Ask Dr. Z

Mammography suite uses HCPCS code C2639 for seed localization placement under mammo guidance along with CPT code 19281. Medicare is denying for device-dependent procedure. Assuming that the C2639 (Brachytherapy source, non-stranded, iodine-125) is not being recognized, any thoughts on how to correct this issue not other supplies are being used?

Our providers routinely perform a bilateral lower angiography (75716) when they are performing their pre-op TAVR left heart caths (93458). NCCI edits indicate the angiography as bundled with the cath; however, our providers believe the peripheral angiography warrants a -59 modifier since an angiography of the iliofemoral system is not a routine part of a left heart cath. Can we bill a lower extremity angiography with a -59 or -XU modifier at the same time as the left heart cath?

Question ID 9849 from 2017 indicates that for a synovial cyst rupture 64999 should be billed. If both a synovial cyst rupture and a facet are completed, are we able to bill for both 64999 and 64493?

I know the codes for the CABG are 33533, 33518, and 33508. I am unsure how to bill for the pericardium reconstruction.

"The pericardium was then reconstructed with the extracellular matrix proxy core. A 4-0 prolene suture was used to anastomose the extracellular matrix to the pericardium circumferentially. Once this was completed, the mediastinal chest tube and one left and one right pleural chest tube were placed and secured."

Would this be just one code 36832, or would a second or unlisted code be used for lipectomy? 

"1. Revision of right AV fistula by way of side branch ligation.

2. Subcutaneous fatty tissue excision overlying cephalic vein and forearm for vein superficialization.

PROCEDURE: After team timeout and performed sterile mapping with ultrasound of the fistula, found a large side branch coursing laterally marked this position. We also marked several positions along the forearm 4 counterincisions versus lipectomy of subcutaneous fat to bring the skin closer to the fistula. After team timeout, we performed a small incision overlying the side branch and ligated this with 3-0 silk sutures x2. We then turned our attention to the lipectomy with 2 transverse incision across and performed cylindrical removal of fatty tissue overlying the vein, we also lysed the vein fascia that was keeping it in place in the forearm, superficializing this and had a nasal groove of palpable cephalic vein afterwards. We had excellent hemostasis."

Would this IT band trigger point injection be coded 20552 or 20550 plus 77002? I don’t know if the IT band is a trigger point or a ligament?

"Fluoroscopy was used to guide a 25 gauge spinal needle to the appropriate location in the area of the IT band. Isovue 200 was injected to confirm positioning along the IT band and injection of 50% of the mixture of 40 Kenalog and 5cc of Bupivacaine was made in this band area. A second injection was made more at the inferior area of the band. Following two locations, the patient reported 100% relief of his pain in the leg and needles were removed. Findings: Right IT band inflammation responsive to trigger point injections. Impression: Successful injection of right IT band into locations."

"The patient had an MRI and was diagnosed with invasive lobular carcinoma of the right breast. A week later, the patient was seen in mammography for evaluation of an area of non-mass enhancement in the right breast as well as a mass in the left breast seen on recent outside MRI. In mammography, she had a bilateral diagnostic mammogram and a bilateral breast ultrasound. On the same day, the patient had an ultrasound-guided core biopsy of the right breast and an ultrasound-guided FNA with micromarker placement on the left breast." What CPT codes would be used for this patient?

"Upper limit vulnerability testing was successful at 20 joules." Does this meet the DFT testing code (93641) requirement?

Patient had EKOS placed at 9:00 pm, and the EKOS cath was subsequently removed 12 hours later (on the following day). Is it appropriate to report 37214 since the service spanned two days? What documentation do we need to support EKOS thrombolysis on the subsequent days of treatment? What documentation do we need for removal? Can patient have EKOS cath removed at bedside in ICU? Should there be a procedure note?

Could you help us understand when to code 35221 versus 34502. We have a case where patient presented for GSW to the abd. Provider documented: "We examined the IVC and it was noted that the injury was well under 50% and this could be repaired primarily. A 3-0 Prolene was brought onto the field and a whipstitch of the IVC was performed along the linear tear". Would 34502 be appropriate for this case?

We have searched your website for the answers, the latest question was from 2019.

In order to use the 93459 for the purposes of LHC with viewing potential grafts WITHOUT PREVIOUS BYPASS, does the catheter tip have to be SELECTIVE (cath tip in LIMA) or can it be NON-SELECTIVE (cath tip in subclavian)?

Physician performed the following: flexible bronchoscopy, esophagogastroduodenoscopy, right thoracotomy, incision and drainage of mediastinal abscess, drainage of effusion, intercostal muscle flap, wedge resection of the right lower lobe of the lung.

The wedge resection was done to repair an intraoperative lung tear. Dictation states: "We were able to elevate the lung and take the inferior pulmonary ligament. There was a small tear in the lung and we subsequently performed a small wedge resection around that tear, placing a nice solid staple line on the lower part of the right lower lobe." Physician wants me to report code 32505, which would be inappropriate since there were no nodules or masses. Would code 32110 (thoracotomy; with control of traumatic hemorrhage and/or repair of lung tear) be okay to use in this scenario? Or, would this code strictly be used for a traumatic laceration? If so, which CPT code should be applied?

Patient has tachy-brady syndrome with complete heart block post AV node ablation. When the biventricular PPM was originally implanted in 2013 the atrial port was plugged. The biventricular PPM generator has reached end of service and was therefore replaced with a new generator; again only the RV and LV leads were attached to the new ST Jude CRT-P generator, model PM3222.

Seeing that CPT defines a multi-lead system as a pacemaker or implantable debrillator with pacing and sensing function in three or more chambers of the heart,  is it appropriate to bill the 33229 due to the LV lead and CRT-P generator model used, or is it more appropriate to bill the 33228 due to patient only having two leads?

If the patient has a dual chamber pacemaker, came in for a venogram where the dislodged atrial lead was removed and due to stenosis could not receive the planned CRT upgrade, does the patient now have a single or dual chamber pacemaker since they still have the same generator minus a lead? I ask because I am trying to code the following encounter where the patient returns for a bivent system, but documentation does not indicate the generator is removed, but states a dual chamber pacing system was placed. They used the existing ventricle lead and placed an atrial lead. The ventricle lead was repositioned. What CPT® codes are used?

Code 93319 can be submitted in addition to codes for TEE exams (93312, 93314, 93315, 93317) as well as congenital TTE procedures (93303, 93304). The TEE codes describe both non-congenital (93312-93314) and congenital imaging procedures (93315, 93317). We are a having a debate whether codes 93306 and 93308 can be billed with add-on code 93319, as there is no NCCI edit, but the CPT Codebook does not state that they can be billed with 93319. What is your thought this?

During an open heart procedure, patient is in need of a pacemaker upgrade to biventricular pacemaker. They removed old generator, removed RV lead, placed LV lead, placed new RV lead, and placed new biventricular generator. Am I right in thinking, 33235, 33202, 33221, 33225? Looks like 33233 bundles and modifier is not allowed. Or am I way off the beaten path? In question ID 13070 (from Dec 5, 2019) Dr. Dunn responded to a question saying that 33202 includes 33225. However, the CPT Codebook says under 33225 to code also placement of epicardial electrode when appropriate (33202-33203). Is this an appropriate time to code 33225 also?

Coding Clinic (4th quarter 2020, page 10) states to report 33206 for pacemaker insertion with atrial and His bundle lead insertions. I believe your advice has been to report His lead based on chamber in which it is placed. If the physician states the His lead is placed in the right ventricle, and a right atrial lead is placed along with pacemaker insertion, do you recommend reporting 33206 or 33208?

Which code should be used when a blood vessel is repaired during a tumor resection? For example, right thigh mass resection with right superficial femoral artery interposition graft using PTFE. Would this be 35661 or 35286?

What code do you recommend for core needle biopsies of the spleen? Code 49180 has been suggested, which we know the ACR recommends for the ovary, and Coding Clinics recommend for the adrenals.

How would you report angiography here? "Catheter was advanced to the suprarenal abdominal aorta and abdominal angiography performed. This demonstrated patent celiac trunk and SMA and its branches. Left renal artery was seen and appeared normal. Right renal artery was not seen. Catheter was placed in distal abdominal aorta and abdominal angiography pelvic angiography performed. Bilateral common femoral and iliac external iliac arteries were patent without significant obstructive disease. Selective right lower extremity angiography was performed, which demonstrated occlusion right SFA throughout its course occlusion of the right popliteal artery throughout its course with extensive collateral filling of the distal vessels and reconstitution of the right posterior tibial artery distally. Catheter was advanced over the bifurcation and left lower extremity angiography performed."

Upgrade of ICD to BiV was attempted - Physician was unable to advance the lead past mid portion of any target vessels so patient was brought back on a different day for "intraseptal pacing.” The lead was fixed in the mid septum. The new lead was then placed in the RV pace sense port and the RV electrode was paced in the LV port of the new device. (There is also an atrial lead that was not moved or changed. Would we still report 33264 with 33225 for the intraseptal pacing?

Which codes would I use for endoscopic robotically-assisted tricuspid valve replacement. My search comes up with 0646T or 33645. There is no sternotomy documented, just the robotic approach.

This is the same issue with endoscopic robotically-assisted mitral valve replacement. My search comes up with 0483T or 33430. Again, no sternotomy is mentioned for the approach. He only mentions the robotic approach.

Do you know why the codes 33990-33997 have status 0 for the PC/TC indicators, meaning they are physician services only and TC/26 modifiers do not apply? Does this mean you wouldn't code any of these codes if you code for outpatient hospital cath labs since that is TC? Do you think that is an error, or do you know the reasoning behind that? Thanks for your expertise!

Would you bill right heart cath with EPS ablation? 

"Patient has atrial fibrillation with tetralogy of Fallot status post repair. Prior to the electrophysiology study, a complete right heart catheterization was performed. Heparin 8,000 units was administered with additional boluses and a continuous infusion to maintain the ACT >300 seconds. Mapping and ablation were performed."

Would this be reported with an unlisted code since it was not done by thoracoscopy?

"A mini-thoracotomy was performed by making a 4 cm anterior/lateral incision at the left 4th intercostal space. The incision entered the pericardium and was carried up to the pulmonary artery, exposing the left atrial appendage. An atrial clip measuring device was used. A 50 mm endo atrial clip was inserted and placed across the appendage using TEE guidance. This was a stand-alone procedure."

Can code 36200 be billed when performed for a distal aortography with bilateral iliofemoral runoff, along with a left heart cath(93458)? Or would 36200 be included in 93458?

Doing a CT cisternogram (facial bone) with pre and post contrast intrathecal injection through thecal sac. Would the CT be a with-contrast 70488 or without-contrast 70486 because no IV was used?

Is the difference between 49405 & 50390 catheter vs needle? Question 15503 says to use 50390 if the needle or catheter is removed at the end of the procedure. In Question ID : 8089 it says The catheter must be indwelling .. Indwelling is not just a couple hours. CPT assistant for 50390 only describes fluid injected or aspirated through a needle that is usually inserted through the skin of the back. No catheter is mentioned. The CDR for 49405 says “A catheter is inserted to drain and collect the fluid... THE CATHETER IS REMOVED... In some cases, the catheter may be attached to a bag to allow for further drainage over the course of days.” So if the OP report says catheter was advanced into a renal cyst. A wire was advanced into the cyst and a French locking all-purpose drainage catheter was advanced into the cyst. The cyst was completely aspirated. Then ethanol was advanced into the cyst. This was allowed to dwell within the cyst for 30 minutes. Catheter was removed and a sterile drain was placed. Would this be 49185 and 50390 or 49405 (&77002-XU)?

Is there a specific code for laparoscopic removal of PD catheter, or should we only use code 49422?

The patient had a dual chamber pacemaker insertion. One lead was placed in the right atrium, and the other lead was placed in LBB/His bundle. Can you tell me if your previous advice from August 10, 2020 is still the way to bill this? Code 33206 was suggested with a possible -22 modifier (depending on insurance).

An ICD was placed, and a LV ventricle lead was attempted. The lead was placed in the right ventricle septum until left bundle was captured. There is an NCCI edit when coding 33249 and 33216 (insertion single transvenous electrode). Would this procedure be coded as 33249 and 33216 with a modifier? 

Per NCCI Policy Manual, code 77073 includes x-rays of lower extremities, but lower extremity x-rays may be reported with a modifier when "performed to evaluate a different problem". Providers order knee and leg lengths with indication of: preop planning for djd of the knee(s) total knee arthroplasty. Would you consider both leg lengths 77073 and knee x-rays, 73560 or 73562, okay for this scenario? 

Would you use code 10035 for placement of wire/needle localization device in the parathyroid gland?

The 2022 coarctation stent codes are driven by either "across major side branches" or "not crossing major side branches". Which CPT code is your recommendation for when the stent "partially protruded out across the front of the LSCA"? Because the vessel opening is partially crossed, it could potentially be more difficult to engage the left subclavian artery. Would that have any impact on the proper code selection?

In a situation where a pediatric patient has a left-sided SVC, what would be the most appropriate code for imaging of the left-sided SVC? Would we still report code 75827, or is there a more appropriate code to use?

For a cryoablation of a desmoid tumor, pectoral, and also infracoracoid, we would use 20999? Would we code this x2? Cryoablation of right pectoral and infracoracoid desmoid tumors.

When a provider places an AtriClip during a CABG, does he need to document that the patient has/had atrial fibrillation, or can he/she report 33268 to prevent Afib?

I'm having a hard time finding a code for an open removal of a foreign body.

"Thrombosed common femoral artery with stent lodged in place. Incision was performed obliquely in the right groin. Dissection was carried down to the superficial femoral artery after localization with fluoroscopy of the stent level. The artery was isolated proximally and distally, and a transverse arteriotomy was performed. Next, the wire and stent were grasped and brought out into the wound. Wire was brought out distally from the distal SFA and cut. Next, the stent was brought out along with a catheter into the wound and cut. The remainder of the catheter and sheath were withdrawn from the left groin under direct vision to ensure removal."

Our neuro radiologist performed MRgFUS (0398T) as an assistant to neuro surgeon. Do we submit the charge to Aetna with an -80 modifier, or since we are a teaching hospital should it be modifier -82?

Patient cut Foley catheter, so piece of the Foley was stuck in the patient's bladder. IR physician documented the following. How would this be coded? We are leaning towards unlisted code 53899.

"TECHNIQUE: After informed consent, the patient was prepped and draped in usual sterile fashion. A 5 French catheter was placed in the urethral meatus, and a retrograde urethrogram was performed. A 5 French catheter was manipulated into the bladder under fluoroscopic guidance. An Amplatz wire was positioned in the bladder. A 10 French sheath was placed into the bladder. The bladder was filled with contrast. I was unable to identify the Foley catheter fragment; however, a 30 mm French snare was then positioned into the bladder, and the Foley catheter fragment was snared and brought out through the sheath. The Amplatz wire was then positioned into the bladder. The sheath was removed. An 18 French over-the-wire Foley catheter was then placed into the bladder. Foley fragment was sent to pathology."

If the NP or PA performs the endoscopic vein harvest (33508), what is the rationale for recommending that the surgeon bill for the performance of the vein harvest (33508) and the NP or PA then bills for the assist (33508-AS)? Is it based on payer payment, or is there an underlying coding philosophy? If so what is that philosophy?

"Patient called EMS for CP that woke him from sleep, along with diaphoresis and N/V. STEMI. No cardiac hx. Doctor arrives to bedside in the ED and requests Brilinta and heparin. Patient then goes into v fib arrest. ACLS protocol followed and patient goes into pulseless v tach. ROSC then achieved. Intubation noted to be difficult but pt has no periods of hypoxia. Levophed required after multiple doses of epinephrine. Pt taken to the cath lab for LHC, coronary angiogram, IABP placement, balloon angioplasty, and placement of one stent for a 100% wrap around LAD occlusion. Patient was then transferred to Hospital B for further care of cardiogenic shock.”

The patient had inpatient-only procedure 33967. Patient presented to ED, went to cath lab, and did not get admitted. The patient was then transferred out. How should this be billed?

Can tunneled cath placement and right cardiac cath be billed together?

"Ultrasound probe was used to identify the [right] internal jugular vein. Guidewire was threaded into the right atrium, and confirmation was made using fluoroscopy. A counter incision was made below the [right] clavicle, and a subcutaneous tunnel was made up to the needle stick incision in the [right] neck. A 14.5F x 23 cm hemostat tunneled dialysis catheter was brought onto the table placed through the track. The access point was dilated serially. The peel-away sheath was placed over the wire, and the tunnel catheter was placed. After this a right atrial angiography was performed through the catheter in the right atrium. The right atrium, right ventricle, and pulmonary artery were patent. The catheter was pulled back 1 cm to achieve adequate placement."

The charge in question is code 93225 (includes connection, recording, and disconnection). If the patient doesn't mail back the Holter monitor, or returns the Holter monitor back to the facility, can we still charge for 93225? Our thought process is yes the hookup portion was complete, but how do we prove the recording took place if patient never returns to do the scanning and analysis of the data? Are there any reduction modifiers that could be appended to this code?

Is code 64647 correct for the following?

"Informed consent for the procedure was obtained, and time-out was performed prior to the procedure. Prophylactic antibiotic administered: Not administered. Position: Supine. Preparation: The site was prepared and draped using maximal sterile barrier technique including cutaneous antisepsis with 2% chlorhexidine. Local anesthesia was administered. The bilateral internal and external oblique musculature was sonographically identified. Real-time ultrasound was used to visualize needle entry into the bilateral internal and external oblique musculature and a permanent images were stored. Sites of access: Right internal and external oblique (three separate sites), left internal and external oblique (three separate sites). Technique Summary: 300 units of Botox were combined with 6 mL of sterile saline. 1 mL of this solution was administered at each of the sites described above. A dressing was placed at each access site. Contrast agent: Omnipaque 240. Contrast volume: 0 mL."

"CT scan was performed that demonstrates the drainage catheter to be partially outside and to the right of the fluid collection in the posterior abdomen. A guidewire was placed, and catheter was manipulated and advanced into the fluid collection. With the catheter in place, we were able to aspirate 1 to 2 cc of fluid. The catheter was stabilized in place for external drainage." Can the aspiration be coded, or is this just a CT follow-up/limited?

We brought a patient with an existing bidirectional Glenn to the cath lab. Through percutaneous access, we created a Fontan conduit by poking a hole through the pulmonary artery graft into the right atrium and placing multiple stents and covered stents from the pulmonary arteries to the IVC, bypassing the right atrium. Would this procedure be covered by 33745, or would an unlisted code be more appropriate?

For this abbreviated report for rt atrial and bilateral pulmonary artery thrombus, are 0644T, 36015-50-XS, 37184-50 correct? "CTA chest was done prior to this IR procedure. Catheter was advanced into the SVC. Dilated with 12 French and 22 French dilator. A 24 French Inari sheath was advanced over the Amplatz wire and positioned in the IVC. The dilator was removed, and an additional 22 French Inari suction sheath was advanced to the SVC. Suction thrombectomy was performed. Catheter was retracted immediately adjacent to thrombus in the eustachian valve. Repeat suction thrombectomy. Catheter was advanced to the main pulmonary artery. 22 French suction thrombectomy cath was advanced into the inferior right segmental pulmonary artery. Thrombectomy was performed. Repositioned into the inferior left segmental artery where suction thrombectomy was performed."

Any updates on a procedure code for Shockwave balloon therapy during coronary angioplasty?

I have two scenarios.

1. Dual chamber ICD upgrade to biventricular ICD using left bundle branch. I coded 33241 removal of device and 33249 implant new device with new lead since the lead didn't go into the left ventricular.
2. Biventricular ICD implant using RA, RV, and left bundle branch NOT the left ventricular? Would this just be a 33249?