Ask Dr. Z

Our providers are sometimes performing stereotactic breast biopsies using contrast enhanced mammography to visualize the lesion within the same setting. In addition to 19081, should we also capture 76499 for that contrast enhanced imaging?

AFTER OBTAINING CONSENT, AN US CORE BIOPSY OF THE RT HIP SYNOVIUM WAS PERFORMED. PREPROCEDURAL IMAGING OF THE RT HIP DEMONSTRATED A TOTAL RT HIP ARTHROPATHY WITH EXTENSIVE SYNOVIAL THICKENING ALONG THE ANTERIOR MARGIN OF THE FEMORAL STEM. THE RT HIP WAS SCANNED AND THE REGION OF INTEREST WAS LOCALIZED, UNDER US GUIDANCE, 5 PASES WERE MADE AND BIOPSY SPECIMENS WERE OBTAINED USING AN 18 GAUGE BIOSY GUN. WOULD THIS BE CODED AS 76942 AND 20206?

Can you please provide the documentation to support that 37244 must be for acute active hemorrhage? We have an outpatient report for embolization of hemarthrosis. Is a planned outpatient embolization for this indication coded as 37242 or 37244? We have a dispute over documentation that it must be acute bleed indication, which we do not see supported in the CPT Codebook.

Patient presented with severe stenosis and regurgitation of bioprosthetic valve (previous TAVR). The patient also has a history of CABG. The bioprosthetic valve was found to be adhered to the ascending aorta and the ascending aorta needed to be replaced from the distal to the sinotubular junction. The bio valve and the native valve were excised, and a new valve was placed. 33405-22 for this portion. The surgeon then had to reimplant the previous coronary bypass grafts into the newly grafted ascending aorta. I am certain we need to go with an unlisted code for the ascending aorta replacement and thinking that we'll utilize 33859 as the comparable code after confirming with the surgeon. Also, adding 33530 for the re-operation. Is there anything additional that you would recommend?

Per the below results how would this Limited Echo be coded - 93308-26 or with unlisted cpt code due to administration of Epinephrine, Vasopressin, Norepinephrine, fentanyl - Implella pump flow measurements and VA ECMO flow rates included in results.

Echo Summary -

1. Overall left ventricular ejection fraction estimated at 10 to 15%

2. Severely decreased global LV systolic function

3. Mildly reduced RV Systolic Function

4. Moderately dilatedLt/RT Atrium

5. Severe MV regurgitation - Severe aortic stenosis

6. MV ERO 0.56 cm2

Vena contracta 1.34 cm

Jet fil1s the lt atrium

Peak continuous wave MR velocity 3.42 m/s

7. Epineprine 2 mcg/min; Vasopressin 0.04 units/min; norepineprine 5cmg/min; fentanyl 5mcg/min

8. Impella CP; P2Impella flow 2.2 1/min, CPO 0.5

9. NSR, HR83.

10. VA ECMO; 5.45LPM,SVo2 75.6; RPM 4315

Patient has paroxysmal Afib. Provider does PVI 93657 confirms isolation in each vein. Then documents -- Extensive left atrial substrate modification was then performed. The posterior wall region between the PVs was debulked by targeting prominent EGMs rendering the region to be scarred as verified by scar mapping. Roof and Floor lines were created by virtue of the posterior wall ablation. Burst pacing was performed from the CS but did not induce SVT. Would this documentation support coding 93657 since the patient has a history of Paroxysmal AFIB BUT it was not induced after the PVI?

HI Dr. Z,

Please let me know if this is how you would code this procedure? Bilateral inguinal lymphatic system accessed with ultrasound guidance. Lymphogram through the pelvis and abdomen. Next accessed the left brachial vein with cannulation of thoracic duct off the left subclavian. Lymphangiogram done in thoracic duct where extravasation seen near surgical clips. Embolization done with n-BCA. I am thinking 38794, 38790-50, 75807, 37244? Is 76937 allowed for ultrasound guidance of lymph system and do we code anything for the left brachial vein access site or is that part of 38794?

Thank you for your help

Do we report code 33289, as we do for CardioMEMS, for the Cordella PA pressure sensor? I am unable to locate coding suggestions. It looks like Cordella is FDA approved recently.

"The patient had successful TAVR placed and developed pericardial effusion. Provider performed an emergent sternotomy and evacuated a large amount of blood and placed multiple sutures. Hematosis was obtained and the chest wall closed. The patient had a dusky lower limb, and cardiology removed the sheath from the TAVR repair and the patient become significantly hypotensive. The provider then re-opened the sternotomy and removed more clots (the patient never left OR)." 

How would you report the emergent sternotomy since the TAVR was successfully completed as a percutaneous approach (33361)?

I am stumped as what I should use for coding this attempt. Can you please advise? Patient has RV lead impedance, so they planned to do an ICD RV lead revision. Doesn't seem like he did enough to charge 33244-53, 33216-53.

"Using general anesthesia with endotrachael intubation, a right infraclavicular incision was made and the old generator was explanted. The right subclavian vein appears occluded. It was decided to leave the original system in because three years of battery is left. Finally, the subcutaneous pocket was sutured using 2-0 Vicryl and the skin was closed using 4-0 Vicryl. The patient tolerated the procedure well and no complications were encountered during this implantation."

I have been unable to find a CPT code for cannulation during the following mitral valve replacement procedure and believe it is included in the MVR. Please confirm. 

"PROCEDURE: Mini access right anterior thoracotomy. Patient was cannulated with femoral aortic cannula and ascending root cardioplegia catheter. Patient was placed on cardiopulmonary bypass, aorta was cross-clamped, once the heart was arrested the antegrade cardioplegic catheter was turned into an aortic vent line. Direct left atriotomy was performed and mitral valve was inspected, and found to have thickened leaflet with poor coaptation, the mitral valve was replaced." (The only CPT code applicable is 33430.)

In EP studies, if the physician documents that programmed stimulation was delivered from the atrium, is it considered the same as induction or attempted induction of arrhythmia? Can we report 93618 for programmed stimulation?

I'm having trouble figuring what exactly was done here. The heading says "Right chest port revision", and then goes on to say a right internal jugular venotomy was performed, but no mention of ultrasound guidance. Then, the existing right chest port was explanted and a new double-lumen Bard port was tunneled. The catheter was inserted through the new right internal jugular access site and then connected to the double lumen port. The port was anchored to the right chest wall and flushed and aspirated appropriately. The impression says "Successful removal of a single lumen right chest port with placement of a new double-lumen port." Would this be coded 36582?

My physician performed a redo TCAR procedure due to in-stent stenosis of the right carotid artery. After procedure was completed and prior to closure the patient began to hemorrhage which was determined to be caused by a transection of the proximal carotid artery as documented below.

"The common carotid artery at the clamp site was 80% transected and the intima disrupted. The access site was fine. The proximal and distal ends of the artery were freed up and the clamps moved to assess the situation. I asked my partner to scrub in to help get to this point. About 1.5 to 2 cm of artery was excised to gent endpoints that are essentially normal. They had too much tension to close primarily. A 6 mm Goretex graft was brought to the field and cut to length. The proximal anastomosis was performed first with running 5-0 Prolene and then the distal anastomosis both end to end."

Would this repair be separately reportable with 35261? It is hitting an NCCI edit and is the same operative session/site?

Generally our pediatric cath surgeons access the PDA via normal connections from the carotid artery or femoral artery and don't go into the heart to place a stent. The stent is placed due to CHD so they do have abnormal connections , but technically our access isn't abnormal. Would you suggest we code these to 33902 or 33900 in 2023?

"The patient with AICD came for NIPS procedure. DFT ventricular fibrillation was induced with burst pace. Joules delivered: 34. Defibrillation threshold testing was successful." Both of the reviewers agree with 93642 because the ventricular fibrillation was induced. Please advise why you suggest 93799 instead of 93642.

The coding book says that 33902 can be used to stent a PDA via abnormal connections or post-surgical shunts. What about our PDA stents we are doing now, generally from carotid artery or femoral artery through the PDA into PAs for access? These patients all have CHD, so they do have abnormal connections, but technically our access to the PDA (which isn’t through the heart) isn’t “via abnormal connections”. Is this still the code we can bill for this case?

Can I bill an ICD interrogation (93287) that was done during the same session as a Watchman implant (33340)?

I'm a charge analyst for a hospital. We've started doing cases where the thoracic surgeon comes to the EP lab to work with an EP Physician to perform a hybrid maze procedure. My question is how to code the maze procedure, 33254 vs 33255. If the surgeon ablates several areas does that make it extensive (33255)? We've performed two cases; the first case was for inappropriate sinus tachycardia. The EP Physician performed an EP Study with drug infusion and 3D mapping (93620,93623,93613). The surgeon performed a Right video-assisted thoracic surgery, right-sided cardiac ablation, crista terminalis ablation, superior and inferior venacaval ablations. The second case was for Postural orthostatic tachycardia syndrome. The EP Physician performed an SVT ablation (93653) along the crista terminalis, the surgeon performed Right video-assisted thoracic surgery, right pulmonary vein isolation, ablations at the right crista terminalis, and right superior and inferior venacava. Would both of the cases be coded as 32555, along with the EP codes I have?

The 2023 CPT book does not list the current reference regarding 75774 from CPT Assistant Sept 2022 and the parentheticals have not changed either. The ZHealth publishing email distributed on 10/31/22 describes the historical background, the code appearance within the “Aorta and Arteries” section of CPT and the following recommendation.

For now, we are recommending following the guidance in “CPT 2023 Professional Edition” over the recent CPT Assistant article, at least until there is clarification of the inconsistencies between these two resources. Should the AMA give guidance specifically addressing this issue, the above comments regarding use of 75774 for additional venous imaging would take effect.

Has there been clarification yet from the AMA or CPT Assistant?

When a fibrin sheath is stripped from the catheter with a loop snare from a femoral access and then tunneled catheter is exchanged through the existing catheter, can 36595, 75901, 36010, and 36581 be coded together with a modifier added to 36595 and 36010?

We received a denial for 36904 that the code was not approved and wonder what modifier should be used when billing this code. What was billed was 36904, 36558, 77001, 76937, and 99204; Diagnostic codes use were N18.6, T82.858A, T82.868A, and T82.898D

Please advise if modifier 52 is recommended, or any other. Thank you

Could you please describe what the differences in the documentation look like between the CPT 33265 convergent and the 33266 convergent?

BYPASS GRAFTS:

1. Due to radial approach the LIMA was not engaged. Previously was thought to be occluded or at least had very poor distal flow. The touchdown to the LAD was not evident on catheterization from August 2021. Today there is clearly a patent graft with competitive flow at the apex of the LAD. Ascending aortogram was performed that did not demonstrate any aortocoronary grafts. Angiography of the right innominate artery did not demonstrate a patent RIMA.

If this isn't billable can you tell me why?

What catheter placements would be captured in this diagnostic case without intervention?

Access obtained with a 4 Fr in the RFA and a 6 Fr in the RFV. This was followed by diagnostic angiography in the aortic arch ruling out vascular injury. Then, the 4 Fr NTAG catheter was advanced from the venous sheath into the left innominate vein. To avoid extravasating the catheter hand injections were performed as it was advanced in the left innominate vein, left subclavian and axillary vein. Hand injections in the left axillary vein and LIJ ruled out venous injury.

1. Power injection with catheter in the descending aorta at the origin of the left subclavian artery shows no vascular injury of the left subclavian or axillary arteries.

2. Hand injection in the left axillary vein shows no vascular injury

3. Hand injection of the left IJ shows no vascular injury

4. Power injection of the left innominate vein demonstrates integrity of the vein

5. Hand injection in the left axillary vein was repeated showing no extravasation of the contrast

Can we report both codes 33477 and 33745? Is the RVOT stent placement in the valve deployment zone, or is it considered pre-stenting (33477)?

"Status post bioprosthetic pulmonary valve replacement with an enlarging right ventricular outflow tract pseudoaneurysm, which has been causing worsening sub-pulmonary stenosis. There has been concern that when his anticoagulated and in the setting of significant RV hypertension, the RVOT pseudoaneurysm continues to enlarge, worsening his sub-pulmonary stenosis and the strain on his right heart. I noted that he had a severely reduced cardiac index at 1.86 L/min/m2 and a 40 mmHg gradient from the right ventricle to just above the bioprosthetic valve due to the sub-pulmonary obstruction and compression by the RVOT pseudoaneurysm. The procedure included diagnostic right and left heart catheterization with oximetry hemodynamics and angiography. Intervention included stent placement in the right ventricular outflow tract and transcatheter pulmonary valve implantation."