Ask Dr. Z

Can X-Rays for INTRA-OP or POST OP checks for needle left after a surgery be coded? Or is this inclusive to the MAIN procedure done by a different speciality?

CLINICAL INDICATION: Needle lost.

XR SKULL LIMITED (70250).

HISTORY: 70-year-old male undergoing evaluation for lost surgical needle.

TECHNICAL DATA: Frontal view of the skull was obtained.

COMPARISON: Intraoperative skull radiograph from same day at 3:36 p.m.

FINDINGS/IMPRESSION: Suture needle overlying the right scalp. Retained needle is noted to be removed on subsequent provided radiographs. Post-surgical change related to cervical spine fixation.

Why do you recommend coding 93655 with a history of that arrhythmia when it is not spontaneous or induced as per the code description? Intro guidelines also state "newly discovered".

Can we bill ultrasound guidance code 76937 with codes 37720-37235? Or only in certain circumstances?

How would you code this procedure since the coronary arteries were not anastomosed to the aorta? Instead they were anastomosed to the RIMA.

MD says: CABG X 3 was performed with LAD to LIMA. Then OM2 was anastomosed to the SVG. Then the Diagonal was anastomosed to the SVG. Then the OM2 vein graft was anastomosed to the RIMA and the Diagonal vein graft was anastomosed to the OM vein graft (which had previously been anastomesd to the RIMA.

The aorta was extremely calcified therefore a no touch aortic technique was used for the bypass graft.

Would you code this with an unlisted code since there was no anastomosis to the aorta? Or would code it with 33533 and 33518? Thank you!

When a cutdown is made over the femoral artery, which is then punctured percutaneously, would this be reported with code 34713 or 34812?

What is the recommended embolization code to use for an intracranial embolization of a sigmoid sinus diverticulum/venous aneurysm? Embolization was achieved by stent-assisted coil embolization in the right lower sigmoid sinus through the right lateral transverse sinus, all vessels accessed/selected were venous. Should the embolization portion be coded as 37241 or 61624? Our understanding of code 61624 is that this is more for arterial intracranial pathology embolized, but we are thinking the 61624 best represents the more complicated intracranial "neuro" work involved. What is the correct embolization code to use for intracranial venous pathology embolized?

Can you charge a stress test 93017 (93015-93018) with cardiac MRI 75563? CPT coding notes for 75563 are as follows: 

• Includes pharmacologic perfusion stress evaluation with contrast
• Code also stress testing when performed (93015-93018)

Can you clarify if pharmacological stress test is performed is that included in 75563?

1.  Technically successful fine needle aspiration of a right pleural/diaphragmatic nodule with ultrasound and CT guidance.

2.  Technically successful aspiration of a right-sided pleural effusion with ultrasound and CT guidance.

3.  Post-procedural right-sided pneumothorax with interval enlargement on 1 and 3 hour post-procedural chest radiographs.

4.  Technically successful placement of an 8 French Abscession chest tube with CT guidance.

Would only the final chest tube placement be coded here (32557)? Would the FNA for the soft tissue nodule be added as well (10021) since guidance is with the chest tube, or report code 10009 since it was done prior to the chest tube placement?

Patient is scheduled for PVI ablation. The baseline rhythm is atrial flutter. The atrial flutter is terminated after transseptal puncture is performed. The physician then performs a PVI for the presence of CFEs. There is no mention of atrial fibrillation in the procedure details, only CFEs. Does the presence of CFEs alone indicate that atrial fibrillation is also present? Should this be coded with 93656 or 93653?

How would a complete abdominal US and a complete retroperitoneal US performed in the same session (combined in the same report) be coded as they have overlapping components to qualify for a complete study?

This is how it is outlines in the report, separated iinto abdominal and renal sections.

AORTA

IVC

PANCREAS

LIVER

GALLBLADDER

BILE DUCTS

RIGHT KIDNEY

LEFT KIDNEY

BLADDER

SPLEEN

If we include the kidneys in the abdominal study, that leaves the bladder only, which would be coded to CPT 76857. If we leave the kidneys for the retroperitoneal, that leaves a limited study of the abdomen with a complete retroperitoneal.

Are there any resources that addresses how to code this scenario? I don't feel it's appropriate to code two complete studies with overlapping components required if they are only being imaged and interpreted once but I am not sure if there are specific guidelines to code this scenario, so any guidance is much appreciated.

Thank you.

I have researched prior questions and have part of the answer, but need some assistance with the CPT code for decortication. THE PROCEDURE: Prior to VATS the Dr performed a bronchoscopy this is not codeable because no secretions or endobronchial lesions were found. Incision was placed in midaxillary line along intercostal space. VATS scope was inserted The parietal and visceral pleura were noted to be inflamed. 200 cc of fluid was drained and whole lung decortication was done for R upper and lower lobes. Debridement was extensive taking 2 hrs. Decortication was performed removing the cortex from the lung, diaphragm, chest wall, and pericardium. Lung and major fissure were partially opened. Due to the appearance of the pleura a pleural biopsy was performed, also 3 nodules were excised for biopsy from the cardiophrenic angle. I used code 32608 for the VATS, drainage, biopsy, and can only find code 32225-52 modifier for the decortication. Would this be correct? 

"At this point, we decided against a bypass and opted for a patch. The patient was heparinized, and a tourniquet was applied to the thigh, inflated to 300. Following this an arteriotomy was made on the distal popliteal artery, and extended past the fibrotic occlusion into the posterior tibial, which was the dominant runoff to the foot, however was extremely calcified in its entire course. A limited endarterectomy of the below-knee popliteal and posterior tibial artery were performed. The endarterectomy this obliterated the origin of the peroneal and anterior tibial arteries with good backflow even while on tourniquet. The great saphenous vein was taken up, and a patch fashioned out of this. This was then sewn in to extend onto the PT for a distance of 5 centimeters, from the below-knee popliteal, with 2 continuous 6 0 Prolene."

Since the arteriotomy was made in the popliteal and extended to the posterior tibial. Would this be coded as just 35303 or can we also code 35304 or 35305?

The patient had an SMA pseudoaneurym. The surgeon states, "The SMA artery was then clamped. We opened the aneurysm. Upon opening of the aneurysm, significant brisk back bleeding was encountered to suggest adequate collateralization. All backbleeding branches were suture ligated. The PSA was unroofed, and specimen was sent to both pathology and micro for evaluation. The main inflow of the SMA PSA was ligated with 4-0 prolene in a running fashion. The SMA was unclamped and noted to be hemostatic."

Would this be a PSA repair (35121), or would a ligation (37617) be more appropriate, or would this be an unlisted code?

We have come across a case where a Watchman was attempted to be placed but was unable to. Physician placed a Sentinel EPD device. Would you use an unlisted code for the EPD? Or charge nothing for the EPD? Usually we see it accompany a TAVR. I'm kind of on the fence since 33370 is not allowed with a Watchman with the CPT code range.

We had a physician check a drainage catheter. After checking the catheter, he injected tPA into the drainage tube and clamped it to dwell. Is there any CPT code for this? I can find for tunneled pleural lines as well as central venous lines only.

When our pediatric CVT surgeon is working together with interventionalist (there are two interventionalists with one assisting, besides our pediatric surgeon) for placing a stent in aortic coarctation, what code would be appropriate for the work of the pediatric surgeon who performs only access the femoral artery cutdown? 

"Transverse incision was performed and carried through the deeper planes until the right common femoral artery exposed. the common femoral artery was dissected circumferentially and purse-strings were deployed. With a Seldinger technique a French sheath was introduced into the right common femoral artery and advanced just distal to coarctation site. (Stents deployed by interventionalists.) Following deployment, the sheath was withdrawn and the purse-strings on the common femoral artery were tightened." 

Is there another code that can explain this situation? I like 34812, but this is an add-on code and not applicable here. Maybe this should be an unlisted code?

Patient came in for an echo after having an AVC repair. Based on the conclusions would you code this as a congenital or non-congenital study?

"Conclusions: No residual atrial or ventricular septal defect. Moderate, eccentric left AV valve regurgitation directed toward the atrial septum and creating a small aneursymal pouch. Mild to moderate left atrial enlargement. Trivial right AV valve regurgitation. Trivial pulmonary insufficiency. Normal pulmonary pressure. Normal biventricular size and systolic function. Known LV to RA shunt, demonstrated in subcostal views.

Indications: AVC repair."

I'm stuck. The following was performed by one of our radiologists. He dictates the exam as a lidocaine challenge. I've been doing this a long time, and this is a first.

"The skin overlying the left total hip arthroplasty was prepped, draped, and anesthetized in usual sterile fashion. Local anesthesia was achieved with 1% lidocaine. A 22 gauge spinal needle was fluoroscopically guided to the synthetic femoral neck and advanced axially. Satisfactory position was confirmed through an injection of a small quantity of non-ionic contrast diluted 2 - 1 with 1% lidocaine. Attempts at aspiration demonstrated no hip joint effusion. 4 mL of 0.25% Bupivacaine was subsequently injected. The needle was removed, and a sterile bandage was applied. Impression: Successful anesthetic challenge with no complication encountered."

My initial thought was to code 20610 and 77002. However, I'm not 100% convinced that is correct.

Our ASC's chargemaster does not include unlisted codes since we were told they are non-covered. Now that the recommendation is to report iFR with unlisted code 93799, how do I report an iFR in an ASC setting?

Is it ever appropriate to additionally code 76380 when cone beam CT is being done for diagnostic purposes in the same vessel angiogram is being coded in? For example: "Selective catheterization of replaced left hepatic artery arising from the left gastric. Angiogram was done in this location along with a cone beam CT angiogram during a Tc-MAA shunting study to locate the enhancing lesions and rule out potential for non-target embolization."

Unable to Obtain ABI - How would this be coded? 93923?

"Procedure: A multilevel physiologic examination of the lower extremity arteries was performed using a four cuff technique and continuous wave Doppler to acquire pulse volume recording and segmental limb pressure measurements for evaluation of peripheral arterial disease.

Bilateral: 1) Patient on VA ECMO at time of exam, therefore PVR/ABI cannot be obtained; toe waveforms and/or pressures only per protocol. 2) Abnormal/flat-lined toe waveforms noted (no pressure obtained) bilaterally, suggesting poor wound healing potential.

Conclusions: Patient on VA ECMO at time of exam, therefore PVR/ABI cannot be obtained; toe waveforms and/or pressures only per protocol. Abnormal/flat-lined toe waveforms noted (no pressure obtained) bilaterally, suggesting poor wound healing potential."

Dr. Z could you advise how to code this procedure. Patient’s right chest prepped. The middle lobe was found and was completely deflated. The lobe was rotated 180 degrees counterclockwise then ventilated confirming good inflation. Once the correct orientation of the middle lobe was verified, the lung was inflated multiple times to select the areas to suture together. Two pledgetted 3-0 Prolene sutures were used to perform the pulmopexy near the apex and anteriorly/inferiorly. Both lungs were then ventilated. There was a clear air leak from one of the suture sites in the middle lobe verifying good aeration. Bronchoscopy verified patency of both the middle and lower bronchi, though there was still edema around the middle lobe orifice. More secretions were aspirated before removing the bronchoscope. The anterior incision was closed with deep Vicryl and simple skin stitches. A small segment of the fractured 6th rib was removed to avoid the edges rubbing together. Pericostal stitches were placed the rest of the incision was closed in 3 layers with Vicryl suture.

Is it appropriate to report unlisted code 37799 for excision of an artery with a femoral stent from a previous in-situ femoral popliteal bypass procedure and code 20525 for the removal of the stent? The procedure was performed with the patient having a recurring sinus tract in the right medial thigh. The pathology report did not show an infection in the sinus tract granulation tissue or removal of tissue surrounding the artery.

One of my providers went to a conference where he was told he could perform an atherectomy and secondary thrombectomy using the Auryon catheter and code for both. My understanding is if it is the same device in a distal vessel, you can't code both. They also said if it was a documented pre-existing thrombus you could code both. What is your opinion?

"Some Auryon (to include adjacent thrombus aspiration when treating stenoses in native & stented infrainguinal arteries) users have reported being paid for both thrombectomy & atherectomy when performed in the same vessel & clinical session. As with many emerging technologies, some payers may not pay for both when performed in the same treatment session. We encourage you to check with your particular payer for any coding, reimbursement, or billing questions that may arise. Current Medicare NCCI guidance says that secondary thrombectomy is inherent in the work of atherectomy and should not be separately reported. Some payers may defer to NCCI guidance, while others do not consider it in payment decisions."

Patient had a CT-guided kidney biopsy (50200/77012). Patient then had two CT-guided drain placements into "perinephric and paranephric fluid collections" (49406 x 2). Can I keep 77012 for the biopsy even though imaging is bundled with the adjacent drain placements?

What is the best way to report this procedure? Three coders reviewed and came up with different coding. 

"Intracardiac echocardiogram was advanced as well as the decapolar coronary sinus catheter. It was noted that the coronary sinus catheter had no signals and that intracardiac echocardiogram was noted to be outside of the right atrium and a large vein at the level of the cardiac border. Pacing was attempted from the polar catheter at multiple levels without capture. A contrast venogram was performed through the long sheath, demonstrating an aneurysmal IVC with direct connection into the SVC. A wire was advanced up this large vein and found to wrap into the SVC and down into the right atrium. Given the unusual anatomy and inability to perform safe transseptal puncture, ablation was not performed. A synced 200 J cardioversion was performed while under anesthesia successfully converting to normal sinus rhythm."

Our providers have started to utilize 4D imaging for their cerebral angiograms. Should we use 76376/76377 or unlisted for the 4D imaging? What should we do if they indicate they used both 3D and 4D imaging?

If the stent placement was just part of the thrombectomy procedure to revascularize only, then 61645 would be most appropriate, but if the reason for stent placement was for atherosclerosis disease then 61635 would be more appropriate. Is that correct?

My understanding is that the reason for stent placement will determine which code to report - column one code 61635 or column 2 code 61645. Or should we still report column 2 code 61645 always when both procedures are performed within the same vascular family?

Please help with coding Vein of Marshall procedure. Intracardiac echo done. Double transseptal puncture performed. Patient cardioverted from persistent atrial fibrillation to normal sinus rhythm. Voltage map performed.

"Pulmonary veins as well as roof and posterior wall were all isolated from previous ablation one year ago. a catheter engaged the Vein of Marshall and balloon inflated. Alcohol injected into Vein of Marshall over 3 minutes. Voltage map performed. The mitral isthmus and the ridge were isolated from the vein of marshall ablation. Ablation was performed endocardially at 35 watts energy from the Left Anterior Pulmonary Vein down to the Posterior Mitral Annulus. Bidirectional block confirmed across the mitral isthmus. Attempted isolation performed of left atrial appendage with lesion around the LAA, but LAA could not be isolated."

Patient had previous tube graft repair of AAA, now presents with infrarenal AAA and iliac aneurysm. Can this be coded as 34705, 34713-50, or 34710/34711?

"Subsequently a universal flush catheter with guidewire guidance was passed up from the left femoral access and bolus angiography was performed visualizing the level of the renal arteries the infrarenal aorta as well as the aortic bifurcation and iliac anatomy. With these landmarks identified a stiff wire was passed up from the right femoral access. The 11 French sheath on this I was now exchanged out with a 16 French sheath. This was passed up into the aorta. Through this sheath and over the stiff wire a Gore-Tex bifurcated IBE endograft was passed. This was specifically a 23 x 14 x 100 device. This was now deployed extending up into the previously placed aortic tube graft. The bifurcation of this device was placed just above the native aortic bifurcation and the right limb of the graft extended down into the distal right common iliac artery just prior to the origin of the internal iliac artery."

Can we code 93922/93923 and 93925/93926 together routinely?

Our facility is requesting an order for ABI (93922/93923) in addition to lower extremity arterial scans (93925/93926). However, per one of the vascular surgeons, LEA is much more comprehensive than ABI but does include that information. So why bill ABI in addition to LEA if it is essentially included and the physician does not feel it is necessary?

The facility believes these are two separate charges and ABI is not included in LEA but should be a separate charge for blood pressure measurements. They were apparently advised by a consultant this is justified because the equipment is different? For ABIs, they use an “arterial unit”, which we assume is not the same as a hand-held Doppler?

What is the correct CPT code for radiofrequency ablation of the S3 nerve root done for deep pelvic pain related to nerve injury from a prior surgery?

We have a patient (transferred from a different facility) with a broken J-wire lodged in the anterior leaflet/chordae tendineae complex of the tricuspid valve. Our MD is going to do a percutaneous retrieval. We are coming up with an unlisted code instead of 37197. Do you agree with the unlisted in this instance?

I am questioning if 10160 or 49083 is the appropriate code. The doctor dictates: "The fluid collection was accessed using an access needle. Position within the fluid collection was confirmed, and fluid aspiration was performed. All instruments were then removed. Thick-rimmed fluid collection in lateral aspect of the left lower abdomen/upper pelvis. The patient is having fluid due to a bilateral tubo-ovarian abscess and had prior catheters placed for drainage per CT report." What code would you recommend please?

Our IR physician started performing pulsed electric field ablation for soft tissue tumors. Is this the same procedure as irreversible electroporation ablation? Can we use CPT code 0600T for PEF ablation? Or should it be an unlisted code?

The description of code 50706 states it is for dilation of ureteral stricture. Can this code also be reported if angioplasty is used to dilate the ureter in order to push a catheter past a stone or stones to facilitate placement of an NU catheter or ureteral stent?

If a patient is taken to the cath lab for repositioning of a Swan catheter under fluoroscopy, would an unlisted code be the only option for billing? 93503-52?

Is there a code for fibrin glue embolization of biliary cutaneous fistula?

"Technique: 1% lidocaine was administered to the fistula tract site. Fistula tract in the RUQ was cannulated with a 5 French 40 cm Berenstein catheter and glidewire. The catheter was positioned near the central ducts, and a gentle injection of contrast was performed, demonstrating no flow into the CBD. The injection also demonstrated recurrent biliary cutaneous fistula. We then attached the fibrin and thrombin syringes to the catheter, and a gentle injection of fibrin glue and thrombin was performed with a total of 6cc into the fistulous tract. The catheter was withdrawn until it was outside of the skin and the injection stopped."

For billing/coding purposes, is reporting a right heart cath (93451) during a heart biopsy for the documentation of “wedge pressure” meet medical necessity. We have not been able to locate any guidance on the specific wedge pressures that would justify medical necessity for billing of a right heart cath with biopsy. ICD-10 coding policy does not allow a coder to document a diagnosis based on hemodynamic findings unless the diagnosis is specifically stated by the physician within the summary reports.

Our CATH Lab/ Heart Transplant providers believe that the following statement justifies medical necessity for coding/billing of the Right heart Cath with Endomyocardial Biopsy.

“It should be noted that the wedge and PA pressures were elevated at 16 mmHg and 23 mmHg respectively.”

Could you please provide us with some references or guidelines that we can utilize to support?

Per Medicare one of the requirements for ICD coverage is that LVEF must be measured by echocardiography, radionuclide (nuclear medicine) imaging, cardiac MRI, or catheter angiography prior to implant. Can you advise on the timeframe requirement/limit for the EF measurement? We have combed through Medicare's coverage database and cannot find a definitive answer. The MD has an echo on file from March 2022 and wants to know if that is sufficient enough for the upcoming implant scheduled in March 2023 or if he has to have another EF measurement performed. The NCD/LCD is very specific about having to be on med therapy for three months, must not have had an MI within 40 days of the date of implant, more than 90 days post PCI/CABG, etc., but not on the timeframe of EF measurement. Any guidance or insight is greatly appreciated!

My team and I are wondering if it is truly okay that moderate sedation (99152-99157) is reportable/codeable in addition to cath lab/IR procedures. Folks cite the Medicare coding article L30719, which seems to state that sedation is part of heart cath procedures and therefore should not be reported additionally.

If the mass is biopsied in the lung but states it is "pleural based" but extending into lung is that a 32400 or 32405?

Can we bill separately for the carotid cutdown/exposure (37799) to selectively catheterize the carotid artery when attempts to access the cerebral artery failed via percutaneous approach? Would this be 61645-22 instead or nothing at all?

"Instead, the left neck was prepped and cutdown in a sterile fashion employing a longitudinal incision to expose the carotid bifurcation.divided and dissection was carried down the medial border of the sternocleidomastoid. The internal jugular vein and vagus nerves were identified. The carotid complex, including the carotid bifurcation was exposed. Circumferential dissection was carried out around the common carotid artery. A vessel loop was placed around the CCA for proximal control. A U-stitch was made around the entry point of the catheter using a 6-0 Prolene. The vessel was accessed with a 5 Fr micropuncture kit and a 6 Fr Prelude 4 cm sheath under fluoroscopic guidance and secured appropriately. Craniocervical digital biplane angiography of the left internal carotid artery was then performed."

How should we code an AVG angiogram, balloon maceration with 8 x 40mm Conquest balloon, angioplasty of venous outflow anastomotic stent with 8 x 40 mm Conquest, Fogarty, angioplasty of inflow artery, arterial anastomosis and juxta-anastomotic segment with 6 x 40 mm Charger, 6 x 60 mm Lutonix balloon, and angioplasty of the intra-graft stenosis 6 x 40 mm Conquest balloon. The doctor reported codes 36905, 37246, 75710, and 36215. Is this correct coding?

If they access the jugular vein, select the right hepatic vein, don't do anything, and further select a portal vein collateral and do a venogram, do we report codes 36011, 36481, and 75887? Or is code 36011 bundled?

Can 61645 be reported together with 37215?

"Pericardial effusion with hypotension: Pericardiocentesis performed by the subxiphoid approach. Unsuccessful pericardiocentesis. After the procedure repeat TTE showed still only a small pericardial effusion. Successful placement of a CVC for pressor support."

Would this be reported with codes 33016 and 36556? Or would I append a -53 modifier to 33016? I know for unsuccessful CV we don't bill 92960 with modifier... would this be same scenario?

"The patient presented to the EP lab in fasting state. She was prepped and draped in the sterile fashion. Propofol sedation started. Analysis of 12-lead EKG showed no PVCs. Isuprel infusion up to 20 mcg per minute resulted in HR increase from 70 yo 170 bpm. No PVCs seen with infusion or washing period, with and without propofol. The procedure concluded. A/P: negative for PVCs."

Please advise on how to code this case. I used unlisted code 93799; however, the physician wants to bill 93463. This was done prior to a possible RF ablation. No catheters were placed. No RF done.

Which is the best way to identify on the cath report if it is a right or left cath or both? I do know that if they enter through the artery or vein, but which is the best way to educate someone else on how to identify for coding purpose? I ask this question because the documentation is not the greatest.

22-year-old male comes in for LHC/ RHC/COR 93460 for anomalous pulmonary venous return of the right PVs with a significant 2.5 Qp/Qs shunt fraction. per Echo. No prior hx of congenital heart disease. Would you use 93460 or congenital codes 93597, 93598, 93563?