Ask Dr. Z

When the doctor documents the patient has a complex thyroid mass with cystic and solid portions; then he does an US guided aspiration of the cystic portion and core biopsy of the solid portion.

Do we bill the solid core biopsy only as this is one mass (one surgical field)? Or can both aspiration and core be billed? My radiologist is insisting we bill both. Need clarification please.

Thank you

Good morning,

MR Neurogram is an unlisted cpt code 76498. My doctor's are asking if there are alternative codes that could be used instead of the unlisted code? Like a MRI code of each of the locations the neurograms are being done on. Would MRI Codes be compliant?

Thank you

Can you bill 33210 and 33975 together, if not why and is there another temporary pacemaker code.

surgeon does a external iliac to profunda interposition bypass graft end-to-end. Then he does a bypass graft from the interposition bypass graft to the SFA. How is this coded?

Please advise re the correct CPT coding for the following case.

Embolectomy of the distal right external iliac artery with fresh thrombus removed from the RCFA and the profunda.

Femoral endarterectomy and patch profundaplasty using bovine pericardium to restore in-line flow to the profunda. Angiogram of entire right lower extremity performed via micropuncture through CFA patch graft, demonstrating patent distal RCF and profunda arteries, occluded right SFA, slow reconstitution of the popliteal with peroneal and posterior tibial arteries serving as run-off. No flow seen beyond the ankle. Injection of tPA down the PT under US guidance.

Hello! Pro-fee coding question here.

Patient came in for right iliac-to right profunda bypass. After placing the bypass graft there were complications nd the patient was bleeding and they believed the aortic clamp had damaged the distal aortic wall. To control the bleeding they placed an aortic-uni-iliac endograft and then they placed a left fem-to-right profunda bypass graft and ligated the iliac-profunda bypass.

We're looking at 35703 for aortic repair of the dissection, 35661 for the fem-fem bypass, but is there anything we can pick up for the iliac-profunda graft placement that they completed and then ligated just distal of the iliac anastomosis? 35665-52? Add a 22 to something else? or nothing at all?

Dr. Z-- is there a CPT code for lumbar drain replacement? Many drain replacements have their own CPT code. Procedure report below without PHI. Thank you!

Contrast was injected into the existing lumbar drain, which was confirmed to be in the epidural space, and this drain was removed.

A 22 gauge LP needle was inserted into the lumbar region above as a guide. A 14 gauge LP needle was inserted into the lumbar region at the L2-L3 interspace.  There was return of CSF fluid and a lumbar tube with a wire was insert was threaded through the LP needle and into the subarachnoid space. The needle was then remove followed by the wire and dressing was then applied over the lumbar drain

If one APP assists with the harvest and CABG and a second APP assists with the MAZE procedure can the second APP also code with AS modifier? If so since the MAZE CPT code 33259 is an add-on code, should they also code the CABG codes since they assisted with the MAZE procedure?

Can the interventional radiologist in the outpatient hospital prior to performing the intervention, order e.g. MRI and may read it too? It may also be read by anyone of the radiologist in the group practice (outpatient hospital radiology) or (office/global radiology imaging). Is this in compliance with the Stark Law's in-office ancillary services exception?

When the Radiologist places 2 separate orders, 1 for 76700 abdomen complete. Another for 76705 abdomen limited, and done 2 hours apart. Same ICD-10.

Can these two be reported together based on separate orders, or is CPT 76705 consider inclusive to 76700. And not allowed in this context.

The patient had a LAAO closure device deployed but there is a gap between the device and the appendage wall. There have been literature showing that ablating the appendage wall around the device will shrink the tissue around the device.

Do you think this would qualify as a AF Ablation?

This pt had a CAGB 33533 and thru a separate incision, had a thrombus removed from the LT atrial appendage. The physician billed 33315. I was just wondering if 33310 is more appropriate because with 33315 aren’t we charging for CPB twice? Here is the op note portion of 33315: I began the operation by lifting the heart, exposing the left atrial appendage. This was opened. The clot was removed and passed off the table as a specimen. The opening was oversewn with a 5-0 Prolene suture in 2 layers.

Thank you.

When the Radiologist places 2 separate orders, one for CPT 73502 hip w/pelvis 2-3v. Another for CPT 72170 pelvis 1-2v. Both for the same ICD-10.

Done 2 hours apart.

Do we code both codes? Or do we combine into one CPT, confusion lies in the separate orders.

If the Radiologist places 3 separate orders for CPTs 72070 thoracic 2v, 72072 thoracic 3v, 72074 thoracic 4v.

For the same ICD-10 code. Done minutes apart.

Do we allow codes with modifier 59? Or combine these services into one code of 72074?

If the Radiologist orders two separate orders for hand x-rays, one for CPT 73120 hand 2v, and another for 73130 hand min 3v. Done 7 minutes apart for the same ICD-10 code.

Do we combine these services into one code of CPT 73130? OR do we allow both codes, since two separate orders were placed?

Can you please help with this one? Dissection was carried down to the sternum, which the entire length was a severe nonunion. The oscillating sternal saw was used to complete a re-do sternotomy. The xiphoid process was removed d/t very protuberant and causing pain. We then developed bilateral pectoralis major advancement flaps by developing a plane beneath the LT and RT pectoralis major muscles. Each muscle was lifted off the sternum and mobilized toward the midline. Ostectomy was performed to freshen the edges of the sternum. I used the KLS plating system. Reduction clamps were used to bring sternum together and for allowing placement of plates and were removed. The flaps were then closed over the midline using #1 PDS suture. Drains were placed and layered closure was performed. Would this be coed as 21750 and 14000 vs 15734 x 2? we are unsure on the muscle advancement flap codes. Thank you.

Hello Dr. Z,

How would you code a cloacagram where scopes were utilized? Would 52000 & 74775 be sufficient or is an unlisted more appropriate? The abdomen and perineum were prepped and draped in the usual sterile fashion. Endoscope was placed in the mucous fistula. A balloon catheter was then placed in the mucous fistula and the balloon inflated.

Cystoscope was performed and a balloon catheter with a marking catheter inserted within the lumen was placed into common channel. Contrast was injected into both catheters under fluoroscopy. BB was placed at perineum. Contrast included isovue and gadolinium. Catheters were capped. Rotational fluoroscopy was performed.

Urethra length was short and common channel length was approximately 3.25cm

Thanks Dr. Z!

The skin site over the targeted lesions was prepped and draped. Lidocaine with infiltrated into the deeper tissues around the lesion. under direct sonographic guidance, aspiration was performed using a 22 gauge spinal needle. Lesion completely collapsed upon aspiration and approx. 2 cc of yellowish fluid was removed. A ring shaped biopsy marking clip was placed at the former site of the cyst.

Compression was held until hemostasis was achieved. The specimen was sent t the lab for analysis.

Post procedure digital CC and lateral mammograms were obtained which show resolution of the mammographic finding and the biopsy marking clip in the expected location

Impression: successful ultrasound-guided aspiration of 2cm cyst in the 4-5:00 position of the left breast.

Since this is a breast aspiration, would that clip placement be considered unlisted? I got codes 19000, 76942, 77065 but unsure of the clip placement. Thank you- DM

Radiofrequency lesions were created with a temperature of 80 degrees Celsius for 80 seconds at the following stated levels. First, the right L5 dorsal ramus was targeted. The right sacral ala was identified using fluoroscopy. The skin over this area was anesthetized with 2 cc 1% lidocaine using a 26-guage 1-1/2 inch needle. Then, a 20-gauge 150 mm Stryker Venom needle with a 10-mm active curved tip was advanced to the sacral ala. Next, the right L4 medial branch was targeted at the junction of the transverse process and superior articulating process of the L5 vertebral body. Next, the right L3 medial branch was targeted at the junction of the transverse process and superior articulating process of the L4 vertebral body. Would the recommended coding be 64635-RT, 64636-RT or 64635-RT, 64636-RT (modifier 59), 64625-RT, or 64635-RT, 64636-RT x 2? There is no mention of the sacral nerves being specifically targeted. Seems like 3 levels (L5-S1, L4-L5, and L3-L4) were RFA’d- any guidance would be much appreciated for coding this.

Please help. What is your direction on billing for an US and then US guidance of same body area/same DOS? What if US guidance is included in procedure? If the US guidance code is bundled into the US body area code, which to bill?How would you code this one? CEUS of b/l legs and then US guidance used for aspiration of b/l infective myositis...76978 & 76979 and 10160 X2, or code also 76942? The CEUS codes are not bundled into 76942. What is the direction with respect to billing for an US of same body area as Procedure using US guidance.....even if US guidance is included in procedure and not billed separately. When bundled; e.g. 76942 into 76705, can we billl the 76705 instead of 76942?

After a PVI ablation, patient remained in atrial fibrillation so decision was made to perform more extensive ablation including a roof and floor line with RF. A tacti-cath catheter was inserted through the flexcath advance. Atrial fibrillation terminated by CV. Remap of left atrium performed. Roof line cryoablated with 4 120 s lesions with achieve anchored in the LSPV, and 2 120 sec additional lesions with the achieve anchored in the RSPV. Floor line cryoablated with 2 120 s lesions with achieve anchored in the LSPV, and 3 120 sec additional lesions with the achieve anchored in the RSPV. Does the floor and roof line ablation post PVI ablation for continued a-fib support coding 93657 x 2?

Can you please help us decide what this pain injection charge should be? The report is suggesting 20600, which we are questioning. "A 22 gauge Quincke needle was placed at the posterior medial aspect of the right lateral L6-S1 articulation from a posterior approach with discussion of the lowermost disc as L6-S1. 0.3 ml Isovue-300, 0.4 ml ropivacaine 0.5% and 20 mg triamcinolone were injected at this site. The needle was removed. There were no apparent immediate complications of the procedure. Follow-up was planned with the referring service. The patient was able to walk following the procedure. Patient denied the possibility of pregnancy with last menstrual period approximately 3 weeks prior to the procedure and with serum hCG level less than 2."

Are the New C codes C7516-C7553 only for ASC or also apply to OP Facility?

According to CPT guidelines CF, SFA and popliteal are considered one terriority for intervention. Does this same rule apply to IVUS performed in all three vessels?

Are there only certain brands of "covered" stents that qualify for use of CPT codes 34707 and 34708 if the proper indication is met? I have looked and have not been able to find a list anywhere, so I was guessing it's just the fact it is referred to as "covered." Our facility uses the Bard LifeStream covered stent, so I'm specifically inquiring about that brand. Thanks!

Hi Dr. Z,

A CT guided core needle biopsy of nodule immediately in front of the left kidney was performed. Technically successful and uneventful CT guided core needle biopsy of the left anterior pararenal nodule. Would this be coded 49180 or 52000,77012.

Thank you.

Hello Dr. Z,

Skin and subcutaneous tissues were anesthetized using 1% lidocaine. Surgical incision was made overlying the area of previous surgical incision from port removal. Port pocket was irrigated and hemostatic. Port pocket was then packed with iodoform gauze.

Looking into 10060 with 52 modifier. Since anesthesia was administered, would E & M code be an option?

Kindly advise. Thank you for your valuable input.

Sincerely,

VJ

Are codes 47554, 47535 correct for the follow procedures?

1. Cholecystostomy tube cholangiogram.

2. Over-the-wire cholecystogram and cholangiogram.

2. Cholecystoscopy.

3. Laser lithotripsy - video guided.

4. Cholecystostomy tube exchange and conversion to transcholecystic internal/external biliary drain.

5. Post tube cholangiogram.

I coded 75625,75716 and 75774 from this part of the OP report

A flush catheter is placed into the aorta at the T12-L1 junction and a complete AP abdominal aortogram taken.Normal arteries are not visualized in keeping with his end-stage renal disease. Infrarenal aorta is atherosclerotic but not aneurysmal. A removable type IVC filter is noted. Catheter is brought down to the L4-L5 iliac bifurcation and a pelvic angiogram taken.This demonstrates patency of bilateral common Iliac arteries, external iliac arteries and internal iliac arteries. External iliac arteries are ectatic.Catheter is then brought down to the level of the right common femoral artery and a selective right lower extremity angiogram taken.This demonstrates patency of the common femoral profunda femoris and proximal SFA. The knee prosthesis is occluding the popliteal artery on the right. Additional selective catheterization is then performed with A 014 quick cross catheter.

Hi, I am seeking clarification on the scenario of retrograde right common carotid origin stenting (with endarterectomy of right internal carotid artery just distal to the bulb). Due to anatomical considerations, I see that the distal left common carotid/left common carotid origin would be intrathoracic. However, with the right common carotid origin being behind the sternoclavicular joint, as this is the junction between the neck and the thorax, I am uncertain if this would be considered intrathoracic or cervical. Could you please verify if stent code assignment for the scenario of retrograde right common carotid origin/right proximal common carotid stenting done concurrently with right internal carotid endarterectomy would be 37217, or 37215/6? Thanks

Hi Dr. Z. Besides 93458, can we bill 92920-74 (hospital) for the attempted intervention? The doctor spent 35 minutes on the attempt, no balloons, just wires and microcatheter. “I used a 6 French EBU 3.75 guide catheter and selectively engaged the left main. I then attempted to cross into the 1st diagonal (culprit vessel) which is a small caliber that is less than 2 mm in diameter with a 95% stenosis and reduced TIMI 2 flow. The 1st diagonal branch has an extremely angulated takeoff. Essentially it goes backward 180° and then turns another 180° in an S shaped with extreme acute angulation that makes wiring essentially impossible. I could not wire with a run-through. I attempted wiring with a different wire she is a choice PT floppy wire crossed into the proximal diagonal but with an S shaped that prevented it from further advancing across the lesion (any time I would advance it it would flop back into the LAD). After a prolonged attempt I elected not to proceed ...” Thanks in advance!

I am confused if code 93356 or 93356-26 can be billed on a professional claim? I work for Cardiologist that is owned by hospital. Is this a facility charge?

His documentation is frequently confusing ...Would you code 93656/93655? Also, I'm struggling identifying additional mechanisms and afib remaining after ablation. any advice is appreciated. Using the intracardiac echocardiography, a single

transseptal sheath was inserted in the left atrium. The mean right atrial

pressure was measured at 8 mmHg and the mean left atrial pressure was

measured at 10 mmHg. The Biosense/Carto mapping system was utilized

during this procedure. After obtaining the left atrial map, RF pulses

delivered to the left and right carinas until pulmonary vein isolation was

accomplished. After completion of the PVI, LA roof line was created.

The LA posterior wall was then isolated by using pacing/capturing technic.

The esophageal temperature was closely watched and high-flow irrigation

was done whenever temperature rise was noted. The catheter was then

removed from the LA and positioned in the RA . RF touch-up lesions were

performed in the SVC and CTI.

50 year patient. Malfunctioning tunneled CVC was removed, after angioplasty of the right IJ with 12 x 40 mm balloon, there was resolution of stenosis to less than 10% residual stenosis. After angioplasty of the SVC with 12 x 60 mm balloon, there was resolution of stenosis. A 23 cm DuraMax catheter was placed over a guidewire with its tip in the atriocaval junction in good position. The catheter was functioning with good blood return and flushed without difficulty.

What would be the correct code(s) for this removal of tunneled CVC, angioplasty of IJ and SVC, and new tunneled catheter on over the same guidewire?

DX: CAD With NSTEMI New Onset Atrial Fib

Procedures: CABG X3, PVI, Left Atrial Appendage Clip Application, Rigid Sternal Fixation

Here is a Portion of the OP note. Coded as 33256.

Is 33256 the correct code for the following excerpt during a CABG Procedure

Thank you

OP Note: Following Arrest, we performed Pulmonary Vein Isolation. The heart as retracted to the right, the ligament of Marshal was incised and the left superior and inferior pulmonary veins were encircled. A medtronic cryoprobe was utilized to ablate the pulmonary veins for 2 minutes. Once the probe defrosted it was removed. The heart was then retracted to the left and the right superior and inferior pulmonary veins were encircled. The cryoprobe was again utilized to ablate pulmonary veins for 2 mins. Following this a 45mm atriclip was applied to the atrial appendage.

Can we code placement of a central line separately to 36556 in addition to 99152 when the physician is using the line for administration of sedation meds in a patient with no IV access? The physician is performing lower extremity arterial interventions.

Male w/infected LT knee was in operative suite when I was called. Had exposure on anterior surface of LT knee & incision in below-knee area on medial aspect of proximal LT calf. Ortho surgeon had been evacuating the area of infection when he noticed bleeding behind the tibia. When I arrived patient had a tourniquet insufflated to 300 mmHg. We let this down & noticed bleeding posterior to proximal LT tibia. I extended incision about a half a CM proximally. Upon doing this, was noted patient had significant venous pressure. By extending incision I was able to see into the depth of the wound better. All bleeding appeared venous in nature. I took Gelfoam soaked in thrombin & packed the area. Tourniquet reinsufflated to 300 mmHg. We left this in position for 10 minutes. Tourniquet released, no evidence of active arterial bleed. Good Doppler signal over DP, no signal over PT. No active pulsatile bleed from knee incision. Gelfoam & thrombin left in position. Ortho surgeon closed incision. Should I code only an E/M for my vascular surgeon's work?

Should 33509 be coded if it is harvested and not used due to calcification and small vessel?

Hello,

Is stating "aortic valve was crossed" or "LVEDP was measured" adequate documentation for billing 93452 or does the provider need to give the numeric value of the LVEDP?

Thank you!

(For percutaneous transluminal coronary lithotripsy, use 0715T). (Use 0715T in conjunction with 92920, 92924, 92928, 92933, 92937, 92941, 92943, 92975)

Patient had a 92920 along with 0715T. Which requires c1761 for the0715T. We are being told not to report code 92920 with c1761. But 0715T requires the c1761. Would we change the supply code c1761 to possibly c1725?

What is the CPT code for aortic root aortoplasty with Aortic valve repair with free margin plication of all 3 cusps and placement of 23 mm rigid annuloplasty ring

Is it appropriate to use the aftercare Z codes such as Z48.03, Z46.82 along with the dx code when the patient returns for drain checks with or without exchanges when the condition is still under treatment such as an abscess? Or should the return visits be coded with the diagnosis code alone with no Z code? Having trouble determining if the drain management visits are considered aftercare during the "healing/recovery phase" since we are still currently treating/evaluating the condition and adjusting the plan of care on each return visit. Also when the abscess is determined to be resolved during the visit would it be appropriate to still report the abscess as the first listed diagnosis since that is what was chiefly responsible for the services during the encounter? Or should it be a Z code alone since the most definitive diagnosis is that it no longer exists and is resolved?

Our physician performed Shock Wave balloon lithotripsy of the Lt SFA (6x60 mm) along with Drug coated balloon angioplasty LT SFA (6X40mm). We are trying to determine if this is 37224 angioplasty or 37225 atherectomy which includes angioplasty and not billing both CPT codes. Our department feels we are not coding this correctly. Does Shockwave balloon lithotripsy mean an atherectomy was performed? If you need any additional information, please let me know. Please advise since Dr. Z is the Expert to clear this up. Just waiting for an answer.

Question 18154

Would it be correct to code a tunneled pleural catheter (PleurX) placement with imaging (32550, 75989) with the same tunneled pleural catheter also getting removed at the end of the procedure (32552) for the reason of the output was too thick for patient to have benefit from home drainage of recurrent pleural effusion? The entire placement procedure (subcutaneous tunneling, PleurX catheter placed, imaging guidance used, minimal output due to thick, loculated pleural effusion) was performed in its entirely, so we are seeking guidance if it is also okay to code for the removal of the tunneled catheter during the same encounter?

TEE with no specific documentation of Right Atria (All other required elements are documented -LV, MV, TV, AV, PV all were imaged and findings documented)

My question is they documented:

Intraatrial septum:

The left atrial appendage is normal in appearance with no evidence of thrombus

Pulsed wave doppler of the left atrial appendage demonstrates normal emptying velocity

No interatrial septum shunt visualized by color doppler.

Is that sufficient to show that they are viewing both the left and right atria to report a complete study?

This pertains to the new pulmonary artery angiogram 93569 and 93573 codes during congenital cardiac catherization. If the MAIN pulmonary artery is selected with bilateral pulmonary angiograms is this a "selected" 93573 or does the selection need to be of the left and right pulmonary arteries?

If the MD orders a limited echo and the report states a limited echo was performed using colorflow and doppler AND all elements of a complete study were resulted (LV and LA, RV and RA, mitral, tricuspid and aortic valves, pericardium and portion of the aorta adjacent to the heart.....should a 93306 be billed instead? Does the order need to match the code and is it appropriate to bill a complete study when the intent is to perform a limited?

Can we code an additional stent when both the right main renal artery and right superior accessory renal artery are stented? 37236 and 37237

Coder used 36904 but I'm not seeing this. However, unsure what code should be used in this case ??

INDICATIONS: Patient had a Cimino fistula ligated due to successful kidney transplant. Now having symptoms in the hand and shown to have prominence over the left radial artery and acute thrombosis of the remaining portion of the fistula.

SURGERY: 15 blade for incision over old incision. Dissection down to the radial aneurysm. Scissors dissected the fistula from surrounding adhesions. Proximal and distal radial artery were isolated, and control achieved. Proximal artery was palpable but distal artery had no pulse and not even dopplerable. Heparin given and proximal radial artery clamped. Aneurysm was cut and thrombus cleared out. Balloon used to thrombectomize the distal radial at which point we noted backbleed. Aneurysm was excised. Arteriogram showed distal radial artery showed no significant supply for the hand and we decided to tie off the distal and proximal radial artery. Hemostasis verified and incision closed.

Percutaneous access via outflow vein close to the antecubital fossa with fistulogram + central venogram.Angioplasty along entire length of the peripheral outflow vein, however, vein was still clearly somewhat diseased.Separate percutaneous access via outflow vein closer to the shoulder with fistulogram and angioplasty of the anastomosis. Repeat fistulogram showed extravasation. Balloon was reinflated, no change on repeat fistulogram which told me that the rupture was at the anastomosis directly. Longitudinal incision was made overlying the AV anastomosis w/blunt dissection of brachial artery. No backbleeding from the outflow vein. Brachial artery was fully mobilized w/creation of end-to-end anastomosis resulting in excellent pulse in the brachial artery. I then ligated the open end of the outflow vein using medium clips. There was a seroma at the basilic vein harvest site with was drained w/needle (100ml). Provider wants to bill 36902,35206,37607. Would this be a revision, 36832-22 (for conversion to open)? Your guidance is apprecicated. Thank you.