Ask Dr. Z

I need your expertise on this case. Our provider performed transesophageal echocardiogram, color flow Doppler, pulse Doppler limited. Our department submitted 93312, 93321, and 93325; however, our second level reviewer recommends 93312,93319, 93321 because 3D was mentioned in the body of the report. I checked the images saved on file and it shows both color flow velocity mapping 93325 and 3D echocardiography imaging 93319 was performed. Per CCI edit 93325 is bundling with 93319 because 93325 is in column 2. However, per parenthetical instruction in CPT manual for 93319 it says "Do not report 93319 in conjunction with 76376, 76377, 93325, 93355." I'm confused on what to report in this case. Should I report 93319 or 93325. Please advise. 

Patient had a PCN in place, which was removed over a guidewire. Then a catheter was advance over the wire, down into the ureter, and out the urostomy. A UDC cath was then placed retrograde over the wire with a pigtail loop formed in the collecting system, and the wire was removed. I want to code 50688/75984 here, but I am wondering if we can also code 50389 for the removal of the PCN?

Looking into possible same day discharges for Watchman patient. Can the patient be discharged same day while still being an inpatient admission? More and more facilities are discharging same day. Please advise if this would affect payment.

What code is used for a barium esophagram performed during a cardiac ablation? 74220?

Provider states that the pre-interventional distal flow is decreased(TIMI 1). Interventional guide catheter was used to successfully engage the vessel. A straight tip pilot 50 was used to cross the lesion. A guidingguidezilla II 7FR guide liner catheter used for additional support. Angioplasty was don with sapphire ballon 1.0x8. multiple infations were performed. maxumum pressure: 20 atm. inflation time: 11 sec. The pos-interventional distal flow is decreased(TIMI 1). He then states that the RCA is 100% stenosed CTO. and was unable to cross the proximal RCA. He did a LHC and coronary angiogram. My question i coded it with 92943-RC and 93458-26-59.My clinic staff are wanting me to amend it with 53 for the professional and 74 for the hospital. My understanding is because he crossed the lesion with the wire it does not need the 53/74.

On balloon assisted embolization of the cerebral AVM would the Scepter Mini balloon be separately coded, provider requested 95999. Left Occipital AVM S-M grade 2, main arterial feeder distal left PCA, aneurysm

Scepter mini balloon was prepped and introduced into the intermediate guide catheter over microwire and placed distal left PCA over microwire. Super selective run from distal left PCA demonstrated good position of the scepter mini, with good visualization of the AVM as well as intravenous gadolinium verses distal arterial aneurysm .3mg Brevital was give, no change in neural monitoring. The balloon was inflated gently underlive fluoroscopic guidance. Next, balloon catheter was prepped with DMSO and subsequently ONYX 18 was injected in under live fluoroscopy guidance to embolize the AVM and the aneurysm, The balloon was deflated and subsequently removed.

With embolization procedures 61624,  would these also be coded with unlisted 95999, comparison code?

Could you please share feedback on billing of IVUS and diagnostic venogram when findings are patent/0% stenosis for the vessel? Should we be billing for both? I have some providers that bill for both with normal findings.

I am coding for a hospital, and we are being told that 0715T is for use for physicians only and not valid for facility billing. Can you confirm whether or not 0715T should be coded for facility when performed in conjunction with the codes listed in the CPT book 92920, 92924, 92928,92933,92937, 92941, 92943, 92975?

I am having trouble coding valve-in valve TAVRs, etc. I was trying to paste the report but too many letters. Procedure: Valve-in-valve transcatheter aortic valve replacement with a #26 Sapien 3 Resilia valve. Is there a good way to get better coding these cases? Does your cardiothoracic book help? My office usually uses CPT 33999, but I do not know why. I tried to post the report but it wasn't letting me.

Real-time visualization of the common femoral artery and vein were identified as the artery was accessed. At this time the Neurosurgery team expose the T10 screw and transected the upper segment of the rod and prepared the screw for removal. Under the protection of a Kumpe catheter a Lunderquist wire was placed into the aortic arch. We upsized to a 16 Fr DrySeal sheath via the left groin. A 28 x 33 mm Gore cuff was advanced to the area where the screw was. Under fluoroscopic visualization the screw was slowly backed out and the stent graft was deployed over the area where was located. The screw was then ultimately removed with no signs of bleeding. We exchanged for a flush catheter and two views demonstrated patent stent graft with no extravasation. Perclose devices were tightened over a stiff wire after the sheath was removed with good pedal pulses. Protamine was given. The remainder of the spine closure was performed by Neurosurgery. 

Would you consider this 37236 or 33881 for the stent graft?

How would you code an LVAD outflow tract occlusion using a combination of embolization coils and vascular plug?

Which code, if any, should we report when a covered stent was used due to uncontrolled bleeding at the access site during TAVR (for pro fee)?

A stent was placed in the severe calcified lesion in the RC. Then another stent was placed in the RC acute marginal branch and was stented across in order to save the main RC and was occluded and the end procedure end. What should be the code if any for the stent placed to occlude the marginal branch? 

The TAVR delivery went smoothly except our cardiologist also did... "The origin of the left main was then cannulated with a moderate degree of difficulty given the cephalad course of the left main and a low coronary height. A BMW guidewire was then advanced to the LAD and a 4 mm stent was advanced to the left main and into the mid LAD. A GuideLiner device was left in place to facilitate stent delivery of a stent in the left main in the event of left main occlusion related to valve deployment." Unfortunately the patient has significant disruption of the femoral artery and needed open repair, which was not done by our cardiologist. Can you please advise if the portion that our cardiologist perform would be considered complex? I know that we cannot bill for the stent, and I am not sure we can bill with the -22 modifier.

We are pretty clear on moderate sedation documentation requirements, but we are a teaching hospital and our attendings are not in the room the entire time. Can a time the resident is there face to face with patient be counted since the resident/fellow is the one performing the procedure under supervision of attending?

Twiddler issue, extracted RA, RV and LV removed and re-implanted the existing CRTD with a new RV lead.

I am thinking 33224 for the LV lead extraction and 33225 for the RV and RA extraction, but I am not finding a code for the removal and re-implanting of the PG and new RV lead?

Is it appropriate to report a -52 modifier when the chest is left open following a heart procedure?

Please clarify if it is acceptable to bill a post-biopsy mammogram 77065 or 77066 unless it is a mammography-guided biopsy as noted in the NCCI Manual. The AHA 1st Qtr 2022 lists an example to illustrate the NCCI guidance, which I think is incorrect but others disagree.

Per AHA answer to Question 1: "It is not appropriate to assign CPT code 77065 following placement of a breast localization device represented by CPT code 19085." "In this case, since the confirming mammogram is not a diagnostic exam, it is not appropriate to additionally assign CPT code 77065."

In regards to repeated imaging studies, the 2023 NCCI Policy Manual (Chapter IX, page 5, C-1) states, “However, if additional films are necessary due to a change in the patient’s condition, separate reporting may be appropriate.” What constitutes a “change in condition”? Can it be any or all of the following: reduction of a fracture, tube reposition, cast placement? 

I'm sure you've answered this question, but unfortunately it seems the information I've shared from your Q&A database doesn't satisfy the provider.

A known thrombus in the SFA is treated with Jetstream catheter, then atherectomy and stent are placed. This is coded with 37227 and 37184.

Meanwhile, secondary thrombus is found in the tibials, and a separate Penumbra catheter is used to treat those vessels to remove thrombus. Provider also wants to code 37186.

CPT guidelines direct coder to NOT report 37184 and 37186 together. The provider disagrees stating that the Penumbra catheter is very expensive to use and should be able to report for the extra work involved.

How would you handle this?

The following procedures were performed: 1) Bilateral internal carotid artery selection and diagnostic angiography, 2) Bilateral vertebral artery selection and diagnostic angiography, 3) Coil embolization of an anterior communicating artery aneurysm. Can the provider get credit for the catheter placement (no angiography) in the anterior communicating artery for the embolization? If so, would 36218 be the correct code since the vertebral arteries were selected?

If a physician sees a patient in the office and performs an NG tube placement (43752) and does not utilize fluoroscopy for the placement, can he/she bill 43752-52, or does he/she need to drop an E&M code for this service? It was not placed due to an emergency, but was placed due to feeding difficulties. An x-ray was taken after to confirm the correct placement of the tube.

For the above tests, the supervising provider listed in the report is the PA. The interpretation is done by the physician. The codes billed are 78452 MC, 26 and 93018. If the physician is only billing for the interpretation of the stress test, do we add a -52 to the 78452 for the interpretation of the myocardial spect studies for the physician. The physician is just interpreting that portion of the test as well?

Op note states: "Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological S&I; US-guided left common femoral artery puncture using micropuncture needle; R lower extremity angiogram; IVUS aorta, right common iliac artery, right external iliac artery, right common femoral artery, right superficial femoral artery, right popliteal artery, right tibioperoneal trunk, right anterior tibial artery, right dorsalis pedis artery, right lateral tarsal artery, right peroneal artery, right posterior tibial artery; IVUS left common iliac artery, left external iliac artery, and left common femoral artery. Angioplasty, atherectomy, and stenting performed right leg, mild disease found L leg. No angiography of left leg performed." 

How many IVUS can be coded? Our coder states one per leg, code description states per vessel, but MUE is 5. Provider wants IVUS coded for every vessel. What guidelines are available to support correct coding?

I have a provider that attempted to do a left heart cath, unsuccessful attempt to obtain radial access, common femoral access, unsuccessful attempt to cross the aortic bifurcation. Intraoperative recommendations/ consultation with another provider who them successfully completed the cath. Can we bill anything for the unsuccessful portion? 

If the EP physician, not the cardiologist, places the semi permanent active fixation lead (33216) because the patient is high risk to develop rhythm problems, can he bill for the placement of the lead? From the hospital standpoint we know it is bundled and not billable.

"During the RFA, patient had transient suppression of the clinical PVCs, and clinical PVCs were seen again. Hence, the decision was made to ethanol ablation for the first septal perforator. A balloon was advanced over the wire in the first septal perforator and dilated. Next, ethanol was injected through the manifold. After 1-2 cc of alcohol, the patient had flurry of PVC and soon led to complete suppression of PVC. A total of 5 cc of alcohol was injected.

CONCLUSION: Successful LV summit PVC ablation - from RVOT/LVOT/CS and ethanol ablation."

Is there a code for the ethanol ablation, or would this be included in 93654 since the RFA and ethanol were both treating the PVCs?

Patient has biventricular ICD with previous capped/replaced RV lead. New RV lead is now fractured and is coming back for extraction of both RV leads and replacement of biventricular ICD with biventricular PM with new RV Lead.

The physician plans on placing a left bundle pacing lead and a cardiac resynchronization pacemaker pulse generator. I will attempt to salvage his chronic right atrial and chronic coronary sinus pacing lead. 

How would you code this? 33241, 33207, 33235?

Please review our coding. A group of us have put our heads together and after research we came up with code 33863 for the following op note.... 

"Aortotomy was performed and aortic valve inspected. Aortic valve was noted to be a bicuspid valve which was removed. Extensive annular debridement & copious irrigation was performed. A #25 Carpentier Edwards Ispiris was sized and sutured into place. The aortotomy was closed. Aortoplasty with aneurysmorrhaphy was performed with 3-0 sutures. Deairing of the aortic root was performed and aortic crossclamp was released. Deairing was confirmed by Tee )93314-26) Good prosthetic valve function was noted. Aortic cannula was removved, hemostasis confirmed, Ascending aorta wrapped with Hemashield graft down to a 2.7 cm diameter using ethibond sutures as stay sutures and then running suture closure."

Previously you had said that placement of a psoas muscle abscess drain you would code retroperitoneal (49406), but I am wondering if 10030 (drainage by catheter, abscess soft tissue) would be more appropriate since the CPT book says "(eg, ... abdominal wall)" and the psoas muscle might be considered soft tissue and not retroperitoneal. If not, can you explain why? Code 49406 pays a lot more than 10030, and I don't want to overcharge these cases.

Case is: MV replace and CABG times 2: LITA- LAD and SVG- OM. My question pertains to the debridement work in the Op report prior to valve replacement.

"..Then I paid attention to the mitral valve. Left atriotomy the mitral valve was exposed, severe dilatated mitral annulus/severe posterior prolapse with a 1.3 cm long vegetation posterior leaflet not able to be repaired due to extension of the infection to the annulus. I decided to replace carefully resected the anterior and posterior leaflet. acceptable annulus debridement was accomplished to perform a mitral valve replacement using an Abbot Epic Porcine tissue valve #29 "

Due to the stated length of the vegetation removed + extent of the infection, can any additional work be billed with 33430? I'm considering:

33426, -59 along with 33430

OR

33430 -22?

How would this be coded? Renal Stent 37236, IVUS 37252, Shockwave balloon atherectomy 0234T?

1. Right and left renal artery selective angiograms and gradients assessments.

2. Proximal left renal artery intravascular ultrasound assessment followed by Shockwave balloon atherectomy (5.0 x 60 mm) followed by predilation, 5.0 x 20, followed by bare metal stent placement, Biliary Express, 5.0 x 19 mm, followed by post-dilatation, 5.0 x 20.

The highest success rate of adequate stent deployment here would be that of applying of a shockwave atherectomy and calcium lithotripsy balloon, 5.0 x 60 mm. Several runs were performed with placing the crystals in adequate positions, and towards the end of our deployment we obtained successful results. We used a new IMA 6-French guider and across the Spartacore wire, we placed it adequately at level of abdominal aorta close to ostial left renal artery. We obtained good angiographic results without a waist on this balloon, and then we placed a balloon expandable bare metal stent.

Would I use CPT 42400, 76942, and 10160?

Ultrasound of the left parotid region was performed. The cyst was identified and multiple images were stored. The skin was prepped using ChloraPrep, and allowed to dry before sterile draping applied in the usual sterile fashion. Using lidocaine for local anesthesia as well as direct ultrasound guidance, using an 18 gauge Biopince needle, 2 core biopsies were performed obtaining tissue from the periphery of the cyst. Next, an 18-gauge needle was used to aspirate 5 mL of red fluid from the cyst itself. Ultrasound images of needle entry were saved and sent to PACS. A sterile dressing was applied. The patient remained stable during and immediately after the procedure.

Impression: Ultrasound-guided percutaneous core biopsy and aspiration of a left parotid cyst.

My provider has selected both the right and left main pulmonary arteries and performed selective bilateral pulmonary angiography. He then further selects the left upper and middle lobes, performs selective angiography in each. Then, on the right also selects the upper, middle, and lower lobes and performs angiography. Does 75743 cover this, or can we bill 75774 for additional selective views?

Is it appropriate to bill for both a PENG block and a cutaneous nerve block for post operative pain management?

Patient came in for a re-do PVI. One pulmonary vein was no longer isolated. Patient did not have atrial fibrillation. Patient had A-flutter and CFAEs. Since the patient did not have A-fib, should this be coded to 93653 (supraventricular ablation), or would the CFAE qualify this for a 93656 (PVI)?

How do I bill when the MD implants a single chamber generator (C1786) attached to only a CS lead (C1900)?

Challenging situation given complex anatomy, with deference of PPM for the same before. Only option for pacing is if coronary sinus anatomy is favorable (for CS lead). Currently, he is HDS, and HR has improved to 50s.

Should we create a new unlisted procedure with CPT 33225?

What would be the CPT codes for ultrasound-guided direct injection of medication into the prostate for prostatitis?

A digital rectal examination was performed, the rectum was cleaned with Betadine solution. Under ultrasound guidance, the medication solution injected directly into the prostate gland.

The solution contained the following:

1. Ceftriaxone

2. Dexamethasone

3. Lidocaine

4. Ketorolac

10 ml of this solution was injection onto each lobe of the prostate gland.

THERMOABLATION OF HEPATIC MASS 43782/77013

Given the occult imaging findings of the liver mass, the decision was made to performed adjunct localization with postcontrast CT via a microcatheter in RHA

SELECTIVE CELIAC ANGIOGRAM,No hepatic artery arises from the celiac trunk.

SUPERSELECTIVE RIGHT HEPATIC ANGIOGRAM,catheter is noted to be in adequate position for postcontrast CT guidance

catheter was exchanged for a 6 mm x 2 cm Mustang balloon. The Mustang balloon was inflated in the mid-to-distal right hepatic vein in order to diminish the heat sink effect.

RIGHT HEPATIC VEIN VENOGRAM

Using CT guidance, the microwave ablation needle (NeuWave Medical PR20XT Intelligent Ablation Probe 20cm x 15Ga) was advanced into the posterior right hepatic mass.

RIGHT COMMON FEMORAL ARTERY ANGIOGRAM

CLOSURE OF THE RIGHT COMMON FEMORAL ARTERY WITH VASCADE CLOSURE DEVICE

Our IR providers are billing 76937 with every sclero they perform. They say, "The targeted vessel was sonographically evaluated and judged to be appropriate for access," but in most cases are not documenting that images were obtained. Should this be 76942 instead of 76937 (if documentation supports)?

What is the proper way to count multiple AP views with limbs in different positions? For example: "AP views of the shoulder with the humerus in external and internal rotations" and "AP Pelvis with the hips in neutral and frogleg positions." If we are counting the views, only an AP view was done (considered one view), just multiple time with limbs in different positions. What are the coding guidelines for multiple images of the same view with limbs in different positions? Do they still count as a one-view study, or does the different positioning count as different views making the shoulder a two-view study and the pelvis a two-view study instead of just a one-view study? Thanks.

How do we code documentation of plaque in the carotid artery when a patient undergoes a duplex scan of the carotid arteries in neck (93880)? Given impression: "Mild atherosclerotic plaque in the carotid arteries bilaterally. No sonographic evidence of hemodynamically significant carotid stenosis." Is it correct to assign I65.23?

Our cardiologist is reporting CPT code 93284 and essentially we are only finding an interpretation summary performed by an EP with just a co-signature by the physician without any further documentation and/or confirmation. We do not feel that this supports the billing of the professional component of 93284. Thoughts?

Is an AngioSculpt scoring balloon coded as angioplasty like a cutting balloon or atherectomy?

What is the CPT code for apical aortic bypass? The descending aorta graft is throwing me off. I was thinking a Bentall 33863, but that doesn't include the descending aorta. "A Heartmate apical coring device was used to make a large cord in the apex of the heart utlizing a 28 mm graft, then a 25 mm connect aortic valve conduit was connected to the 28 mm gelweave graft and then it was anastomosed to the 18 mm partial bypass was connected to the descending aorta." Is this an unlisted procedure?

Per CPT Assistant (September 2017, Volume 27, Issue 9, page 15), the following elements are required to report a complete fetal echocardiogram study(76825):

- imaging of the fetus to identify fetal orientation and the fetal cephalic/caudal ends

- Extremities

- Spine

- Determination of fetal sinus (fetal visceral orientation)

- Evaluation of all parts of the heart (including venous connections, chambers, competence, and movement of valves: great arterial connections; and evaluation of cardiac function using M-mode (and /or spectral Doppler, when indicated)

Please elaborate as to the documentation requirements to satisfy the elements of the extremities and spine. Would it be acceptable to say something like “spine and extremities visualized”? Would that cover the requirement?

How is venous insufficiency with ulcer of lower extremity coded?

I87.2 plus ulcer code or I87.31_ plus ulcer code?

Should we query if the provider for IR is documenting the selected vessels under the broad term "selected vessels separately" from the body of the report and not stating they are within the vessels using the term selected, in vessel, or sometimes using direct catheterization within the vessels? There is debate over this on a coding team, and I'm curious to know what would be acceptable terminology for selective catheterization. 

If facet joints are aspirated for fluid due to septic arthritis, should we code 20600 or 62267 as suggested on question 5136? The answer for question 16327 was for cyst rupture/aspiration which is not the case I have.

Patient had stent placed for CTO of LD and angioplasty for CTO of the diagonal.

Would I use 92943-LD and 92921-LD?

Or would I use 92943-LD and 92944-LD?

Physician is questioning.