Ask Dr. Z

The gist of the report is: "Limited CT of the pelvis was performed, safe window to the bilateral sacral alae was identified via bilateral transgluteal approach. Following standard prep, attempt was made to access the bilateral sacral via an 11-gauge bone biopsy needle. However upon placement of the needles, patients BP dropped & bone biopsy needles were subsequently removed. Procedure was aborted. IMPRESSION: Attempted bilateral S1-S2 tarlov cyst aspiration. Procedure aborted as patient became hypotensive etc. & transported to ED"

I understand that 77012/64999 are the codes supposed to be used for a complete procedure but I am unsure if modifier 53 should get added or no codes at all?

Can a radiologist bill an E/M visit for a report such as the following?

"The patient presented today for diagnostic follow-up of a focal asymmetry marked in the posterior lower inner quadrant of the left breast on screening mammograms of 3/14/2022. However, in review of prior studies, this area is a stable chronic findings consistent with a previously demonstrated sebaceous cyst, demonstrating no appreciable change in size or appearance dating back to mammograms of 9/23/2015, and also seen on multiple earlier studies dating back to 2003. In 2013, this area was notably larger in size and underwent ultrasound-guided aspiration on 5/24/2013 with cytology indicating only inflammatory changes and no malignant cells. I discussed today with the patient the benignity of the previous work-up and the chronic appearance of this lesion over numerous prior studies, and I advised that additional diagnostic work-up was not necessary today, but still offered diagnostic work-up if she desired. The patient was satisfied with no diagnostic work-up."

"Procedure: Left-sided venogram in the setting of the patient having a device. After appropriate consent was obtained, the patient had a left arm IV placed, and we proceeded to inject 20 cc of contrast and followed by fluoroscopy showing patent left subclavian system.

Conclusion: Patent left axillary and subclavian venous system.

Plan: We will proceed with CRT-D."

Based on documentation, is it appropriate to submit codes 75820 and 36005?

What code would be reported for portal vein thrombectomy after liver transplant?

I would appreciate your advice on coding an endomyocardial biopsy with right and left heart cath and coronary angiography in a pediatric heart transplant patient. The cardiologist states the reason for the procedure is "for routine evaluation including heart biopsy and coronary angiography". I understand that per OIG I can't code the right heart cath, but what about the left heart cath and coronary angiography? Can I report code 93458 (LHC with coronary angiogram) or 93454 (coronary angiogram) with 93505 (endomyocardial biopsy)?

Would this be considered congenital 33897, or would the scar tissue/cord lesion mean this was 37246?

"Patient was admitted for a cardiac cath for evaluation of CHD consisting of recurrent coarctation of the aorta. He was diagnosed with a discrete juxtaductal coarctation and ascending aorta hypoplasia. He underwent a surgical coarctation repair via extended end-to-end anastomosis. At recent cardiology visit, the velocity across the descending aorta had a large increase from his post op echo. He presents for cardiac cath balloon angioplasty of recurrent coarctation of the aorta. A pigtail catheter was inserted into the descending aorta. Angio and pressure gradients were obtained. We advanced a balloon over across the cord lesion. An inflation was performed by hand. There was a discrete post-surgical coarctation of the aorta just distal to the lower segment artery. Angiography demonstrated much improved angiographic appearance of the cord lesion. Patient had successful balloon angioplasty of recurrent coarctation of the aorta. An angiogram suggests that the scar tissue has been liberated." 

Multiple endarterectomies performed via one incision in the common femoral. Remote endarterectomy in the SFA, profunda, and profunda branches. Stent also placed in the iliac and SFA. Would it be correct to bill 35371, 35372, 35302, 37226, and 37221?

Patient with stage 5 chronic kidney disease who has had a left brachial fistula placed in preparation for dialysis if needed in the future. I cannot find a code that seems to be appropriate since the brachial fistula has not been used. Would maybe Z98.890 be appropriate?? I have had one coder say to use I77.0, but I don't feel this is appropriate since this was not an abnormal connection. Any help with this matter is greatly appreciated.

How would you code the following?

CLINICAL INDICATION: Breast ca.

NUCLEAR MEDICINE SENTINEL NODE LYMPHOSCINTIGRAPHY INJECTION

HISTORY: Breast cancer

COMPARISON: No prior studies are available for comparison.

PROCEDURE: Informed consent was obtained from the patient. A timeout procedure was carried out. The skin was prepared with a sterile technique. A total of 1.5 mCi of filtered sulfur colloid was injected into the upper outer periareolar region of right breast.

FINDINGS: No imaging was performed for this procedure.

IMPRESSION: Sentinel lymphoscintigraphy injection of right breast performed as described.

"Native common femoral artery, profunda femoris, and superficial femoral arteries were isolated as well. Distally below-the-knee calf incision was made. Dissection down to the below-knee popliteal artery using sharp dissection. A tunneler is passed between the two incisions, and the 6 mm PTFE was passed between the two incisions. Next the limb and vessels were clamped in the groin. A longitudinal graftotomy was made with Potts scissors. There was immediately encountered fresh thrombus. This was removed and irrigated. A #6 embolectomy catheter was passed up into the aortic limb with multiple passes and retrieved a large amount of fresh thrombus. There is great inflow #2 embolectomy catheter was tested on the profunda femoris vessel and clot was removed with good backbleeding. The graft was then beveled and sewn in place using 5-0 Prolene suture x2."

I know typically the thrombectomy is inclusive to the bypass graft. Since this took place in the right aortic limb, can we report codes 35656 and 37184? Or would that be considered all one continuous vessel?

"Patient is a 5-month-old. PDA was ligated, and there was a large cyst in the mediastinum. It was underneath the aortic arch, deep to the PDA, displacing the left bronchus and trachea to the right, pushing on the main pulmonary artery, and displacing the esophagus posteriorly. The cyst was resected in its entirety." The best CPT code I could find for this is 32140. Would there be any other code to better suit this procedure?

What CPT code can we use for CT-guided coil placement to mark pulmonary nodules prior to surgery for resection? C9728 for hospital?

I am not sure if this description is valvuloplasy (33426) or replacement of mitral valve (33430). What are the key words to look for to figure this out? Is it the fact that a ring was used or pledgeted sutures?

"Dome of left atrium was opened, and mitral valve was inspected. Annular dilation was confirmed. Anterior leaflet was resected. Annular pledgeted sutures were placed, and posterior leaflet was preserved. Valve was sized to a 27 mm magna mitral. Sutures were brought through ring, and valve was lowered into place."

I have a patient who was born with 22q11 deletion syndrome, PA/VSD/MAPCAs with hypoplastic confluent PA. S/P VSD patch closure, MAPCA repair, placement of aortic homograft valved RV to PA conduit, and a melody valve implantation. Pt is here for hemodynamic assessment with consideration for intervention if indicated. Pt had a right/left heart cath and pulmonary angiogram. Is the RT/LT heart cath coded as 93596 or 93597? I coded 93597 and 93568 but the provider dictated normal connections.

I work on the hospital side, and we have a situation that I need some advice on. Patient was brought to the IR suite for anticipated endovascular treatment of moderate to severe vasospasm. Patient came to the lab intubated and when the patient was placed flat his intracranial pressure rose. Anesthesia was started, and despite two hours of trying to stabilize the patient the procedure was aborted. I'm not sure what I can realistically procedure code here. I thought of coding 61650-74 but that seems too much.

Based on description below, which code is correct 93656 or 93653, 93655x2?

"PREOPERATIVE DIAGNOSIS: Recurrent refractory atrial flutter & atrial fib with prior pvi procedure

CS catheter & Intracardiac echocardiographic catheter was advanced. Transseptal catheterization was performed for left heart catheterization. Left atrial pressure 14. The left atrium was mapped using the NavX system. All veins were isolated. There was also ablation of the left atrial roof in the posterior wall. The radiofrequency catheter ablation of the left atrial appendage was performed, but was intentionally not isolated. Catheter withdrawn into the right heart. Radiofrequency catheter ablation for atrial flutter was performed. Vein of Marshall ablation was performed following coronary sinus venography. The patient was cardioverted to sinus rhythm.

--POST OP- Intact PVI from prior ablation, Status post ablation of the left atrial appendage, alcohol ablation of the vein of Marshall, and radiofrequency catheter ablation for atrial flutter."

If US guidance is also used during a fluoro intussusception exam, would you just consider it part of the imaging and only use 74283 (no code for the US guidance)?

The new Category III code 0715T for coronary intravascular lithotripsy needs some questions answered about its use.

1. Is it reported x1 no matter how many different coronary arteries it is used in? Or is it reported for each coronary artery it is used in?

2. If used in multiple coronary arteries (RC, LM, LD, LC, RI), would the coronary artery modifiers be appended?

Can you bill for 36245 for placement of a stent to the mesenteric artery via open abdominal access through the aorta? The aorta itself was not opened.

My question is about when to report x-ray performed intraoperatively with hip/knee replacement procedures. Can we bill radiology service separately and apply modifier -59? Or not bill imaging with procedure? (Hospital - facility billing)

Can you please explain how to correctly code a VATS segmentectomy followed by a lobectomy? The operative note states the following: "The left lower lobe superior segment was then resected with multiple firings of robotic green staplers. This was reported on frozen section to be an adenocarcinoma. As such, we proceeded to complete left lower lobectomy." Would I code just the lobectomy (32663) since it's of the same site, or would I bill 32668 along with 32663? The surgeon does not state wedge resection, but I feel like we should be able to bill for the segmentectomy portion.

What CPT codes are billable, and can you explain the logic?

Procedures to be performed: Left Heart Cath with intervention.

1.  Drug-eluting stent angioplasty of the ostial left circumflex in-stent restenosis, using the right femoral arterial access.  Radial access was attempted but was unable to pass wire due to radial artery obstruction-

Findings:

1.  Hemodynamics

AO:  160/78

CORONARY INTERVENTION:

LESION 1: 

Vessel: 90% ostial left circumflex in-stent restenosis-   

Anticoagulation: Heparin 80 units/kg guide catheter: 6 French EBU 3.5 from the right femoral approach.

Guide Wire: Fielder XT wire initially to cross the lesion for predilatation.

Pre-Dilation Balloon: 2.5 mm Abbott trek 15 mm PTCA balloon at up to 20 atm. Following predilatation, the Fielder XT wire was exchanged for a VersaTurn wire Intervention Device: 2.5 mm Abbott Xience Skypoint 12 mm drug-eluting stent delivered at 16 atm. Post Dilation: Stent delivery balloon at 16 atm.

Results: Reduction of initial 90% stenosis to less than 10% residual stenosis with no evidence of dissection, distal embolization or loss of side branch.

Our coders are having trouble differentiating between coding 36468 vs. 36471 with the documentation that follows. We believe the report represents a 36468 procedure, but due to the "varicose" vein verbiage the physician feels this report should be coded as 36471. What is the correct way to code the report below? The physician's typical 36471 reports normally reference traditional sclerotherapy for refluxing varicose veins treated, so the surface vs. traditional sclerotherapy is confusing.

"Patient presents today for medically necessary RLE surface sclerotherapy. Signed consent was obtained. The patient was placed on the table in supine position, and legs were cleaned with alcohol and 4 x 4 gauze. Utilizing a vein light, the varicose, reticular, and spider veins were injected with polidocanol 0.5% utilizing 1 ml syringes and 30 gauge 1/2" needles for a total of 3 mls. The treatment was diffuse involving the lateral, posterior, and medial aspects of the right leg. The patient tolerated the procedure well and was instructed to wear compression hose for ten days."

I need your opinion on this case. I'm thinking 33216 for subcutaneous coil implant, 93642 for DFT testing, and 33215 for RA lead reposition. Note: patient had inpatient status and presented with existing multi-lead ICD.

"Indications: Unsuccessful shock for VT, RA lead dislodged. Procedure description: Add subcutaneous ICD coil, repo RA lead, ICD lead/generator testing (existing generator). Using tunneling tool, sheath was advanced posteriorly with fluoroscopy for coil placement. Lead was secured and incision made over previous ICD incision to capsule around generator, which was explanted. RA lead was disconnected and then repositioned in RA and fixation deployed with excellent sense/pace thresholds. RV coil (HVB) plug was removed, and subcutaneous coil was connected to its port. RA lead was secured. Tunnel was created from subpectoral pocket to anterior axillary pocket, and lead was pulled into pocket, then connected to ICD generator. Device testing was performed. Ventricular fibrillation was induced through device which detected VF and terminated it with single 20 joule biphasic shock."

If an angioplasty is performed in three separate areas of the IVC ["suprarenal" inferior vena cava (60% stenosis), "infrarenal" inferior vena cava (50%), "retrohepatic" inferior vena cava (60%)], would it be appropriate to code three units? 37248, 37249 x 2.

I see this frequently from one of my clinics, and we are getting MUE edits for these codes. Typically during these types of cases, the surgeon is also doing venoplasties of the lower limbs. So, the codes I typically see are like: 37248-50, 37249-50, 37249-XS, 37249-XS, 37249-XS, 36011, 75822-XU.

When an angiogram is performed during a stent placement, are AO pressures sufficient to charge code 93454, or must there also be an LV pressure?

Here are the findings for left main coronary artery: ostial portion of the artery contains 50% stenosis. Hemodynamics: Pressure: AO 29/28 (29) mmHg/AO 144/55 (85) mmHg.

LAD 100% thrombotic occlusion in the junction of the proximal to mid vessel. Left Main mild stenosis with no thrombus

POBA with thrombectomy "I quickly inserted a 3.75 EBU catheter and cannulate left main. Angiograms were taken. I traversed the stenosis with a run through wire and it immediately restored flow to TIMI II level. I then inserted a 2.5 balloon and did inflations of the proximal vessel which restored flow to a normal level. There was still residual thrombus in mid vessel. I performed an export thrombectomy. I then post dilated aggressively with 2.5 balloon and 3.0 balloons. I then performed an IVUS of mid to proximal LAD and left main. This showed nice stent apposition and expansion." 

I'm coding 92978-LD, but not sure if I can bill for the LM. Would this be considered a pullback? In the CATH Lab procedure log shows IVUS performed left coronary artery to left main.

"The wound in question on the left jaw was sharply incised with a 15 blade, and necrotic tissue removed. A cavity was found where there was evidence of a prior glass foreign body, but it was not present at the current time. A vigorously bleeding branch of the facial artery was encountered, which had been lacerated. It was suture ligated with a 3-0 vicryl suture. Wound was irrigated and closed with multiple deep interrupted 4-0 Monocryl sutures."

There is some internal debate if 37600 can be reported since the facial artery is a branch of the external carotid, or if unlisted code 37799 is more appropriate.

It is being presented that, for auditing purposes, documentation stating just the balloon alone for kyphoplasty is not enough and could be interpreted as the balloon only facilitating the injection of cement, thereby down-coding the procedure to vertebroplasty. The rationale being that just using a balloon does not mean a cavity was created unless specifically stated in the note. So, to counter that logic I pointed to your example in your book and was told it is too vague. But my argument is that if a balloon is inflated it’s going to create a void or cavity, referencing your example. Now the question is how much detail for creation of a cavity does there need to be? What must be included to satisfy the CPT descriptor, CPT Assistant, and Coding Clinic instructions?

Does the final location of the tip of the catheter have to be documented in order to bill for a central line placement? CPT Assistant leads us to believe it must be documented.

One of our providers has started documenting CT 3D reconstruction performed at the start of the EP study portion of ablation, codes 93653, 93654, and 93656. The OP note states, "The patient's CT scan was segmented and 3D reconstructed for procedural planning." Would this be coded as 76376? Is it separately reportable with an ablation (no NCCI edits to indicate either way)? Is the provider's one sentence above sufficient documentation?

"PROCEDURE: Fistulogram and ligation of branch of the fistula as well as angioplasty of fistula.

We brought our attention to the right arm where we accessed the cephalic vein in the direction of the anastomosis. We did a fistulogram, which showed stenosis distal to the anastomosis. We also saw a large branch, in which we then made a small incision and dissected it out. We ligated that branch, and then balloon angioplastied the cephalic vein just past the anastomosis with a 6 mm balloon. Once we were done, there was better flow, and a palpable thrill could be now felt higher up in the arm. At this point, we felt that we had improved the flow through the fistula and then removed the sheath and closed the access site with the use of Prolene suture."

Under 36832 in the CPT Codebook it states to not report 36832 with 36902. Does that mean we only code 36832? We get an NCCI edit that 36832 bundles into 36902.

A patient has an existing nephrostomy tube. Contrast is injected, which confirms that the nephrostomy tube is malpositioned. The tube is removed. The physician attempts to place a new nephrostomy tube via the existing access but is unsuccessful. He then places the new nephrostomy tube via a new access. Would this be coded as 50435 for an exchange? Or would it be 50432 since it is via a new access?

Would this be reported with code 33208 or 33206?

"Under fluoroscopy, a pacemaker lead was introduced in the right ventricle. Using a steerable sheath, the left bundle area was targeted. The QRS was 63 msec pre implant and 53 post implant. After adequate numbers were confirmed, the lead was screwed out. The lead was tied down with 0-silk x 2, and a tug test was performed. Using a similar method the RA lead was placed in the right atrial appendage. The leads were attached to the pulse generator, and another tug test was performed. Adequate numbers were again confirmed. Atrial lead and ventricular lead sensing were noted."

In the hospital setting, a patient comes in as a trauma with head and face injuries. Can codes 70450 and 70480 be billed together?

Based on your IR coding reference, you recommended: "Usually multiple genicular arteries are embolized. Report codes 36247 and 36248 x 2 for catheter placements, and, since this is one surgical site, report code 37242 once, regardless of the number of arteries embolized. Report code 37244 if embolization is for post-operative hemorrhage (e.g., after knee replacement)." My question is that the vessel was accessed from right superficial femoral artery to treat the same leg. Would you code 36247 or 36246?

Single contrast upper GI was performed with water-soluble contrast (Q9967) administered through an indwelling nasogastric tube. Is the water-soluble contrast billable with Q9967?

"Multi-trauma patient: Catheter was used to select the distal right brachiocephalic artery. Digital subtraction angiography was performed. Through the Kumpe catheter, a microcatheter and wire were used to select the right internal mammary artery. Digital subtraction angiography was performed. Next, the Omni flush catheter was used to perform a distal aortogram with visualization of the pelvis. A 5 French Kumpe catheter was advanced into the left external iliac artery. Digital subtraction angiography was performed. A microcatheter was used to select the left corona mortis artery arising from the left inferior epigastric artery. Digital subtraction angiography was performed."

Is this cath selection coded as 36247 or 36248? Is angiogram coded as 75774 for the corona mortis anomaly?

Can/would you bill code 0715T more than once if they perform 2-3 different coronary arteries?

Patient has history of rectal cancer with concern for perirectal mass. A percutaneous CT-guided coaxial needle biopsy is done. I'm not sure what biopsy code to use. Please advise.

When a patient is coming in for a planned PCI with Impella insertion, would it be appropriate to pick up the fluoroscopy of the coronary artery code B2101ZZ? We always relook at the coronary artery prior to invention, so we are torn on whether it should be coded since it would not be diagnostic, but weren't sure if the same CPT rules applied in PCS. This changes the DRG, so we want to make sure we are accurately reporting this.

A Duplex scan was done on the left to rule-out DVT and then on the right a venous reflux scan was done on the same date of service. Each study was documented on a separate report. I coded 93970 but my tech explains this would not be the correct code because a reflux scan is twice as much work. Can you please let me know what I should have coded? I have been under the impression the complete study 93970 includes all images and maneuvers necessary for the study.

"A patient was scheduled for a lead reposition. Before the procedure started, interrogation showed that the atrial lead was dislodged. The lead was fluoro-ed and was shown to be in an adequate position, identical to the final fluoro when the patient originally had the pacemaker placed. Interrogation of the pacemaker was performed again, and lead sensing and pacing parameters were adjusted to obtain appropriate pacemaker function for the patient without physically adjusting the lead. Given the patient's advanced age and risk for hematoma, this was felt to be the safest option for the patient." 

In this instance, my facility coded 93280 for the interrogation and adjustment of the lead and pacemaker parameters, but we were wondering about coding fluoroscopy (76000) as well since the fluoro of the actual lead is what drove the outcome of the procedure. What would you have done here? 

"History of May-Thurner, chronic thrombus in existing iliac stent. Venography and IVUS documents only thrombus, no narrowing or stenosis. Thrombectomy and venoplasty performed. Repeat IVUS performed for the purposes of determining appropriate stent size. The chronically thrombosed left iliac stents were then relined with placement of a stent extending from the confluence of the IVC and left common iliac vein into the left external iliac vein. This was then extended with deployment of a 12 mm x 60 mm overlapping Cook venous stent extending into the left common femoral vein." 

Is it appropriate to report codes 37238 and 37239, or should only the thrombectomy be coded? Is the history of May-Thurner enough to justify the stent placements without an underlying stenosis documented? An external audit company is recommending coding 37238 and 37239. Thank you for your advice!

If an aorto-bi-iliac graft is used for an iliac artery aneurysm only, would you report code 34707 or 34705?

Patient has a ruptured Iliac aneurysm. Provider performed the following:

1. Bilateral ultrasound-guided common femoral artery access (16 French sheath in the bilateral groins, Perclose x 2 in the bilateral groins).

2. Iliac branch endoprosthesis (IBE) with a 23 mm x 10 mm x 10 cm main body device.

3. Extension of the left internal iliac artery with a GORE IBE limb 16 mm x 12 mm x 7 cm extension piece, extended distally with a 13.5 x 5 cm Viabahn to the bifurcation of the anterior and posterior trunks.

4. Extension of the proximal component within the proximal right common iliac artery using a 23 mm x 3.3 cm GORE EXCLUDER main body extension.

Should this be coded as 34708, 34709, 34713-50? How would you code this?

Can code 0715T for coronary IVL (Shockwave) be reported with C9600-C9608 for coronary interventions performed with the use of drug-eluting stents? Or is its use limited to 92920, 92924, 92928, 92933, 92937, 92941, 92943, and 92975?

What should I charge for when the MD places a CS lead in a single PPM?

"The MD attempted to place a PPM lead (C1898), but given severely dilated RA and suspected scar, several different sites within the RA were assessed for adequate sensing of the p waves. No p waves were sensed. Therefore, the RA lead and sheath were removed. A Medtronic LV lead was placed in a posterior lateral vein of the left ventricle, adequate pacing was confirmed, the sheath was peeled away, and the lead was sewn into position with 2-0 silk pop-off suture. The Medtronic device was then connected to the lead with adequate connections of all the one lead to the generator was confirmed. Appropriate sensing, pacing impedance, and pacing thresholds were tested and verified through the device."

Trying to figure out if this this procedure should be coded with or without modifier -74. Please advise. "WaveLinq catheter placed in both artery and vein and magnets lined up and electrode lined up with the backstop. The generator was fired and fistula creation attempted. Repeat venography showed venous extravasation from the radial vein with out evidence of communication with the radial artery. Due to extravasation and possible compartment syndrome the procedure was aborted." Since the device was placed, but not with the desired result, does this warrant adding modifier -74?

"Thoracoabdominal Type B 2,10 aortic dissection extends from L carotid to iliac bifurcation bilateral. Dissection flap impedes flow to L renal artery. Initial TEVAR device deployed just distal to L subclavian. Second device deployed proximal and landed just distal to L common carotid covering L vertebral (anomalous origin) and L subclavian. Laser fenestration of proximal TEVAR device via brachial approach, with L subclavian stent placement. Decision to place an additional Cook dissection stent graft. ZDEG advanced from the right groin, deployed with approx. 5 cm overlap with prior stent, landed with distal extent approx. 6 cm above celiac axis. Next, Cook bare-metal dissection stent advanced to more distal TEVAR stent graft and deployed through the visceral segment with 1 stent overlap, landed just above the aortic bifurcation. Aortogram demonstrates robust flow within the celiac, SMA, bilateral renals, improved flow of bilateral iliacs and hypogastrics." 

Is stent placed in visceral aorta for flap included in code 33880, or is code 34701 supported?