Ask Dr. Z

Our radiologist changed out a patient's port reservoir for a larger size and connected it to the existing catheter. Are we able to report this using 36578 for partial replacement? 

"An incision was made over the existing port. Using a combination of sharp and blunt dissection, the existing port was delivered through the incision. The existing port was a small port body. A new large port body was attached to the catheter. The new large port was then advanced into the subcutaneous pocket with a small amount of dissection."

Should any contrast used in an insufflator be considered as wasted contrast?Example: isovue 300 44cc used (20cc in the insufflator).

Would it be appropriate to code 92920 with TAVR? Patient has a patent LM/LC stent protruding into aortic root.

"Via the right femoral artery, a 6F XB 3.5 guide catheter was advanced to the aortic root and BMW Universal 2 coronary guidewire was used to wire the LM stent into the distal LCx artery. A 3.5 x 20mm non-compliant balloon was then prepositioned into the LM/LCx artery stent. The aortic valve was crossed using a 6F AL-1 catheter. An Amplatz Extra Stiff wire with a broad distal curve was positioned in the left ventricle. A 23 mm Edwards Sapien 3 Ultra valve and Commander deployment system were prepared and inserted into the introducer sheath; final assembly was performed in the descending aorta; and the valve was advanced to the aortic annulus. After confirmation of valve positioning, the NC balloon was partially withdrawn with the proximal segment protruding into the aortic root and inflated to 18 ATM. The valve was then deployed in the aortic valve annulus under rapid ventricular pacing at 180 bpm."

Is it correct to report codes 36247, 36247-XS for bilateral selective catheterization of prostatic/uterine arteries? As the arterial system is a whole vascular family, we felt that modifier -50 would not be appropriate. Please advise.

Intracranial Mechanical Thrombectomy, Foreign Body Retrieval with Coil Embolization

A Guide catheter was navigated over a Bern cath into the LT Vert. The Bern cath was removed and the aspiration catheter was navigated to the level of occlusion. A stent retriever was unsheathed across the occlusion. The microcatheter was removed and concurrent aspiration through aspiration catheter was performed. The aspiration and stent retriever was removed. Post removal of the aspiration catheter and stent retriever, the distal end of the stent retriever remained within the LT V4 segment of occlusion. Attempts were made to remove the stent retriever distal limb with a loop snare device. Contrast injections demonstrated contrast extravasation from LT V4. Given extravasation, coil embolization of the LT Vert was performed. 

Can we charge for the embolization? 61645-xu, 37197,61624 and 75894-xu

During aortic valve replacement (33405), a questionable fistula was repaired. Physician notes the significant aorta to the pulmonary artery defect was repaired by direct technique (suture repair). Would this be reported, and what CPT code would be used? Code 33500 does not seem correct since it was noted as questionable and appears to be an incidental finding. Also, aortic root abscess was noted, and debridement of the aortic valve and root abscess was completed with closure. Would this be included in code 33405 since it was necessary to complete the valve replacement?

My provider performed an atherectomy procedure on a patient in the morning, and the patient later developed a hematoma and was brought back to the OR to perform a diagnostic angiogram. Can I bill the diagnostic angiogram?

Pt w/peritoneal carcinomatosis. With fluoro guidance, an angled glide catheter and stiff Glidewire were advanced thru the nose and into the stomach. A 24mm x 4cm angioplasty balloon was advanced into the esophagus over the guidewire. The balloon was inflated and US of the left neck showed a safe window of access for percutaneous transesophageal gastrostomy between the thyroid gland and LT carotid. With US guidance, an 18-g trocar needle was advanced between the thyroid gland and LT carotid. The needle was used to puncture the angioplasty balloon. Through the needle a J-wire was advanced/coiled within the angioplasty balloon. A 2nd operator then advanced the angioplasty balloon and wire into the stomach. Once in the stomach, the wire was separated from the angio balloon and the balloon was removed. Over the wire, after serial dilatation, a 12Fr x 60cm drainage catheter was advanced. The pigtail portion was formed within the stomach. Position was confirmed with contrast and catheter was secured to the skin. 

Would this be 49440 or unlisted 43999? 

The code 75889 falls under the venography CPT rules. I have the below documentation from an IR physician. The actual portion of the pressure measurements within the report, doesn't state the necessity. Doesn't he have to give me more than the below to support?

Pre-procedure diagnosis: Cirrhosis

Post-procedure diagnosis: Same

Indication: Suspected portal hypertension

Additional clinical history: None

Complications: No immediate complications. 

IMPRESSION: Transjugular liver biopsy with 3 x 19-gauge core biopsy samples obtained. The corrected sinusoidal pressure (wedged hepatic vein pressure minus free hepatic vein pressure) is 9 mmHg.

Venography

Vein catheterized: Right hepatic vein

Indication for venography: Document catheter position

Findings: Patent right hepatic vein.  

Pressure measurements

Pressure measurements were obtained via balloon occlusion catheter.

Mean right atrial pressure (mmHg): 7

Mean free hepatic vein pressure (mmHg): 9

Mean wedged hepatic vein pressure (mmHg): 18

Thank you

Is it appropriate to bill for cryoablation of intercostal nerve(s) for the same surgeon that is performing a VATS procedure (or sometimes open thoracotomy procedure)? Per CPT Assistant (November 2019), code 64620 should not be billed because the procedure is to control pain, which is inherent to the global surgical package. Is this correct?

Please advise how to code PV imaged from PA wedge position during cardiac cath (93596). Pt hx: MAPCAs, bilat PV stenosis, s/p repair, ongoing 2ndary pHTN. 5 vessels were selectively cathed w/ hand angio: RUPA, RLPA, LLPA, LLingPA, LUPA, and the findings demonstrates that all pulmonary veins are patent and draining normally into LA, except the LUPA is small and stenotic at entrance to the LA. The new pulmonary imaging codes don't seem to be adequate for this scenario. 93573 is for bilateral selective PA imaging, which doesn't really adequately capture selecting 5 pulmonary artery branches, and also, there are no PA finings, only PV. 93574 is for selective PV imaging, but only for selecting the veins from the LA...unless the superselective PA wedge position counts as PV selection? 93568 can no longer be reported for non-selective PV imaging, and any other cath or imaging codes for pulmonary vessels can't be reported at time of 93596. Imaging the PVs from PA wedge angios is very common at my hospital, how do we appropriately code this with the new codes?

Physiologic means present at birth. Would physiologic tricuspid/pulmonary valve regurgitation be considered a congenital echo?

"Summary: Normal echocardiogram.

Normal chamber sizes.

Normal biventricular function.

No ASD or VSD imaged.

No outflow obstruction.

No evidence of pulmonary hypertension.

No pericardial effusion

Findings:Pulmonic valve: Transvalvular velocity is within the normal range. There is physiologic regurgitation. Tricuspid valve: Transvalvular velocity is within the normal range. There is no evidence for stenosis. There is physiologic regurgitation. Peak TR gradient is 16 mmHg, suggesting normal RV pressure."

If a procedure started as a VATS but was converted to a mini thoracotomy, this would be coded as the thoracotomy, correct?

We received a claim denial for excessive procedures based on the following codes: 35355-50, 37221-50, 37236. The patient had bilateral LE AS with life-limiting claudication and severe proximal aortic stenosis. Our physician performed the following procedures: bilateral iliofemoral endarterectomy with patch angioplasty, aortogram and bilateral iliac angiograms; placement of an 8 x 39 VBX stent within the proximal abdominal aorta; SWL of the left common and EIA; placement of a 6mm x 10cm Viabahn stent in the left EIA; placement of a 7 x 40 bare metal self-expanding stent in distal common and proximal EIA; placement of a 7mm x 15cm Viabahn stent within the right common and EIA.

Are the endarterectomy and stenting procedures bundled, as in two treatments in one vessel? If so, which should be coded? Did we miss coding any of the procedures? Please advise on the correct coding for this case, and why. Thank you.

What would be the most appropriate CPT code for a CT scan of the salivary gland?

"Patient presents for an ICD generator change as well as the removal and replacement of the LV lead. RA and RV leads are functioning properly and are not replaced. Provider removes the ICD generator and removes the existing LV lead. New ICD generator is placed. RA and RV leads are attached to the new generator, and a new LV lead is placed."

Would this be coded as 33241, 33244 for the removal and 33249 since a new generator and a new lead are placed, even though the new lead is a LV lead?

Do you code any catheter placements or imaging when doing a migrated stent (from stent placed in innominate vein) into the pulmonary artery? I'm looking at code 37197. They also did IVC and RT pulmonary arteriogram from right common femoral vein access.

First time i've coded one of these. Please advise.

My provider is submitting 64722 for phrenic nerve neurolysis during TOS procedure. Documentation states, "Complete neurolysis of the phrenic nerve facilitated exposure of the underlying anterior scalene muscle and subsequent structures." Would neurolysis of phrenic nerve be considered bundled with 21615?

Femoral vein central venous line placement: Under ultrasound guidance, right femoral vein identified as being patent. Right groin prepped in sterile surgical fashion. Cannulated right femoral vein. Using a Seldinger technique, central venous line catheter was advanced. The cath was matured, dressing placed. Physician was queried for location of catheter tip and replied "No clinical reason to identify positioning of a femoral catheter. This is not standard of care." The CPT guideline, in part, states: "To qualify as a central venous access catheter or device, the tip of the catheter/device must terminate in the subclavian, brachiocephalic (innominate) or iliac veins, the superior or inferior vena cava, or the right atrium.” This guideline also states that central insertion sites are “jugular, subclavian, femoral vein or inferior vena cava catheter entry site.” Is it necessary for the physician/HCP to also document where the catheter terminates when it is inserted via a central vein such as femoral, jugular, subclavian? Thank-you.

One of our vascular surgeons says that there is often trapped blood after performing sclerotherapy and that she must drain this. She says it takes 30-40 min and is wanting to code 10160 for this. Is this appropriate? What would the dx be in this case?

For facility coding, the patient had removal of a PCN under fluoroscopic guidance (50389) and in post op experienced leakage of urine from the nephrostomy site. Decision was made to replace. Same DOS, four hours later,  a nephroureteral tube was placed. Would this be coded 50389, 50433, or 50434?

During an endovenous laser ablation, the physician also completes a ligation of the greater saphenous vein. "The distal portion of the saphenous, which was directly against the skin had been previously marked, a small 11 blade incision was made utilizing a stab phlebectomy hook the vein was brought to the surface it was doubly tied with 3-0 Prolene suture and returned subcutaneously." How would the ligation utilizing a stab phlebotomy hook be reported? Would this portion of the procedure be reported with CPT 37700?

"The patient arrived in the EP lab in atrial flutter with CL 200 ms. Entrainment was done that showed equal PPI from cs 9-10 and CS1-2. Entrainment from the lateral RA wall showed that the RA was out C/W left sided atrial flutter. We decided to do an emperic RA isthmus line and then cardiovert.

Conclusion: 1) Atypical left-sided flutter. 2) Empiric RA isthmus ablation. 3) Cardioversion of LA flutter."

I am thinking the only thing we may bill for the facility is 93620 because it was a LA flutter, but the RA isthmus was an empiric ablation. Your thoughts are appreciated on this very unusual encounter.

"Under fluoroscopic guidance needle advanced into the epidural space at L3. Contrast injected to confirm needle position and 10 mL of Tisseel was injected."  I have been unable to find any coding guidance on this. It seems similar to a blood patch. How should this procedure be coded? 

We have a question what CPT code should be used for a percutaneous psoas mass biopsy. Should we use 20206 or 49180?

The patient was positioned prone. Initial imaging was performed.

Biopsy target:

- Organ or target location: Other-psoas mass

- Laterality: Right

- Maximal diameter (cm): 4.1

Other findings: None

Biopsy

Local anesthesia was administered. Under CT guidance, the biopsy needle was advanced to the target and biopsy was performed.

Coaxial needle: 17 gauge

Core needle biopsy device: Argon Biopince

Core needle size: 18 gauge

Number of core specimens: 3

Need clarification please on 76937 for congenital heart caths 93593-93597. We understand U/S guided access is included for adult heart caths and all ep/device procedures and "imaging guidance to target zone" (fluoro) is included for cong. heart caths. What about the access done by ultrasound for cong.? Craneware suggests adding modifier (59) to code 76937 with 93593-93597 would be acceptable. Thoughts?

If a synovial cyst is injected with meds, is this still considered an unlisted procedure code, or would this be considered a facet joint injection?

"The needle was then withdrawn into the extraspinal component of the synovial cyst located lateral to the left L4-5 facet joint. The cyst was aspirated and lavaged with preservative-free sterile saline, and then 1 mL dexamethasone was injected into the synovial cyst. The needle was then removed."

If a patient has bilateral PVD and then has a right lower extremity angiogram with a diagnosis of atherosclerosis in the right leg, can I73.9 still be coded in addition to the atherosclerosis code for the PVD in the opposite leg that was not imaged? There is an "Excludes 1" note, but would this be an "unrelated" exception where both codes can be used since there is PVD in one leg and confirmed atherosclerosis in the other?

There has been a lot of discussion around reporting 93571/93572. If FFR is done after administration of IV nitroglycerin, but no adenosine, would it be appropriate to report those codes rather than unlisted code 93799?

What is the correct CPT code for a carina ablation?  We have EP providers that perform additional RF lesions after the initial first pass in the region of the posterior right carina, right roof, and anterior carina in close proximity to the course of the phrenic nerve. This is performed before PVI is completed. 

Due to the carina anatomical location we are wondering if the carina ablation qualifies for the use of code 93657. Does the patient still need to be in A-fib in order to charge 93657 for the additional carina ablation? Does the carina ablation need to be in a different location or is it included in the initial PVI ablation code 93656?

One of my providers pointed out that their coders should be billing stent placement in the Sano/RV-PA conduit with code 33745 when it is the proximal end of the conduit and the documentation supports the portion of conduit stented. My take is that SANO stenting distally, extending into the PA, is reported with the new PA, unilateral, abnormal connection code 33902. But SCAI said in a recent webinar that for the proximal SANO, "if this extends into the RV, then yes, it is an intra-cardiac stent."

So my question is if the scenario is: I stented a Sano were the was distal stenosis and proximal stenosis extending into the RV.  I stented the distal Sano and the proximal Sano connecting with the RV using two separate stents. Can I bill for stenting main PA and intracardiac stent?

Do they get both 33902 and 33745? They are saying two lesions, but they are in the same vessel. I realize one is not covering an undersized stented lesion, but still. 

"A 4 cm incision was made around the prior incision carried down to the device pocket with device extracted. The capsule was carefully dissected. We then disconnected the single-coil, bipolar, defibrillation lead. The capture threshold was 1.0 V at 0.4 ms. The R wave measured 14.6 mV. The impedance was 456 ohms. The bipolar atrial lead was also tested. Pocket flushed with vancomycin solution. Cardiac synchronization defibrillator was re-attached to the leads and implanted in the preformed pocket. Correct needle, instrument, and sponge counts were reported. The wound was closed in two layers with absorbable sutures. The skin was approximated with staples." 

Is it appropriate to only charge 12032?

Hello!

This is regarding Pro-Fee coding only for which we code services for all doctors involved: Physician inserted a new Trans-venous trans-pulmonary pacemaker with lead at the epicardial left atrium via a trans-artery approach for which I came up with 33206. Problem is that 33206 does not allow for assistants (mod 80) but our physician actually had TWO, only one is documented as being an actual assistant though.

All three physicians are part of the Pediatric Cardiology department.

Dr. A is the primary and gets the 33206.

Dr. B is the documented assistant to the procedure and is also credited specifically with helping with the intracardiac echo.

Dr. C is not listed as an assistant but did come in and "assist" by performing a biplane angiogram with pigtail cath in the left pulmonary artery.

Assuming 33206 is the correct code, is there anything we can code for physicians B and C?

Can you confirm if provider treats the AASV in two separate segments/accesses - should it be 36465 or 36466?

I have a case where the patient has two abscess drains. One is left flank into abdomen. The other is left transgluteal into pelvis. Separate abscess collections. For the left flank drain, they do an absessogram and then an exchange (49423, 75984). The left transgluteal drain, they do an abscessogram and then, based on that, decide to remove the drain (49424, 76080). Normally, it's the same drain and abscess and we code 49423/75984 only, due to the separate procedure rule. However, in this case, do you think it's an exception to the rule and we should code these four CPTs together due to separate procedures, drainage catheters and fluid collections? Thanks for your expertise.

The patient had a CABG, and 14 days after the patient has a subxiphoid pericardial window for symptomatic pericardial effusion with respirophasic variation. Is this still code 33025-78?

Hospice patient with malignant melanoma of RT thigh and inguinal lymph node that has eroded thru skin causing acute blood loss anemia. Taken to the OR for debridement, epinephrine injection, and compression packing. Patient wants intervention if indicated for bleed, but does not want any further oncologic treatments. Two days later, due to continued bleed, transferred to our hospital for angiography and IR intervention. Two feeding branches arising from the RT SFA are selected and embolized with microspheres. We are on the fence with this one, as it is the first time we have encountered a severely bleeding tumor. Should the embolization be coded as 37243 because a tumor is treated; or 37244 because the stated indication is bleeding?

Sudden onset of pulsatile bleeding from rt groin pressure applied rt groin immediately. CT angiogram showed pseudoaneurysm & large hematoma in rt groin. external iliac artery stents. Iliac arteriogram revealed large common femoral patch & patent proximal anastomosis of bypass graft w/o evidence of active extravasation. A stiff Glidewire in aorta & brought over 7 mm balloon into external iliac artery and stent graft portion. Incision was made in the rt groin after staples removed. Immediately a hematoma was evacuated. Opened incision, to femoral artery. This is actually a large dacryon or interposition graft. We followed the graft distally until identified bovine pericardial patch on proximal anastomosis of the bypass graft. Immediately there was pulsatile bleeding from the patch. Proximal & distal control by inflating the balloon to 7 mm & clamping distal bypass graft with a straight PV clamp. This provided adequate control for repair. Two 5-0 Prolene sutures were used to repair bleeding from the patch using figure-of-eight sutures. 

Repair 35860 or 35142?

On 1/1/23, CPT guidelines state, "Do not report 50081/50080 in conjunction with 50433/5434 (when performed on same side)." If the nephrostomy is performed by IVR prior to and on same date of service as PCNL 50081/50080 (performed by urologist in OR), would an unlisted procedure be appropriate to report? (Trying to capture the resources and complexity performed in the Interventional Radiology deparment.) This is for facility coding.

Would you code this with 35355 even though there's no mention of endarterectomy? I am thinking this is more of a repair of CFA with thrombectomy open of EIA. I appreciate your expertise!

"Patient had recent TEVAR and now has thrombus in EIA. Arteriotomy over CFA with control of vessels. Fogarty for thrombectomy retrieved clot in the left EIA. With back bleed we noticed intimal injury on posterior wall of CFA, which we thought was the culprit for thrombosis. This may have been secondary to sheath placement for TEVAR. A bovine patch was brought into the field and placed in standard fashion/ anastomosis. Duplex should injury was not flow liming after patching. The one arteriotomy was closed." 

I have a provider that performed an embolectomy of popliteal/tibia vessels with a vein patch (34203). Would you bill for the vein patch with a 35256 on top of the embolectomy 34203?

"We therefore elected to make an incision down in the distal calf overlying the posterior tibial artery after the gastroc muscle thinned out, identified the posterior tibial artery. It was soft. It was disease free, but was firm and hard with thrombus. Because of the size, we made a longitudinal arteriotomy with an 11 blade and a micro Potts scissors. We then passed a 2 Fogarty embolectomy catheter all the way down into the forefoot and were able to pull out a large amount of fresh and old thrombus. We then passed it proximally up to the popliteal artery and pulled it out and we were able to get good pulsatile flow now. Two more passes yielded no more thrombus. We were pleased with the result. We ossicles on the posterior tibial artery and then we splayed open the small vein that we had used and used that as a patch with 7-0 Prolene suture."

What is the CPT code for selective catheterization of thoracic aortic aneurysm sac via laser atherectomy generated transgraft tract?

"52-year-old female presented with multiple myeloma not having achieved remission.

PROCEDURE DETAILS: The area was marked, prepped, and draped. Local anesthesia was administered.  A 14-gauge radiofrequency ablation probe was advanced into the lesion in the right glenoid.  The lesion was  ablated for 4 minutes.  Subsequently, 8 mL of Omnipaque 240 were administered into the lesion via a 10-gauge Bonopty introducer needle.  4 mL of cement were then administered into the lesion via the introducer. All needles were removed. Images were stored.

DEVICES USED: Ablation Needle - 14 gauge Amica. Access Needle - 10 gauge Bonopty.

ESTIMATED BLOOD LOSS: Minimal.

NUMBER AND TYPE OF REMOVED SPECIMENS: None.

RESULTS: Successful CT-guided right glenoid lesion radiofrequency ablation and cementoplasty."

We are suggesting codes 20982 and 23929 for cementoplasty of the glenoid. Is the cementoplasty included with the RFA or reported separately?

After stent placement from the pulmonary side for treatment of a PDA, the physician elected to place a second stent within the aortic side. Would code selection be 33902 with 33904 or 33902 with 37236 for the aortic portion, or possibly only 33902 since this is a single intervention?

Provider inspected level 5 and level 6 but only removed one node from level 5 as a sample. Is this sufficient enough to report 32674-52? STS and AMA coding book state mediastinal AND regional lymphadenectomy, which would lead us to more than one would be typically removed, but he did inspect the area and deemed it was not necessary.

"A level 5 lymph node was isolated and dissected free using the Ligasure. Level 6 was inspected but no nodes noted. The chest was irrigated and suctioned. The area of surgery was inspected for hemostasis, which was adequate."

Question: Is it appropriate to charge venogram 75827 along with 36581?

"Attention was focused to the malfunctioning dialysis catheter initially, which was partially removed with blunt dissection under local anesthetic over a guide wire. An SVC cavogram was performed through the catheter, which showed only a small fibrin sheath in upper SVC unlikely to cause any issues with flow of catheter during dialysis. Subsequently a new tunneled dialysis catheter was advanced over the guide wire. The 13.5 French dialysis catheter was tunneled under skin over right upper chest and then introduced over the guide wire with the tips positioned in right atrium under fluoroscopy guidance."

Can we report codes 36410 and 76937 for midlines and IVs placed using US guidance by our trained vascular access team on inpatients? Also, can we report 36573 for PICC lines placed by the same team of RNs on inpatients?

Can you please give us a source for not coding the biopsy at the time of an ablation procedure such as renal? It has been mentioned at seminars not to code for the biopsy if the ablation procedure is planned, but there is no edit and clients are questioning.

Would the following be coded as 64640 or 64999? The procedure was performed for severe debilitating pain.

"Two 22 gauge Chiba needles were advanced anterior to the vertebral body at the L2-3 level lateral to the aorta under CT guidance. A total of 10 mL dilute contrast material was then injected and repeat imaging obtained. Next, a total of 10 cc of alcohol were injected in each Chiba needle for a total of 20 cc for a lumbar sympathectomy. The needles were flushed and then removed. Follow-up CT was obtained to identify any complications. Successful needle placement anterior to the L2-3 vertebral body level at the lumbar sympathetic nerve complexes with contrast seen in the region of the nerve complexes crossing the midline. Successful alcohol injection for a lumbar sympathectomy."

Should findings described as "trace", "trivial", or "minimal" be coded from diagnostic imaging reports? Are they clinically significant? Why or why not?