the RV septum in the area of the His bundle. A His bundle potential was mapped. The lead was advanced and moved slightly infereriorly. The lead was screwed into the septum, pacing from this lead did not produce a narrow QRS with iRBBB morphology. A number of sites on the septum were tried with a final site showing adequate pacing and sensing thresholds, a fairly narrow paced QRS and stim to peak LV activation of less than 80ms. BiV pacing from this site and the RV produced a very narrow QRS."

I'm having trouble deciding how to code this. "Patient came in with biventricular pacemaker with an infected pocket. All three leads and generator were removed. New lead was inserted into right ventricle via right internal jugular. Old generator was cleaned, attached to new lead, and sutured to neck to be used as a temporary pacemaker."  Can you please help?

Indications: Syncope and sinus pauses for cardiac ablation. Do you suggest 93656 and 64620 for the destruction of nerves within the autonomic nervous system with radiofrequency or unlisted?

"Fractionated electrograms in the anatomical areas of the ganglionated plexi (superior-anterior to the superior pulmonary veins, anterior ridge between the left pulmonary veins and the appendage and inferior posterior to the inferior pulmonary veins) were tagged for ablation. Radiofrequency current (40 watts) was delivered through the 4 mm-tip electrode catheter using two adhesive conductive pads positioned over the left posterior chest for the return electrode. Multiple RF applications were delivered to the anatomical areas of the ganglionated plexi with some automaticity elicited and rare transient decrease in the sinus CL but no pauses. Additional ablation lesions were delivered to tagged areas in the posterior SVC corresponding to the ablation site in front of the right superior pulmonary vein."

Can you give clarification for billing codes 37220-37230 for angioplasty/stent with thrombolysis (overnight lysis) when treating thromboembolic occlusion? I'd like to give my physicians some clear instructions for documentation guidelines on these interventions, and I have seen conflicting information and even some instruction that you cannot bill any intervention with thrombolysis since that is not for stenosis. Must there be the specific word "stenosis" used to bill for interventions with thrombolysis? What if just "occlusion" is used? Physicians use stenosis/occlusion interchangeably. If stenosis is not stated and they are treating thrombosis or thromboembolic occlusion, can intervention be billed with 37236-37246? Or do they just get nothing? 

Need help with codes... should I bill code 32480 (lobectomy) and 32488 (completion pneumonectomy) (modifier -51) or just use 32440 for pneumonectomy? Also plan on using CPT code 38746 for lymph node sampling.

PROCEDURE(S) PERFORMED: Robot converted to open thoracotomy. Left upper lobectomy, completion pneumonectomy. Mediastinal lymph node sampling. Lysis of adhesions.

How would you code a VenoValve placement? I would think it is either 37238 or an unlisted code, but the doctor thinks it is 37226. The reps also say to use 37224, which I know that is incorrect because that is arterial and the VenoValve goes into the vein. Of note, the patients who are getting this valve are enrolled in a research trial. 

Is it correct to report codes 37184 and 37185 if a thrombectomy of the right pulmonary artery and the truncus anterior and interlobal pulmonary artery is performed?

Is it appropriate to report code 50200 x2 if a radiologist performs multiple core biopsies on multiple lesions of one kidney? I know the CT guidance can only be used x1.

Since 33222 requires relocation, what would be the appropriate (facility) code for this case? 

"The pocket was opened and carried to the device. The device was freed from the capsule. Visual inspection confirmed that the previous lead cap was pushing through at the base of the pocket towards the outside. We removed that. We created a space for this underneath a very thick capsule of remnant of an Aegis pouch. We recapped the lead and buried it there and reinforced that with Ethibond. Wound irrigation was done with antibiotic flush. We then put the device back into the same pocket and closed that with a deep layer of 0 Vicryl followed by a superficial layer of 4-0 monocryl."

What CPT codes and modifiers would you report for HM3 LVAD insertion with closure the next day? Chest left temporarily open to protect RV function and hemostasis. They did a mediastinal exploration, washout, and open reduction and internal fixation of sternum using titanium plates.

My physician did a thoracotomy and excision of a descending aortic mass with an aortotomy. I'm not sure what CPT code this would be. Could I use a repair of a blood vessel code?

Patient received a treatment with mCi iodine-131 orally. One week later whole body with SPECT/CT imaging is performed. Are we allowed to code for 79005 separately, or is it integral to nuclear medicine imaging procedures subsequently performed a week later? Are codes 78018 and 78830 correct for the NM imaging?

"EXAMINATION: NM THYROID ABLATION TREATMENT

ASSOCIATED DIAGNOSIS: Papillary thyroid carcinoma

TECHNIQUE: The patient was treated with 102.5 mCi I-131 sodium iodide orally without immediate complication. 1 week later, delayed anterior and posterior whole body imaging from the vertex of the skull to the upper thigh was performed. Additional spot views of the neck with and without markers were also obtained.

FINDINGS: Planar whole body scan demonstrates an area of focal asymmetric iodine uptake in the right central neck compartment, which on SPECT/CT imaging corresponds to a small iodine-avid soft-tissue nodule in the right tracheoesophageal groove at the level of the thyroid bed consistent with postsurgical thyroid tissue remnant...."

When coding 75710, is the -RT or -LT modifier required ? I have an outside company reviewing charges, and they are requiring the laterality modifier.

We have a stroke patient who had a left internal carotid injection for diagnostic angiogram. Following that the physician placed a Sofia catheter to try to aspirate clot from MCA, but had to abort the procedure. 

Documentation states: "Multiple attempts were made to cross occluded M1 segment of proximal left middle cerebral artery using microwire and microcatheter without any success due to very calcified lesion likely subacute or chronic occlusion. Unfortunately, I was not able to advance intermediate catheter to M1 segment of left middle cerebral artery for direct suction due to very tortuous vascular anatomy, and the procedure was aborted."

Would you only code the diagnostic angiogram, or would you also add the attempted thrombectomy with a -74 modifier to account for the extra work?

A clamshell incision for chest and mediastinal exploration (bilateral anterolateral thoracotomy with transverse sternotomy) and intrapericardial pneumonectomy with resection of large tumor mass are performed along with bilateral explant and reimplant of breast prosthesis because of where the anterolateral incision had to be made for exposure. Are the explant/reimplant of breast prosthesis procedures separately billable, or are they bundled into the mediastinal exploration with intrapericardial pneumonectomy procedures?

"Due to size of tumor and extension into mediastinum, clamshell incision was performed. The breast prosthesis pocket was extended and was actually opened bilaterally because of where the anterolateral incision had to be made for exposure. Pocket was opened, and breast prosthesis was removed and re-implanted at the end of the clamshell incision for left chest and mediastinal exploration (bilateral anterolateral thoracotomy with transverse sternotomy) and intrapericardial pneumonectomy with resection of large tumor mass procedures."

Would it be appropriate to bill for a pocket relocation in this scenario?

"Initially a 4 cm incision along the left deltopectoral over the prior incision was made along with electrocautery and blunt dissection, but it was noted that the device had migrated significantly inferiorly and laterally. The device was unable to be reached via this incision. This incision was sewn in three layers. Next fluoroscopy was used to locate the device more accurately. A second incision was made inferior to the first, and using blunt and electrocautery dissection the pacemaker was removed from the pocket floor. The leads were removed from pacemaker generator inserted into the new generator."

If embolization of a carotid body tumor was performed without diagnostic angiography (previous recent diagnostic study), how would the selective catheterizations used for embolization be reported? We've been told to use the diagnostic codes 36222-36228 with a -52 modifier to indicate that the angiography wasn't performed. We don't agree, and feel the 36215-36218 codes should be used. Which is correct? Are there guidelines from AMA or CMS regarding cerebral catheter placement without diagnostic angiography? 

Are we still to use unlisted code 64999 for erector spinae blocks? I have seen them reported with the unlisted code and as paravertebral blocks, but I can't find any recent official guidance.

Five-vessel CABG performed with modified Maze. Left atrial appendage was ligated using a AtriClip. Can code 33268 be submitted with 33533, 33521, 33257, 33508? Is the atrial ligation included in the modified Maze? Patient has paroxysmal Afib.

Our hospital is looking to start performing FUS for treatment of tremors/Parkinson's disease, and we are trying to figure out logistics for the coding/billing.

Who would code for the FUS if:

• Neurosurgery puts the cage on patient's head
• Neuroradiology provides MRI guidance/reads the MRI location
• Neurology performs the focused ultrasound?

I assume the guidance is included in 0398T? So the neuroradiologist wouldn't get to bill anything? Would this be considered an assistant modifier -82?

"We have a TAVR performed via transfemoral approach that was completed, but after the delivery system was removed, the soft wire was put back in when we noticed the valve had embolized into the ventricle. This was not causing significant ectopy. We then placed a pigtail in to keep the valve from obstructing while the surgical team was preparing for open surgery. Patient's vitals and blood pressures remained good throughout the case. The large E sheath will be removed, and the artery will be sutured using the preclosed devices. The 5 French arterial sheath and an 8 French venous sheath were left in place. They will be removed at the end of the surgical case. Please see Dr. K note for full details." In this case would you report code 33361, as the TAVR was fully completed and then a complication was noted, or would you report code 33361 with a modifier (-52 or -53) since there was a complication?

I have denials for 93571 as the the pharmacologically induced stress in not included in the report, so a -52 should be added to the code. My doctors responded to my question to them about are they performing the induced stress with this answer.

"The new device the adenosine is not needed. Pharmacologically induced stress is no longer required or needed with the newer measurements of coronary flow such as DFR and iFR, as they are not dependent on maximal hyperemia. Almost the same degree of work is involved as in measurement of FFR, as you have to place a guide catheter into the coronary artery and then advance flow wire across lesion and take measurements of DFR or iFR."

Is there a better code or alternate for these measurements since they don't have to do the stress part?

Is there a CPT code for exchange of malfunctioning nephrostomy tube drainage bag, or this part of the maintenance of the nephrostomy? There was no contrast injected only the exchange of drainage bag.

In a previous question, you responded that anything beyond the right or left pulmonary artery would be considered segmental/subsegmental, and therefore, 36015 should be used. Do you consider the right and left interlober arteries to be "beyond" the right and left pulmonary arteries?

My physicians frequently perform Flowtriever thrombectomies from the bilateral interlober arteries, and it's causing some confusion if we should use 36014 or 36015.

In an OBL (place of service 11) when an injection for extremity pseudoaneurysm is performed (36002), can you also code for the thrombin used, or is it bundled into 36002? When I checked what is included in the Practice Expense for 36002, thrombin was not included. Also, is J3490 the correct code for thrombin?

Accessing the patient from the tibial vessels. Example: Dorsalis pedis and going up to the Iliac vessels taking pictures on the way up. What selective catheter placements can be coded when no intervention is done? If selective catheter placement cannot be billed, please give me rationale as to why not and what you would code?

My provider states that he opened the pacemaker and the generator and leads were just subdermal with threatened erosion. The pacemaker leads and pocket had extensive calcification and the leads were coiled on top of the generator. With extreme difficulty the generator was removed from the pocket and leads dissected away from scar tissue. The leads were dissected away from the fat and the pocket was then made down to the prepectoral fascia. The leads were then followed to the muscle and secured. Leads tested functioning normal. Scar tissue was removed from pocket. New generated inserted. He is wanting to bill a 33215, 33222, and 33228. I know that he cannot bill 33215 for moving leads around within the pocket. Also, basically the pocket was made deeper and not moved. Would just billing the generator change 33228 be correct with perhaps a -22 modifier for the extra work for the pocket revision?

One of our physicians attempted to implant a leadless PPM with resultant cardiac perforation/tamponade. Leadless PPM was removed. Pericardial drain was placed (33017). After patient was stable, a tranvenous PPM with dual leads was placed (33208).

Would it be appropriate to code for the removal of the leadless PPM 33275 or insert of the device 33274 with modifier -74? Here are the codes I was thinking: 33275, 33017, 33208.

If the doctor performs an angioplasty in the 1st diagonal branch and places a stent in the 2nd diagonal branch, would you code it as 92928-LD and 92921-LD?

I just wanted to confirm that we can only report 33315 in addition to the codes listed under the parenthetical list. In the example where a valve replacement or CABG is performed at the same time as the 33315, we would NOT be able to separately bill because the service CPT codes are not in the list, correct?

"Treatment is: R&L - L3, L4 & L5 - medial branch neurotomy. The L5 posterior ramus was lesioned at the junction of the sacral ala & root of the superior articular process of S1. RF curved probe was placed under fluoroscopic guidance. Impedances were appropriate & sensory testing c/w proximity to medial branch nerves. Testing was carried out to check proximity of probe to motor nerve and all were negative. The patient was then exposed to 1, 90 thermal RF @ 80 C. In order to treat the involved (2) levels L3-L4 & L4-L5 it was necessary to address each of the following three lumbar medial branch nerves: L3, L4, & L5." 

Can you resolve a debate? Some of us coded this as: 64635-50, 64636 & 64636-XS. Others coded it as: 64635-50 & 64636 x4. Please indicate the correct coding and if -KX modifier is required.

A gallbladder drain was placed and then brought back the same day, due to malposition of the existing catheter. The catheter was cut and removed, then a new drain was placed via separate access. Can this be coded as an exchange with 47536 or removal 47537?

Axillary artery dissected free, isolated w/ Vesseloops. RT groin, longitudinal incision to inguinal ligament. CFA w/o pulse. LT groin, longitudinal incision, dissection to inguinal ligament. PFA felt better target vessel, crossing vein divided,2-0 silk ties placed. Distal exposed aspect of PFA isolated w/ vessel loop. Vesseloops placed on CFA & SFA. Gore axillary bifem bypass graft tunneled from RT groin to RT subclavian incision. Crossover portion of bypass graft tunneled between groin incisions. Anastomosis to axillary artery performed. Vesseloops secured, arteriotomy made in RT axillary artery. Graft artery anastomosis sewn. Vesseloops secured on RT CFA, PFA & SFA. Arteriotomy made in distal RT CFA. Graft artery anastomosis sewn. Attention placed to LT groin. Vesseloops secured. Arteriotomy made in distal LT CFA into PFA. Heavy calcified plaque in PFA & CFA. CFA & PFA endarterectomy performed using freer elevator to gain an opening to allow for anastomosis.. Graft sewn to distal CFA & proximal LT PFA. Provider coded 35654, 35371, 35372.

We are going back and forth on a case, and I'm hoping you can help.

"Patient has an existing single lead pacemaker with RA lead and comes in with a plan to add RV and LV leads and upgrade the generator to an ICD biventricular. They removed the old generator and added the RV lead easily, but after multiple attempts they could not get the LV lead to engage. They ended up removing the attempted LV lead and just hooking the RA and RV leads to the new ICD generator. The plan is to address the LV at a future date."

Would you report 33225-74 with codes 33249 and 33233, or just leave it off since the LV lead was not placed in the end?

For hospital billing, is the fem/pop area considered one area for IVL? How would the following scenario be coded? "IVL in the 70% calcific stenosis of the distal right common femoral artery and atherectomy/PTA in the 95% calcific stenosis of the distal right superficial femoral artery." Would the hospital report C9766 for this procedure or C9764 and 37225? 

Provider #1 opened the left subclavian pocket and removed the pacemaker generator, untangled leads, and enlarged pocket to accommodate new pacemaker generator and leads. Provider #1 than assisted Provider #2 with laser lead extraction and implantation of the new generator. Each provider dictated separate reports with details of their portion of the procedure noting the other provider as assistant or lead. This is not a teaching facility, and I only code for Provider #1 and do not know how Provider #2 is coding. Would Provider #1 only code for the generator removal (33233)? Or how should they be coding these scenarios when they remove the generator and then act as an assist to the lead removal and placement of new generator and leads?

Would this be considered just an embolization? Never seen CARTO before.

"A 5 French angled catheter/glidewire combo was subsequently used to select the left renal vein and the gastrorenal shunt. Over a J-tip wire, vascular sheath with gently advanced into the gastrorenal shunt. Exchange was subsequently made for two 4 French Navicross catheters, with one positioned deep within the gastrorenal shunt and the second positioned within the proximal gastrorenal shunt near the left renal vein. A venogram was performed demonstrating a large patent gastrorenal shunt. Following that, the gastrorenal shunt was subsequently coiled with six 0.35 detachable coils (Azur, three 13 x 240 mm coils, three 16 x 320 mm coils). Approximately 13 mL of Gelfoam slurry was gently administered into the second Navicross catheter until there was opacification of the gastric varices up to the level of the GE junction. IMPRESSION: CARTO of gastric varices."

How would you code a carotid cutdown done on conjunction with stent placement (33745)?

1. Is 77263 applicable (when documented) for the IR physician acting as the sole authorized user (AU) during the Y90 treatment course if a medical physicist (not an AU or MD) performs the dosimetry calculations (77300) but the IR physician (AU) administers the Y90 on treatment day?

2. Why does Coding Strategies Navigator recommend 77263 for reporting Y90 treatment planning? What do you recommend we look for in the documentation to choose a treatment planning CPT code?

3. What is the best resource to learn more about treatment planning codes (77261-77263) & dosimetry calculation code (77300) documentation requirements & application?

Normally when I read Y90 reports there is one access (right common femoral artery) and one treatment area (right or left hepatic artery) and one block prior to Y90 treatment encounter. Based on the Optum encoder lay description that seems to better suite simple treatment planning.

"Procedure was aborted due to patient noncompliance and pain. The left radial was accessed and 4 French glide sheath was advanced over the wire without difficulty. With the glide sheath in place the patient complained of tenderness over the wrist area and pain in the elbow area. A 5 French JL3.5 diagnostic catheter was advanced without any difficulty into the ascending aorta. However, the patient continued to complain of increasing pain in her elbow, shoulder and forearm. For patient's safety due to her pain and her uncooperative it was decided to abort the procedure. Patient had moderate sedation." Would I code 93458-53, 93458-74, 93454-53, 93454-74, or for the aorta catheterization 36200-53, 36200-74?

I have received a couple of Medicare denials for 93922 stating MUE procedures cannot be done in the same day/setting as 93880. However I am having difficult finding this information from Medicare. I did not see anything reference in my Dr. Z reference book. Could you please point me in the right direction? 

Anthem has a payer-specific edit bundling 36200 with 34713. Do you think an unbundling modifier may be added to 36200 or allow it as bundled?

"CFA was accessed with micropuncture kit under ultrasound guidance. Microsheath was upsized to 5 French sheath. Right groin access site was preclosed with ProGlide x2, and 5 French sheath was upsized to 9 French sheath. Pigtail catheter was advanced into the ascending aorta, and it was connected to the power injector. The patient was moderately heparinized with 3000 units of heparin. Right groin 9 French sheath was upsized to 20 French Gore DrySeal sheath over stiff wire. Gore C-Tag 28 mm x 10 cm endograft was deployed just distal to the left subclavian artery. Completion angiogram showed successful exclusion of the aortic pseudoaneurysm. The sheaths were retracted from the groin. Right groin access was closed by completing the deployment of ProGlides. Left groin access was controlled with manual pressure. Sterile dressing was applied to bilateral groins. Patient tolerated procedure well."

Patient is undergoing a cardiac stent while under cardiopulmonary bypass. The cardiologist performs his own access in the left femoral, does IVUS, and places the stent. The CV surgeon does a right femoral cutdown and places the patient on cardiopulmonary bypass. Once the procedure is complete he takes the patient off bypass and repairs the vessel. Is there anything the CV surgeon can bill for in this procedure?

Would thrombectomy of an AV fistula and stenting in the peripheral zone of the graft be considered thrombectomy with revision (36833) or thrombectomy without revision (36831)?

Can you please clarify whether it is appropriate to pick up TEE with TAVRs or Watchman procedures in PCS? We pick up code 93355 in CPT, but there is no specific guidance in PCS.

"A Baylis needle and created a 3D geometry and activation of the left atrial while in tachycardia this was a very meticulous procedure since arrhythmia will terminate by catheter manipulation we had to reinduce over and over the earliest activation was in the anteroseptal portion but we could not get pre P wave activation we then change attention to the right atrium and using a great catheter at the same catheter used to map the left side we mapped the right atrial activation again in the very meticulous way the earliest activation was just above and behind the His bundle area this area had a significant amount of complex fractionation. Atrial tachycardia induced and map to the right atrial septum just behind the His bundle. Successful atrial tachycardia ablation."

We are thinking of reporting code 93656. Would you agree?

Based on a prior question "Angiograms for large bore access" Question ID 12066 from 2/21/19, we should not charge for the iliofemoral angiography since it was for guidance. Our follow up question is can we code the selective catheter placement into the common iliac arteries (36245-50)? Here is the report: LHC w/o LV study. Coronary angiogram. Selective bilateral CIA angiography with r/o to bilateral CFA bifurcations. This was performed via right radial artery access...A selective RCIA and LCIA angiography with runoff to the bilateral CFA bifurcations was performed. Findings: Severe multi-vessel CAD...the arteries in the bilateral iliofemoral systems are of adequate caliber to accommodate large-bore access. The bifurcations of the bilateral common femoral arteries are above the inferior border of the femoral head; conducive to large-bore access." Thank you!

I looked back into the archives and want to make sure this is the correct/current information. Physician is doing a tunnel catheter replacement. He says the balloon was inflated and gently advanced and retracted to disrupt the fibrin sheath at the level of the SVC and cavoatrial junction. Should I use unlisted for fibrin sheathoplasty? Medicare will not cover that code even when we send documentation to support. I have gotten commercial payers to cover it. My radiologist asked me to check with you again on how to code these.

For treatment of post epidural headache, one of our physicians is using viscous contrast instead of the patient's blood. Since 62273 is for blood patch, would this be reported as 62323 for therapeutic injection into the epidural space?

"Clinical Indication: Previous spinal drain with spinal headache. Patient for epidural patch. Procedure: Under fluoroscopic guidance, a 22 gauge needle is advanced from the skin's surface to the epidural space at the L5 level. Approximately 10 mL of viscous contrast was injected into the epidural space for epidural patch."