Ask Dr. Z

There was a mass that was overlying the left coronary ostia and was carefully removed and also found to be at the base of the aortic valve and was no long competent and needed to be replace. Is there a code to remove a thrombotic mass from the non-coronary sinus of valsalva during an AVR?

Have there been any updates to the advice on coding open Impella insert through axillary conduit as 33990 and 34716? The manufacturer rep is stating coding should be 33975 34716 to the physician. Description of procedure as follows:

"Axillary artery clamped and incision created. A 10 mm Hemashield Dacron graft was cut with bevel and end to side anastomosis was created between graft and axillary artery. The graft was then tunneled and made inferior and lateral to axillary incision. Valve was placed on end of graft and wire was passed and manipulated across the aortic valve. Catheter advanced over wire and placed into ventricle. Impella device was advanced over wire and placed across aortic valve. Wire removed and device activated. Graft was cut back to skin level and introducer secured to graft and device secured to skin."

Would removal of same device through same access (axillary conduit) be coded as 33992 or use unlisted since the axillary has to be repaired from conduit? Or 33992 with a 22 for repair of axillary?

"Multi-focal biopsy-proven atypical ductal hyperplasia bordering on DCIS in the lateral 3 o'clock axis of the left breast anterior depth and posterior depth respectively. Calcifications stretch 7.5+ centimeters anterior to posterior. Two Savi Scout reflectors were deployed: one posterior to the posterior margin of the calcifications in the lateral left breast 3 o'clock position and another anterior to the anterior margin of the calcifications in the lateral left breast 3 o'clock position."

My question here for dx calcifications is this part of atypical ductal hyperplasia or coded as separate dx N64.89?

Do we code 19281/19282 or these calcifications treat as one lesion and one 19281?

We have a patient who has an AICD, implanted in 2018, that recently developed a large pocket hematoma. We are going to report 10140 for the evacuation of the hematoma, but may we also report 93287 for the pre and post RV and LV lead testing? "Medtronic was present, and we tested her RV and LV leads with no significant change in function from the implant. She is pacemaker dependent status post AV node ablation and was set VOO 70 bpm during the cautery and then set back to baseline settings of VVIR with biventricular pacing afterwards and detections back on."

Trauma providers are asking if they can bill for a removal of a REBOA days after it was placed. They are asking if they can bill 33971. I don't feel this would be appropriate, but I would like to know your thoughts. Is there a code that can be billed for removal of REBOA?

Our vascular doctors performed an ECMO decannulation of the right iliofemoral artery and vein with vessel repair. Would you suggest coding 33984 or 35226 x 2 for this? Not sure if 33984 includes suture repair of the vessels or just the repair of the open approach? The RVUs are significantly different.

It doesn't look like modifier -62 is an applicable modifier for 0646T per Encoder. Our IC and CTS are involved with the transcatheter tricuspid valve implants, and both are documenting reports. Do we report 0646T with modifiers -62 and -Q0 as we do with the TAVRs? I'm not finding much in the way of coding/reimbursement guidance as exists for the TAVRs.

Can this be coded as an intervention, or because they are extraluminal then is this is unlisted?

"After demonstrating a chronic total occlusion of the left anterior tibial artery, revascularization was initiated. Over a Bentsen wire, a 55-centimeter 6 French Ancil sheath was advanced into the superficial femoral artery. The origin of the anterior tibial artery was then selected using a combination of CXI catheter and 0.035 angled Glidewire.

Having gained favorable purchase on the origin of the vessel, we probed with a combination of wires in catheters. However, the system became extraluminal, and I was not able to locate pathway back. At that point, the cranial portion of the anterior tibial artery was partially revascularized using Dottering techniques, and there were new collaterals demonstrated arising from the proximal segment."

Would you please advise how you would code the following documentation?

ARTERIAL DUPLEX WITH COLOR-FLOW IMAGING AND SPECTRAL ANALYSIS OF VELOCITY WAVEFORM WAS PERFORMED THROUGHOUT THE ABDOMINAL AORTA AND RENAL ARTERIES WITH THE FOLLOWING RESULTS: 

THE CELIAC AND SUPERIOR MESENTERIC ARTERIES ARE PATENT WITH NO STENOSIS IDENTIFIED.  

THE ABDOMINAL AORTA IS PATENT WITH NO STENOSIS OR ANEURYSMAL DEGENERATION IDENTIFIED.

 THE RIGHT RENAL ARTERY IS PATENT WITH NO STENOSIS IDENTIFIED.    

THE LEFT RENAL ARTERY IS PATENT WITH ELEVATED VELOCITY (461 cm/s) IDENTIFIED, CONSISTENT WITH A STENOSIS IN THE RANGE OF (60-99%) BY VELOCITY CRITERIA.  

THE KIDNEY DIMENSIONS ARE WITHIN NORMAL LIMITS BILATERALLY (NORMAL 10-13 cm x 5-7.5 cm). 

THE RENAL RESISTIVE INDICES ARE 0.63 AND 0.64 ON THE RIGHT AND LEFT RESPECTIVELY. (NORMAL O.6-0.7)  

THE RENAL/AORTIC RATIO IS 1.45 AND 5.6 ON THE RIGHT AND LEFT RESPECTIVELY. (NORMAL <3.5) 

THE COMMON ILIAC, EXTERNAL ILIAC AND COMMON FEMORAL ARTERIES  ARE PATENT BILATERALLY WITH NO STENOSIS OR ANEURYSMAL DEGENERATION IDENTIFIED.

I know recent guidance in August of 2021 suggested to use 93655 if the VOM is ablated for atrial flutter, or 93657 if VOM is ablated for atrial fibrillation. CPT Assistant as of March 2022 states to use unlisted, 93799. My facility had been using unlisted until I stumbled upon your guidance in August of 2021. We started using 93655 or 93657. Now that we have new CPT Assistant guidance, we are back to being stumped. Which do you recommend?

According to NCCI policy- The chest radiologic examination (eg, CPT codes 71010, 71020) is integral to the procedure and should not be reported separately, when performed by the same physician. If interpretation of the chest X-ray is performed by a different physician, the NCCI edits do not apply.

If there is an indication of post biopsy or post CVC placement chest x-ray ( with no complication), are those x-rays are billable if were done by different physician within the same group of practice?

Could you please interpret the second statement regarding interpretation of different physician from NCCI guideline? Thank you!

How can we properly code for 93010 ECG done multiple times, same day but different sessions: 93010-; 93010-76 x 4? Or when it is performed by a different physician, same day, different session as 93010-77; 93010-76x4?

Should we list 93010 on different lines with mod. 76 for each repeat (e.g. 93010; 93010-76; 93010-76; 93010-76?

Can you please clarify?

At the start of a TEVAR procedure, a left subclavian to carotid bypass using a graft was necessary due to the aortic anatomy. Once the bypass and the TEVAR were compete, an Amplatz plug was placed in the left subclavian artery via the left brachial artery. My codes include 33880, 75959, 35606, IVUS, and the cath placement. Can I also code for the subclavian Amplatz plug (37242)?

Our vascular providers are performing the TAVR access for the CTS/interventionalist co-surgeons. This is not being captured separately; however, the vascular surgeon recently performed an access via a subclavian artery cutdown and the creation of a conduit. After the valve was placed, the vascular surgeon removed the sheath and then ligated and divided the graft just above the subclavian artery anastomosis. We feel that this is still considered inclusive to the reimbursement of the TAVR procedure being submitted by the two co-surgeons, as it was created specifically for the TAVR access. The vascular surgeon, however, is asking about the additional work for the conduit creation and is asking for separate reimbursement. Your thoughts on this would be much appreciated.

I was wondering what the requirements are for use of 79445 with Y-90 procedures for professional component. I know our hospital was not billing it before, and now I am getting messages that we should be adding it.

Can you please provide clarification on thoracentesis with post chest x-ray? We have an experienced coder stating if a thoracentesis is done in one modality and then the patient is moved to another modality to do the follow up chest x-ray, then we can code for the chest x-ray. We would add the modifier on the chest x-ray. I believe this is incorrect regardless of where the chest x-ray was performed. The chest x-ray is a follow-up to the thoracentesis, and it is bundled. What are your thoughts?

What CPT code would you recommend for robotic-assisted hemi-diaphragm plication?

"Landmarks were identified for robotic port placement, daVinci Xi robotic surgical system docked to camera port and robotic endoscope placed in pleural space, examination performed to facilitate subsequent port placement. Under direct endoscopic visualization instrumentation was placed via the ports and the intra-thoracic procedure initiated.2.0 ethibond double armed pledgeted mattress stitches were used and I started at the dome of the diaphragm performing a plication and a medial to lateral direction. After the first stitch was placed the diaphragm naturally formed pleats which were elevated taking great care not to allow the passage of the needle to involve the abdominal viscera beneath the diaphragm. Gradually the diaphragm was lowered and additional areas were then identified for the placement of mattress stitches. Pledgeted mattress stitches were required to achieve a satisfactory plication."

This is in response to guidance in question ID 15210 where you recommended the joint injection/aspiration code for barbotage of calcific tendonitis. Since the work they performed is so much more than just injection and aspiration, why would we not report an unlisted code along with the injection code to capture all of the extra work performed to break up the calcifications prior to pain injection?

"Then an 18 gauge needle was positioned within the calcification, and lavage technique with 5 cc of normal saline followed by multiple passes through the calcification was done with a calcific material noted within the syringe. Then another 18 gauge needle was positioned within the calcification in a slightly different plane, and lavage technique with 5 cc of normal saline was performed with calcific material noted in the syringe. Then 5 extra passes with the needle were performed to barbotage the small leftover calcification until the calcification was unidentifiable. Post procedure scanning did not reveal calcifications in the supraspinatus tendon."

"Arteriotomy initiated on proximal right SFA; eversion endarterectomy of SFA beyond circumflex femoral artery and allow landing zone of PLANNED right SFA stent. Endarterectomy was done down to dep external elastic lamina with good endpoint on CFA and distally on SFA. Bovine patch was sewn to femoral artery defect and distally on SFA. Previous angiography confirmed long segment occlusion of right SFA from its origin to the adductor hiatus. The right SFA occlusion was then primarily stented with 6 x 250 Viabahn and additional overlapping 6 x 100 Viabahn."

Can the stent procedure be coded in addition to the thromboendarterectomy in this situation?

Patient with a history of a gastrostomy tube presents to ED with a Mic-Key button dislodgment. Physician replaced a new button without imaging guidance or without any radiographs. Would we report code 43762, or would this be included in the E/M (facility setting)?

"On day 2 of thrombolysis to right leg from EIV to popliteal vein, the physician removed the EKOS catheter and performed inferior cavogram and right lower extremity venogram followed by mechanical thrombectomy to CFV, EIV and CIV. Venogram was repeated and showed minimal clot and stenosis in CIV, EIV, and CFV. Balloon angioplasty and stents were placed in the CFV and EIV. Repeat IVUS performed and showed stenosis in the EIV above the stent. A single 18 mm x 80 mm Wallstent was used to across CIV, EIV and CFV without any extension into IVC."

I have coded 37187, 37214, 37238, 37239 x2, 37252, 37253 x2, 75825, and 75820-RT. Are RLE venogram and inferior cavogram billable with the additional interventions?

8-year-old patient with heart transplant came for heart biopsy to check to possible rejection. Right heart catheterization with superior vena cava angiogram, pulmonary artery angiogram, and right ventricle angiocardiograms were done with biopsy. How do you code for right heart catheterization: 93593 or 93451?

Would we report code 93318 for monitoring purposes for ongoing assessment of cardiac pumping function and therapeutic measures on an immediate basis, while the patient is in the OR, even if the probe was not placed by the cardiologist performing the TEE? The descriptor states "including probe placement", but if the cardiologist performs everything that this code describes minus the probe placement, would we still use 93318 or a different code? We aren't sure, because it does not say "including probe placement, if performed".

Which are the primary codes for 47550? This code is identified as an orphan add-on code. No recommended primary codes are identified and/or the primary code may be published by the MAC. How do we code spyglass scope cholangioscopy with biliary tube removal? Is it okay to use 47550 with 47537? Please advise.

How do we code breast biopsy procedures when two lesions were biopsied by two different doctors on the same date of service? Would it be 19083, 19084? Primary breast biopsy codes have 1 MUE. Please advise.

I would like to confirm the coding instructions included in the Interventional Radiology Coding Reference 2017 edition are the same in years 2014-2016, for CPT codes 37238-37239. These instructions are listed on pg. 271 of the 2017 edition (Peripheral and Visceral Arterial and Venous Stent Placement Guidelines.) I only have access to the 2017 edition. According to the 2014 CPT Changes book, the instructions look to be the same throughout 2014-present day, just wanted to confirm with the expert.

Why is 34716 allowed with open heart surgeries when the NCCI Policy Manual states: "Cardiopulmonary bypass requires insertion of cannulas into the venous and arterial circulation, which is integral to the procedure. HCPCS codes for insertion of the cannulas into the venous and arterial circulation shall not be reported separately." https://www.cms.gov/sites/defa...

We have a case where the coder feels 34716 should be billed with 33533 and 33405 because the CPB is placed in the innominate artery. There is no mention of a diseased or small vessel. The CPB appears to be standard, but mentions that a Dacron graft is sewn to the innominate artery to assist in cannulation.

1. Why is 34716 allowed with CPT codes 33533-33848 if CPB is integral to procedure?

2. On the flip side, is the coder correct in reporting 34716 with CABG/AVR when the innominate was cannulated. Is it considered to be close enough in the territory of axillary/subclavian to report 34716?

"Provider performed coronary artery bypass grafting x3

1. Saphenous vein to the posterior descending artery.

2. Saphenous vein to the obtuse marginal.

3. Left internal mammary artery to the left anterior descending (skeletonized, in situ); taken down

4. Saphenous vein to the left anterior descending artery

The LIMA flow had become significantly decreased, the graft had dissected proximally. the provider then harvested saphenous vein left leg. He took down the left internal mammary artery anastomosis to the left anterior descending artery then he completed the distal vein graft to the left anterior descending artery anastomosis."

Would you code this as 33533-53 33518 or 33512-22?

I have another question in re: to Question ID : 8468. Would a fellow working under the direct supervision of the attending physician be considered a qualified healthcare professional for billing moderate sedation purposes?

Should this be reported as 49424 and 76080 or with an E/M level since the intent was for removal?

"HISTORY: Pyelonephritis. Left renal abscess drain tube removal requested. Contrast was gently hand injected through the existing 10.2 French multi-purpose drain tube under fluoroscopy. Fluoroscopic images were archived. The skin site was cleaned, and the dressings were changed. FINDINGS: The existing left renal abscess drain is patent and in expected position. No resistance with injection. Images demonstrate resolved abscess cavity with no evidence of any communication hollow viscera. IMPRESSION: Resolved left renal abscess cavity. Drain removed without complications."

When coding for pelvic floor Botox injections, how would a case be coded if Botox was injected into the following muscles:

• Bilateral obturator internus
• Bilateral pubococcygeus
• Bilateral piriformis

What if we also complete a pudenal nerve block in the same encounter with 1% lidocaine?

I have myself confused. The lumbar region was prepped and anesthetized. 22 gauge spinal needle was entered into the intraspinal space, and 24 mL of Prialt was injected. Is it correct to report code 62322? No guidance was used. Injection was given so 62270/62272 not accurate?

Our facility is seeing TMVR with Edwards Sapien M3 Encircle Trial. We are not sure if this is coded 33418, 0483T, 33999, or another code. Can you please advise on the correct CPT code? "OP: DX Severe MR, high risk for surgery, enrolled on the SM3 EFS clinical trial. Procedures: Transcatheter mitral valve replacement under Encircle Trial using a transfemoral venous route and a 29 mm Sapien M3 device. Atrial septal defect closure."

1. Successful left atrial ablation with linear lesions for posterior wall isolation.

2. Successful cavotricuspid isthmus ablation.

Procedures:

1. Ablation of atrial fibrillation with pulmonary vein isolation.

2. Ablation of second distinct tachycardia focus.

3. Linear lesions/CAFE ablation for treatment of afib.

It was found that there was four vein pulmonary vein isolation persisting since the prior ablation.

Wide area of left atrial circumferential ablation was then performed. Radiofrequency energy was delivered within the left atrium to widen the isolation of the antra of the right inferior pulmonary vein.

1. Baseline persistent four vein pulmonary vein isolation from prior ablation.

2. Successful delivery of linear lesions to the left atrium for posterior wall isolation.

3. Successful radiofrequency ablation of cavotricuspid isthmus curative therapy of right atrial flutter.

Is this case a posterior wall ABL,  or is widening the antrum a PVI? Pre/post dx is afib only. No history of flutter. What is meant by curative CTI and is 93655 appropriate for the CTI?

Which code would be appropriate for sclerotherapy of cluster varicose veins? 

"Attention was directed toward treating the left cluster varicose vein. Access was obtained near the mid calf, andguide wire was easily passed up to the proximal calf. Local anesthesia was administered, then the left cluster varicose vein was ablated from the mid calf to the proximal calf using chemical ablation with a foamed solution of 5ml 1% Varithena foam. Attention was then directed toward treating the second cluster varicose vein. Access was obtained near the mid thigh, and guide wire was easily passed up to the proximal thigh. Local anesthesia was administered, then the left cluster varicose vein was ablated from the mid thigh to the proximal thigh using chemical ablation with a foamed solution of 5ml 1% Varithena foam."

Patient comes in for a CABG where the doc is going to use an artery and a vein. He harvests the saphenous vein endoscopically (33508), but once he looks at it he determines he can't use it. The vein is damaged from a previous sclerosing procedure and not viable, so now he can't use it. The doctor harvests the radial artery instead (35600) with another internal thoracic artery.  The intended procedure was 33533 and 33517. Now, since we are using two arterial grafts and not the saphenous vein, wouldn't we have to change to 33534 and 35600? Also, what about the saphenous vein that couldn't be used? The doctor still performed the harvesting, and I think he should still get paid for that, but 33534 can't be billed with 33508... such a dilemma! What is a person to do?

We often have patients that are seen in the radiology suite for wire/clip placement prior to going to the OR for excisional biopsy of the breast. Can we report both codes 19125 (excision of breast lesion identified by preop placement of radiological marker, open, single lesion) and 19285 (placement of breast localization device)? This question was asked back in 2015, but I wanted to see if you had any updated advice for 2022.

What is the correct code for a percutaneous paraaortic/periaortic lymph node biopsy, 38505 or 49180?

Would code 33222 be appropriate for this scenario?

"Local anesthesia was then administered to the skin and fascia in a more medial location to existing generator. A new more medial incision was made. A pocket was created more medially using both sharp and blunt dissection. Next, the old generator, RA lead, and RV lead were freed and removed from the pocket. With gentle traction of the chronic RV lead, the RV lead was removed from the generator header confirming a loose set screw. The chronic RV lead was tested and revealed acceptable pacing/sensing values. The pocket was then irrigated with antibiotic containing saline solution. The RV lead was then reconnected to the chronic pacemaker generator. The generator and lead system were then positioned in the pocket. A TYRX antibiotic pouch was placed in the pocket. The pocket was then closed."

Would 33223 be appropriate for this scenario?

"The MD abandons the existing ICD device pocket and decides to put the existing ICD device submuscular through the same incision."

I found similar situations, but was unable to find one pertaining to this scenario. Patient came in for LV lead placement to an existing pacemaker, but after imaging there was an obstruction. Therefore, patient's existing RV lead was moved to his RAA, and a new lead was inserted into the His bundle. We are wanting to use codes 33215 and 33216, but there is an NCCI edit for these codes. Is a modifier appropriate? 33215-59 with 33216? Or would only the comprehensive procedure 33216 be billed out?

How would we code the bovine patch pericardial repair in this scenario?

"As the surgeon began to place the annular suture for the aortic valve replacement, there appeared to be a separation of the intima within the aortic sinus. This was likely a chronic type A dissection involving the sinus superior to the coronaries. This probably caused his severe AI, as the l/R commissure was likely weakened. We sewed a piece of bovine pericardium to the edges of the dissection. Our bites involved full thickness bites of intima, media, and adventia on the aortic side. With the dissection excluded, he then proceeded with the valve replacement."

"History of necrotizing pancreatitis, infected pseudocyst post gastrostomy, distal pancreatectomy and multiple washouts Patient with a fistula between stomach and left upper quadrant fluid collection, presenting with existing pigtail in place with concern for residual phlegmonous change, request for fibrinolytic therapy. Patient was placed supine in the angiographic table. Approximately 2-3 cc of normal saline flush was performed. Contrast was very slowly injected via the existing tube under fluoroscopic guidance, immediate extravasation was noted into the superficial soft tissues of the left lateral body wall. At this point the procedure will was aborted and TPA was not instilled given extravasation."

Is it appropriate to report code 49465 since the fibrinolytic therapy was not performed?

A biventricular ICD replacement was performed with existing RV, RA, LV leads. The existing LVL was capped, and there were no appropriate branches for LV pacing, so a left bundle lead was placed. Is 33264 the appropriate code for this procedure?

Would this be 33240? Or 33262 with 33202? "17-year-old status post AICD for primary prevention in 2013 via small left anterior thoracotomy with generator in right upper abdomen who now presents with v-lead fracture requiring new ventricular lead. After sternotomy was performed, 25 cm epicardial bipolar leads were brought onto the field and held in place in what appeared to be good locations. The old pacemaker generator incision was re-entered, and we dissected down to the old generator itself. This was carefully excavated from the pocket, and we could see an area of insulation fracture at the spot where the lead inserted into the device. The new generator was brought onto the field. It was wider than the other generator at its base, but tapered in terms of width and thickness more distally. The pocket was therefore widened to accommodate the new generator. The old ventricular leads were capped. The new v-leads were tunneled from the inferior aspect of the pericardial well into the old pocket. These leads and the AICD leads were then inserted into the new generator and secured."

My physician did a bilateral lung transplant on ECMO instead of cardiopulmonary bypass. Is it appropriate to bill the bilateral lung transplant codes 32853, 32856 with the VA ECMO code 33947?

During open excisional axillary node biopsy procedure (deep - 38525), the surgical oncologist saw there was hemorrhaging and called in the vascular surgeon, who then discovered venous and arterial bleeding from the main thoracodorsal artery, which he suture repaired, and a nearby vein, which he suture ligated. My first thought was to report code 35216 for intra-thoracic artery repair; however, this artery does not seem to be intra-thoracic but rather runs down the side of the body from the armpit. Is there a code we can use for the arterial suture repair and the venous suture ligation, or should we use unlisted code 37799?

Why is there an NCCI edit so that you cannot bill 93355 with 33361, 33340, 33418, 93580, and all other structural heart procedures? Depending on the above procedure I have a physician mix of interventional cardiologist, CT surgeon, and anesthesiologist, with anesthesia managing the TEE during case, now unwilling to do because of billing and liability.

Would code 93563 be appropriate without SVT being induced/treated? "He presented in AFL with CL 240 ms with proximal to distal CS and RR 490-700 ms. QRS 70 ms, HV 43 ms, QT 380 ms. It was counterclockwise CTI dependent flutter with full CL in RA. Short 8 French sheath replaced by long RAMP sheath. Linear ablation was performed in AFL from 6 o'clock position at tricuspid annulus to IVC junction. We used 35 watts at 25 sec lesions. During ablation, AFL terminated to sinus brady. RF done on septal aspect of CTI close to TV annulus resulting in bidirectional block across CTI. Post ablation trans isthmus conduction time was 165 ms medial to lateral to 170 ms lateral to medial. Aggressive burst pacing and programmed stimulation using single and double atrial stimuli did not induce any SVT, AF, or AFL. Successful CTI ablation for typical AFL."

When billing the interpretation for Holter monitors placed in the IP or ER setting: What would be the correct place of service to use/bill for the interpretation CPT if Holter monitor is placed in IP/ER setting but report/interpretation was completed in the physicians office?

Our hospital acquired a new type of imaging, and we are wondering what CPT codes we can use for Loop-X, Airo, and O-arm. This is for facility billing.