Ask Dr. Z

"VATS with mini thoracotomy was completed. The chest was entered, and a soft tissue wound retractor was placed as well as a minimally invasive rib spreader. The lung was then retracted anteriorly, identifying the posterior mediastinal mass. Biopsy forceps were then used to perform multiple excisional biopsies. The specimen is sent for pathology." 

What CPT code should be reported for mediastinal mass biopsy by mini thoracotomy?

"Access into the endograft was established. Occlusion of the left graft limb within the aortic bifurcation. An aortogram was performed, demonstrating widely patent right side occluded left. Intravascular ultrasound was then undertaken to evaluate the CIA and EIA on the left side and aorta. This demonstrated compression of the graft with adjunctive presence of thrombus. Decision to proceed with intervention was made. Penumbra CATx catheter was used to undertake mechanical thrombectomy of the graft within the aorta and in the iliac artery. This significant amount of thrombus was removed. Revision of the endograft repair here was undertaken with VBX stent with deployment from the aortic bifurcation and reaching just close to the end of the graft. The contralateral limb was protected with a 10 mm balloon inflated opposing leg."

Provider wants to bill codes 37220, 34710, 37184, and 37185. Could you advise on correct coding for this scenario? I'm not sure about 37220 and 34710 together.

Would you recommend billing a pectoralis minor Botox injection(s) as a trigger point injection (20552-20553)? These are being done at the same time as scalene Botox injections for TOS (64616). Is it appropriate to add a -59 modifier to the trigger point injection?

"This patient is a 35-year-old male with right upper extremity thoracic outlet syndrome. The skin over the right anterior scalene was prepared and draped using sterile technique. Under ultrasound guidance, a 1.5 inch 25 gauge needle was advanced into the right anterior scalene muscle belly under ultrasound guidance. The right scalene muscle was then injected with 50 U of Botox. The skin over the right pectoralis minor muscle was prepared and draped using sterile technique. Under ultrasound guidance, a 1.5 inch 25 gauge needle was advanced into the right pec minor muscle belly under ultrasound guidance. The right pec minor muscle was then injected with 50 U of Botox."

Patient with sepsis underwent explantation (complicated by extensive scar tissue) of two old, failed AV dialysis grafts from the RFA: one infected (source of sepsis) and one occluded. All anastomoses taken down. The two arteriotomies were repaired with harvested left saphenous vein patch grafts. Venotomies were repaired with sutures. May 35903 be used for the AV graft explantations? How are the patch grafts represented? 

Reference Question ID 16596 - If the physician dictates that the cholangiography is done with ICG cholangiogram, is this still coded as 47563? Or should it be 47562. There is no mention of of contrast injection with the ICG injection. I code only for physicians that perform the procedures as inpatients or observation patients.

"I made an initial port incision in the midaxillary line in approximately the 8th intercostal space. The chest was entered, and a port was placed, as well as a thoracoscopic camera, which was a 30 degree camera. Using this, we placed two more port incisions, one in the anterior axillary line and one in the posterior axillary line. The lung was nicely deflated. We retracted the lung anteriorly with an endoscopic grasper and dissected out the vagus nerve inferior to the recurrent laryngeal nerve. We dissected it out and encircled it with hook electrocautery. We then divided the vagus nerve with electrocautery. The ports were closed, and a chest tube placed." 

Should I report unlisted code 32999 (lung procedure since VATS was used) or 64999 (unlisted nerve procedure)?

If a patient is having a PICC or non-tunneled CVC inserted for the sole purpose of having a line before an upcoming surgery, and there is no other information provided, would it be appropriate to use diagnosis code Z01.818? Or is there a better Z code to choose in this situation?

I am really in need of help on this case. I was thinking of coding 35081 and 35646, but another coder said to just report 35102. Please let me know what you think is best in this case. 

"Patient has Ao aneurysm with Ao and iliac dx with rest pain of rt leg. There is atherosclerosis bil CFA. "We opened and controlled the bil CFA, then open abdomen and worked on the RT IIA as planned for anastomosis. Controlled the Lt CIA and then entered AO aneurysm infrarenal and bifurcation region. Repaired infrarenal aortic aneurysm with graft. This bifurcated graft was then anastomosis to the Lt CFA and Rt IIA. Due to Rt EXT iliac artery chronic occlusion a jump graft from the right limb of the Ao graft to the Rt CFA was completed with Dacron graft. " From the op report he states the bilateral CFA anasomosis where tunneled retroperitoneal. After completing we evaluated for signals in Bil CFA and they were excellent."

I have a radiologist who would like to schedule a patient for T4 chemical/alcohol ablation. Then, two weeks later,  possible kyphoplasty. Is there a CPT code for the ablation, or would we need to use unlisted code 22899?

We have a patient who presented for a right ventricular outflow ablation. Prior to any access being obtained in the EP lab, Isuprel was infused and the patient observed for one hour with only four PVCs. At that point the procedure was aborted. Do you recommend reporting unlisted code 93799 for the Isuprel infusion?

Is this coded with an unlisted for FAD or 62290/72295 for discography each level or both? 

Provocative discogram of L2-3, L3-4, L4-5, L5-S1. (4 separate levels). Technique: The patient was prepped and draped in usual sterile fashion. Local anesthesia was achieved with 1% lidocaine. The L2-3 disc space was accessed with a 22g Chiba needle introduced coaxially through a 18g spinal needle from the left. The L3-4, L4-5, and L5-S1 levels were similarly accessed. Injection of contrast was performed at each level, blinded to the patient. Findings are listed for each level similar to this: Level L2-L3: Opening Pressure: 30 psi CC's of contrast: 1 End Pressure: 100 psi Pain Severity: moderate Pain Classification: Concordant Moderate concordant pain elicited at L2-3, L3-4, and L5-S1. No pain elicited at L4-5. Endpoint for each level is as follows: 1) 3cc total contrast volume, or 2) pain level of "severe" or 3) pressure of 100 PSI in a normal disc or 4) pressure of 50 PSI over the opening pressure if there is grade 3 degeneration or higher.

Provider makes a decision for talc pleurodesis to be instilled via an existing chest tube. Under the Risk column on the Table of Risk, would this procedure be considered low risk or moderate risk?

What CPT code is used for embolization of left occipital?

Can code 20610 be used for sacroiliac joint injections, or must you use 27096?

Are we able to code for Impella device placement for a patient coming in with STEMI? Coronary angiography and PCI were done.

"A 4 French angled glide catheter in concert with a Glidewire was advanced into the main portal vein. The Glidewire was removed, and venography was performed, demonstrating a large left gastric varix and posterior gastric varix. The large left gastric varix was cannulated with the 4 French angled glide catheter and embolized to stasis using a combination of coils, Gelfoam, Sotradecol foam, and n-BCA glue. A 4 French Cobra glide catheter was used to cannulate the posterior gastric varix. A 2.8 Progreat and 0.016 Fathom microwire were used to further cannulate the posterior gastric varix. The posterior gastric varix was embolized. Cobra glide catheter was positioned within the splenic vein. The Cobra catheter was exchanged for a 5 French flush pigtail catheter. Venography was performed." 

I'm thinking 36481, 36011-XS, 36011-XS, 75887-XU, 37241, 75891-XU. Is this correct? 

Can you please help me with the following case? Provider performed a 'lend a hand" external bypass from the left common femoral to the right superficial artery. Documentation states the following: Successful placement of an external bypass from left common femoral artery to right superficial femoral artery via 5 French antegrade sheath. Technique:I decided to perform an external bypass from the left common femoral artery to the right superficial femoral artery via an antegrade sheath in the right SFA. A 7 French sheath was placed in the left common femoral artery under real-time ultrasound guidance and micropuncture technique after administering local anesthesia. Similarly, a 5 French sheath was placed in the right superficial femoral artery. Subsequently the 2 sheaths were connected using a male-to-male connector after adequate de-airing. 

I am leaning more to an unlisted code, but would appreciate your expertise on this. 

Would hydrodilatation for a frozen shoulder be coded with 20610 and 77002? 

"Under fluoroscopy contrast was injected from a syringe containing 3cc of Omnipaque 300. The contrast was seen to be distributed within the joint. A total of 60mg Kenalog, 10cc of .25% Bupivacaine, 9cc of Omnipaque and 12 CC of sterile saline was injected. The needle was withdrawn. Successful non-complicated therapeutic steroid injection of the left glenohumeral joint with Hydrodilation under fluoroscopic guidance."

When reporting the diagnosis code for total occlusion of the subclavian artery, would we consider the subclavian artery to be a peripheral artery or an extremity artery?

We know that a right heart cath is included in the biopsy. However, if the provider does a right/left heart cath with a biopsy, is the right/left heart cath appropriate to bill?

Can you assist whether 37229 would be appropriate for this procedure?

"The patient was systemically anticoagulated. A 018 wire and catheter were used to recanalize the total occlusion of the anterior tibial artery with re-entry at the dpa in the foot. A 014 wire was then exchanged for the 018 wire in preparation for atherectomy. IVUS was used over the wire for vessel sizing in the vessel. This was used in the anterior tibial artery, superficial femoral artery, and popliteal artery. SFA and popliteal artery had minimal disease. The ATA was occluded with a native vessel size of 2.5 - 3 mm. The segment was treated with CSI atherectomy throughout. Angioplasty with a 3x0 x 220 mm balloon was performed. There was recoil of the vessel with incomplete revascularization. The patient had a labile blood pressure during the CSI, likely secondary to the low dose vasodilator. This returned to normal with additional IV fluids. At this point, the case was completed. The wire and catheter were removed."

"Radiology report: Gray-scale and color Doppler ultrasound of portions of the liver was performed for ultrasound-guided biopsy. Please note that a radiologist was not present for the intra-operative acquisition of these images. No immediate complication. No large perihepatic or parenchymal hemorrhage is detected."

We are not reporting the biopsy; however, it is appropriate to report the 76942-26.

If a dual chamber ICD is upgraded to a biventricular ICD, CS lead inserted, and an old capped RV lead removed, how would this be reported? The patient has a functioning RV lead and RA lead (which were left in), and a capped RV lead that was removed. Our coding software does not offer a choice for lead removal without lead replacement. This assumes leads were replaced, which is not the case, and leads us to replacement codes. CPT instruction states 33244 can be used with 33264. Which coding group is correct in this case: 33249, 33225, 33241, and 33244? Or 33264, 33225, and 33244?

We have an embolization involving the posterior inferior cerebellar artery. It was originally coded with 61626; however, the provider and I feel it should be 61624 since it is intracranial. The coder is citing the definition of intracranial as the vessel needs to branch from internals or directly from spine. I am somewhat new to this and would like clarification.

We have a scenario where the physician was trying to pass a wire to get the CS catheter through, and it was discovered that the patient has a total occlusion of the left subclavian vein. Physician performed venoplasty and said intervention allowed for easy passage of the CS guide catheter. Physician does document venous stenosis of the subclavian vein and the occlusion.

We stumbled upon an October 2022 CPT Assistant that is making it seem like we can report for the venoplasty. The CPT Assistant mentions a stenosis found during a "transcatheter electrophysiology procedure". Would our scenario qualify for reporting the venoplasty with the upgrade to a CRT-pacemaker? Thoughts?

Indication: Right lower extremity DVT. FINDINGS: Patient's placed in prone position on the fluoroscopic table. The right popliteal fossa region was scanned using the linear probe. A permanent copy of the ultrasounds placed the patient's records. Popliteal vein appears patent. The scheduled thrombolysis was not performed since the patient's clinical condition has significantly improved and no longer has pain in the right lower extremity and swelling has significantly improved. Recommend continued conservative management with anticoagulation. 

Previously the recommendations were to use 76881/76882 per ACR in Question IDs 8142, 8366 and 10687. Since 76881/76882 are for non-vascular structures, is this still the current recommendation or can we use 93971-52? Please advise what the best CPT to use in this case is.

I have a physician wanting to do CTA A/P venogram with contrast, but I'm having trouble locating a CPT code. The test is being done for DVT and varicose veins.

What documentation is needed to bill code 93662? Is a separate report with permanent imaging in the patient's chart needed? My provider is saying they do not document a separate report and all information is documented in the operative report.

In the process of a diagnostic congenital cardiac cath, a catheter is placed in the right ventricle, and indirect pulmonary angiography is performed (93568). Additionally, the catheter is advanced and placed in the LUPA where angiography is also performed. Is it appropriate to bill both codes 93568 and 93569?

If a patient has a shockwave lithotripsy and stent to the external iliac and then also has angioplasty and stent of the common iliac, should this be coded with C9765 plus 37223? I am getting an edit that 37223 cannot be billed without the base code, but 37223 seems the most appropriate.

I want to verify that IABP removal (33968) should not be reported with insertion (33967) when removed at the same session. Is that correct? For example, IABP is placed for use during the procedure and removed at the conclusion of the case, or IABP is placed and used for the case but removed and exchanged for Impella at the conclusion of the case. 

"Left/right common femoral SFA and profunda were isolated and dissected. Retroperitoneal tunnels created LT/RT a 14 x 7 step graft limbs. Clamp on the aorta below renal arteries. Arteriotomy within the aorta and extended. Significant clot in the aorta removed. Graft was tailored to fit. LT common SFA and profunda are placed on vessel loop. Made arteriotomy within the common femoral and extended. The graft was tailored to fit. SFA and profunda placed under traction on the right. Significant atherosclerotic disease within the common arteriotomy extended to the proximal SFA. Endarterectomy common femoral and the proximal SFA. Plaque in the proximal SFA had eaten through wall of the vessel. Bovine pericardial patch was tailored to fit. Still some bleeding from the repair of the wall of the SFA common region. This was reinforced with a piece of felt. Aortobifemoral limb on the right was tailored to fit."

Would this be 36246 only? Or 34832 due to an open procedure? The indication does not specify AAA.

Our provider was implanting a Watchman device. During the procedure, before the Watchman was placed, the provider stated the following:

"Due to the thickness of the septum, the dilator would not advance into the left atrium. The VersaCross sheath was then placed across the septum, and the pigtail RF wire was exchanged for a 0.035 Amplatz wire,which was placed in the left superior pulmonary vein. Then, an Armada 6 x 40 mm balloon was placed across the interatrial septum, and two inflations were made up to nominal pressure. Once the venoplasty was completed, the Watchman access sheath was then placed into the left atrium."

Is there a code that we can bill in addition to the Watchman for balloon septoplasty for left atrial transseptal access?

The physician implanted a dual PPM a few days before, and both the RA and RV lead became dislodged. Patient was brought back, and the physician completely removed both leads. He then implanted a new RV lead and re-used one of the leads he removed from the RV and implanted it back into the RA. For the hospital, we billed 33235, 33216, and 33215-XU. Do you agree with this coding? Do these codes cover the work performed adequately? Our issue was making sure the CPT codes aligned with the work performed as well as supplies billed.

Incision in midline sternum-pubis we dissected the infrarenal aorta. Blunt dissection at infrarenal aorta completely freed of the surrounding tissue.  Please note that inferior mesenteric vein was ligated during the process. Retroperitoneum opened. Iliac arteries and aorta was clamped. Aorta was opened in the middle. Identified 3 lumbar arteries which were controlled with the help of 2-0 silk ties. Our cryo artery was brought into the field, soaked graft with rifampin.  The side branches were tested on the back field and all but 1 was tied off. The proximal aorta was cut in a beveled fashion. Graft was cut to the length we need. Brought to RT retroperitoneum where we had exposed the RT EIA the hypogastric artery anastomosis was made again in an end-to-end fashion.LT side anastomosis was made at the level of the iliac bifurcation. Next the IMA was dissected further and in the it was anastomosed to the main graft with the reimplantation of the renal arteries. Tongue of omentum created & brought to the wall of the retroperitoneum. 35638, 35697 x’s 2 & 49905?

The patient comes in for right ischiofemoral impingement. Doctor localizes the ischiofemoral space (skin prepped with anesthesia/lidocaine), and under CT guidance 12 mg of Celestone and 2 cc of Marcaine 0.75% were mixed and injected into ischiofemoral space. What CPT code do we use for injection?

Professional coding team inquiry for G mastitis steroid injection with aspiration, US guided. Interpretation is 96372, 10160, 76942. Would 19000, 76942, 96372 be more appropriate based on GL?

"After obtaining informed consent through PARQ conference, the area was reidentified at the right breast 3:00 7 cm from the nipple measuring about 2.5 x 0.8 x 0.9 cm. The second site with echogenic central debris at 1:00 8 cm from the nipple measures about 3 x 1.1 x 2.6 cm. A Team Timeout was performed. The breast was cleansed and draped in sterile fashion. 1% lidocaine was utilized for local anesthesia. A 22 gauge needle was advanced to the both areas under direct ultrasound guidance and aspiration performed. A total of 6 mL of viscous fluid was removed and discarded. A total of 160 mg of Methylprednisone mixed with Ropivacaine was administered into the cavities and surrounding tissues. The needle was removed, gentle pressure applied for hemostasis, and a sterile dressing placed. Estimated Blood Loss: <5mL Complications: None."

He has had prior placement of CRT-D device which is at ERI status. Biventricular pacing percentages were at 97% and is presented today for generator change. He has preerosive changes on his device and leads. He has had a well-functioning CRT-D device with an abandoned prior RV lead. His abandon lead was originally placed in the submuscular pocket, we then changed out the device pacing through the prior LV lead. Through the device the leads were interrogated, the patient was in underlying atrial fibrillation with fibrillatory waves at 1 mV. Lead impedance was 390 and stable. The RV lead showed no sensed R waves at VVI 30 pacing threshold of 0.75 V at 0.5 ms and an impedance of 430 ohms. The LV lead showed a threshold of 1.5 V at 1 ms impedance of 600 ohms and high-voltage impedance was 55 ohms. Bradycardia parameters were set DDIR with a lower rate limit of 70 VT monitor was set at 160 VF zone at 200. Standard outputs were programmed with the device. No immediate complications of the procedure. 

33263? 33264? or 33249?

Are the robotic surgeries always coded as VATS (32663), or can they be coded to open (32480)?

A skin block was performed. A peri-prostatic block was performed by placing a spinal needle on each side towards the prostate base and injecting 10ml of 1% xylocaine for a total of 20ml. Under ultrasound guidance 3 gold markers were inserted into the prostate (right apex, mid-gland, and left mid-gland) placed at the appropriate depth and avoiding the urethra. A long spinal needle was then used to hydro-dissect the perirectal space with sterile normal saline. Separation was confirmed in both the transverse and sagittal planes. The needle was aspirated slightly to ensure the needle was not intravascular. While keeping the needle in place, the hydrogel applicator was attached. The hydrogel was then injected over 5 seconds. The placement of the hydrogel was evaluated and the ultrasound probe was removed. After 15 minutes of observation the patient was released. Would you code 55874 with 55876 and 76942 or is the ultrasound guidance included in 55876 because you used 55874?

What is the correct charge for Magtrace injection following localization device placement? This will be done the day before surgery.

"An 18-gauge 7CM Magseed localization device was advanced under ultrasound guidance, targeted to the Vision clip. Satisfactory positioning of the needle was confirmed sonographically and the Magseed was deployed. 1 mL of Magtrace with a small bolus of air was then injected posterior to the clip."

19285 for the localization with 38999 for the magtrace injection since 38900 is an add-on code without the appropriate primary code?

If they did it without localization such as the procedure below, would it be 38999 with 76942?

A 21-gauge needle was advanced under ultrasound guidance posterior to the previously placed mag seed. Satisfactory position of the needle was confirmed sonographyically and 1.0 cc of Magtrace was injected.

Thank you

When performing angioplasty of the right posterior tibial, common plantar and lateral plantar arteries, are all arteries included in CPT 37228 or is it appropriate to add 37232 x 2 as well? Thank you.

Does this documentation support CPT 78582 with 78800?

Comparison: There are no prior studies available for comparison.

Procedure:

Ventilation study: Dynamic planar scintigraphic images of the lungs were obtained in the posterior projection while the patient was breathing a mixture of 9.5 mCi Xenon-133 and air, through a breathing apparatus. Images were obtained during initial breath hold, rebreathing to equilibrium and during wash-out phase, over a 3-minute period.

Perfusion study: Following the intravenous administration of 5.4 mCi technetium 99m MAA, static planar images of the lungs were obtained in the anterior, posterior, RAO, LAO, LPO, right lateral, and left lateral projections.

Findings: The ventilation study demonstrates heterogeneous distribution of inhaled radiotracer centrally, with mid to upper lung persistent radiotracer on washout images suggesting air trapping. There are small subsegmental defects at the left lung hilus region, without peripheral wedge-shaped large perfusion defect.

Impression: Mid Lung Air trapping

Our vascular surgeon performed repair of brachial artery transection, and we are not sure what code to report. We are only coming up with 35206. What are your thoughts?

"Small bulldog clamps were placed on the proximal and distal ends for control. The proximal and distal ends of brachial artery were cut back with scissors, then it was repaired with end-to-end anastomosis using two running 7-0 Prolene sutures. Once anastomosis was completed, the bulldog clamps were removed."

I have a physician who is doing a pulse volume recording only.

"Study: Right lower extremity pulse volume recording. Indication: Gangrenous changes of prior foot amputation. Interpretation: Pulse volume recordings were obtained at the right high thigh, low thigh, calf, and ankle level. This showed decreased amplitudes at all levels. Impression: Pulsatile recordings of the right lower extremity are suggestive of more proximal disease."

Would this be reported with code 92923 or 92922? If neither, what should I be coding?

Patient's LAD distribution is subtended by TWO different grafts. Drug-eluting stent is placed in the distal 1st Diagonal via access thru the saphenous vein graft. Via separate approach, a DES is placed in the native mid-LAD via the left internal mammary artery graft (LIMA). May we code C9604-LD, C9604-LD-XS for these two interventions because the two grafts are completely separate from each other with separate ostia?

Do you have recommendations for how the X-modifiers should be used with IR and CV? For example, would selective catheter codes get XS for separate structure? Would a true diagnostic angiogram get XU when done with an intervention? If you are switching from 59 to the X-modifiers and code IR and CV, what would be the correct way to use these? Thank you!

What advice can you offer for this encounter? Patient was originally scheduled for an AV shunt imaging for maturation. Only an US scan ended up being performed. "US exam of the left upper extremity in the area of the surgically created fistula was performed. A patent radial artery was identified. The anastomosis was identified, however, no flow was noted within the outflow vein. A segment of approximately 1 1/2 to 2 cm of the juxta anastomotic vein was thrombosed/occluded. There is reconstitution of the outflow vein via collaterals. Given that the juxta anastomotic outflow vein was very small and already occluded no intervention was done at this time." Since no attempt at access was performed, I don't think it is appropriate to report an aborted 36901. This is an extremity, but 76882 doesn't seem appropriate since this is vascular. Not a Duplex study. This doesn't seem to fit 93922. Thank you for your help.

Is it appropriate to bill 76380 in conjunction with cerebral angiography codes 36224, 36226 based on this documentation:

PROCEDURES:

1. Selective bilateral internal carotid artery cerebral angiograms.

2. Selective left vertebral artery cerebral angiogram.

3. Ultrasound-guided access and catheterization of right common femoral

artery.

4. Cone beam CT imaging performed in each vessel

IMPRESSION: Successful three-vessel cerebral angiography with cone beam CT

performed during each vessel injection of the Jefferson preoperative protocol.

No vascular abnormalities evident.

If atherectomy and PTA of the radial artery and the palmer arch are done, do we report two atherectomies? I currently have 0237T, 37246, and 36216 (brachial access). Is the palmer intervention separately reportable?