Ask Dr. Z

Are we allowed to perform carotid stenting by the new criteria after the decision memo was released 10/11/23? I cannot find an actual effective date change on the policy yet, so I wanted to make sure we were clear to stent by the new rules.

Question ID 5448 says report code 49406 for trans-gluteal approach. Code 10030 would be for a soft tissue drainage in the buttocks, not in front of the sacrum, which is in the pelvic cavity.

Question ID 8089 says The catheter must be indwelling for 49405, 49406, 49407, and 10030. Indwelling is not just a couple hours. It is intended as a long-term drainage (more than on a single DOS).

If 49405-49407 & 10030 must be indwelling and 10160 is for superficial / subQ drainage and 49083 is for ascites, and 50390 is for a cyst, what would be the appropriate code for when only a needle is used to drain a deep peritoneal fluid collection and no drain is left behind?

Example: US-guided and therapeutic aspiration of intra-peritoneal fluid collection around transplant kidney.

Local anesthesia was administered. .. ultrasound guidance .. 5 Fr Yueh advanced into the fluid collection with spontaneous return of fluid. A total of 65 cc of fluid was removed, a sample submitted for laboratory analysis. Hemostasis was achieved.

Thanks!

I have been asked this question many times, and there is always conflicting information. For remote and in office pacemaker, ICD, and LOOP recorders, which diagnosis codes do we use? I was taught to use the Z95 series codes; however, there are some sources that state to use the Z45 series codes. Can you clarify which is correct and the reasoning behind it please?

The patient has a Watchman fabric separation. Right thoracotomy, cardiac arrest, decision made to cover Watchman with bovine pericardium.--anastomosed around Watchman to cover completely. I can't find a code to describe this procedure, or a code close enough to use 33999.

When a patient comes in for a procedure related to a research study, say a biopsy or CVC placement, what diagnosis code should be first listed on the IR claim? Should it be Z00.6? Or should it be the diagnosis prompting the study?

Based on the description below, are the following codes correct: 93654, 93462, 93662)? 

"Right femoral venous access was obtained; catheter was advanced to the R atrium & ablation catheter was introduced into the R atrium to create geometry, then advanced to the SVC, transseptal access was obtained under ICE guidance; the PVC was mapped & localized to the anterior mitral annulus, lesions were successfully made."

The list of procedures performed indicates the doctor performed R & L ventricular pacing & recording, but when I read the report I can not find any reference to the ventricles. Any help you can give is appreciated.

Is partial anomalous pulmonary venous return or congenital pulmonary vein stenosis considered abnormal connections?

In spite of having all the correct wording to code 76937 and an understanding that lymph vessels generally code to venous, I do not feel that 76937 would be appropriate here for injection into the lymph node. Can you please clarify based on this documentation? They are injecting for lymphangiography.

"The vessel was sonographically evaluated and judged to be patent. Real time ultrasound was used to visualize needle entry into the vessel and a permanent image was stored. The lymphatic access was confirmed by slow infusion of lipiodol by hand. Intermittent fluoroscopic and spot images were obtained. Vessel accessed: Left inguinal lymph node."

I reported code 38790-50 for the bilateral injections performed.

Can we code separately for iatrogenic ASD closure when done in conjunction with MitraClip insertion (33418)? If so, do we use code 93580 or unlisted since it is an acquired defect?

"MitraClip device was prepped and advanced under the guide sheath into the LA. Proper adjustment was completed, and after several attempts the device was able to grasp both anterior and posterior leaflets of the mitral valve in a medial position. The device was closed and deployed successfully. The acquired ASD from the transseptal was felt to be large (19 mm) and noted to have significant L-R shunt. Decision was made to close the acquired ASD defect. A 37 mm Gore Cardioform ASD occluder was advanced and deployed under TEE and fluoro guidance with excellent result. No residual interatrial septal shunt."

Does this documentation qualify for 76937 since MD does not state "needle" or "real-time" but micropuncture catheter?

"Left radial artery was assessed and confirmed for patency, and accessed with a micropuncture catheter in a retrograde fashion with permanent recording of ultrasound images."

Some dictations state "kit" and I have the same question - kit or catheter suffices?

Do we need to add the -KX modifier for an attempted placement of a dual chamber pacemaker?

"Patient was given Ancef for antibiotic prophylaxis. Several angiograms were performed in the AP cranial AP views to visualize the axillary and subclavian veins. Ultrasound guidance was utilized to try to visualize the axillary vein. Despite multiple attempts access could not be obtained. The procedure was aborted, and family wishes to have the procedure done at the XX Clinic." 

Are we allowed to bill 33208-74 and append the -KX mod for an MCR patient? 

A provider would like to do two LEV on separate days. One to test for reflux, and the 2nd day US to check for DVT. Since the 93970 description is inclusive of all of those elements, would both DOS be billed as limited (93971) or only one DOS to be billed at 93970?

We have a physician who will occasionally deploy two Watchman devices in a large bi-lobed left atrial appendage. Would you recommend any charges for the deployment of the additional device?

Would you report code 37197 for the snare retrieval of the lead since the physician had to create a separate access for this?

"While upgrading a DC pacemaker to a CRT-P, our physician had to access the femoral artery and vein. From a right femoral approach using a 25 mm Amplatz gooseneck snare via the 7 French sheath, the chronic RA lead was snared and remained connected to anchor this lead in anticipation of extraction for the chronic RA and chronic LBBAP lead. This was done to anchor and retain access." 

I coded the following as 37238 and 37239 x 2. Was this correct?

"Indication/findings: Better visualized focal stenosis at the right transverse sigmoid sinus junction with long segment narrowing of the right transverse sinus and occipital superior sagittal sinus. Procedure: Stenting of the superior sagittal sinus was subsequently performed using a 6 x 40 mm PRECISE stent. Next, a 7 x 30 mm stent was placed across the torcula into the right proximal transverse sinus. Next, a 7 x 40 mm stent was placed into the right transverse sinus. Finally, a 8 x 40 mm stent was placed from the transverse to the sigmoid sinus."

Our vascular access team is looking into placing a PICC via superficial femoral vein (i.e., mid-thigh PICC). I'm thinking this is a central vein and would not be considered peripherally inserted. What CPT code would be reported for insertion of a venous catheter into the superficial femoral vein?

When plaque is excised from the common femoral artery walls using a scalpel before eversion endarterectomy, is it appropriate to report code 35371, or would I report unlisted code 37799?

Can you please help us understand which CPT code to use when they are performing a PET/CT brain with attenuation and correction for metabolic evaluation? Some references seem to direct us to 78608, but others seem to direct us to 78814 since it was performed with CT. What would you recommend using and why?

How would you code a right vrachiocephalic venogram?

"Access is on the right vasilic vein with catheterization of the right brachiocephalic vein. Findings: Patent RT BCV and SVC stent with no evidence of stenosis."

Would I code this as 36005-RT and 75820, or 75827?

A patient with recurrent A-fib undergoes PVI, as well as AVJ ablation to create complete heart block. There does not appear to be an NCCI edit between codes 93656 and 93650. May we report both of these? Or should we report code 93656 and 93655 instead?

For the CardioMEMS device 33289 I know the remote interrogation code is 93264. Our doctor performed reprogramming in person. Is the cpt code still 0417T? I can't locate any information.

In September 2022, CPT Assistant gave the guidance to use 75774 for selective add on venography after a main vessel venography. As per AMA's proposed code change summery in September 2023, AMA accepted and revised the change, but it is going to be effective from Jan 2025. Should we start using this guidance as per CPT Assistant or wait till Jan 2025? Please advise. Thank you!

Our provider is requesting the correct CPT code for "performing a limited assessment of the abdominal veins by utilizing spectral Doppler images overlaid on grayscale images to obtain hemodynamic information. This does not typically involve arteries except in the kidney to measure resistive index."

We are a little stuck on the description of limited code 93976 stating BOTH arterial inflow and venous outflow. Does the "limited" portion refer to the targeted organ or part of the organ? Or is venous evaluation only enough for an otherwise limited study? We would like to confirm that reporting limited study, 93976, is appropriate when either arterial or venous evaluation performed.

Sometimes when I am coding LINQ placements (hosp OP billing), the provider lists a CVA or TIA as the only indication, and I presume they are looking for a latent, previously undetected arrhythmia. Then when I look into the patient history, I see that the CVA actually occurred 4-6 weeks prior to the LINQ encounter, and usually the patient has made a full recovery. The cath lab supervisor wants me to code these as an acute CVA from I63. She says that a history code like Z86.73 can never be used as a first listed diagnosis, but I believe that is actually an IP coding rule. Does Z86.73 support medical necessity for an OP LINQ placement?

Does this support code 93459? I don't see the graft selectively engaged.

"Under direct US guidance, access was obtained to the right common femoral artery with a micropuncture needle and micropuncture wire, and then a micropuncture sheath was placed. After that, it was upgraded over a J-wire to a 5 French sheath, and initially a JL4 catheter was used. We were unable to engage the left main coronary artery ostium. That catheter was replaced with a JL5 catheter, which was then engaged into left main coronary artery ostium. Multiple angiograms of left coronary systems were done. That catheter was then removed. Right coronary angiogram was performed with a JR4 catheter. Saphenous vein graft angiogram x2 was performed with that catheter, and the same catheter was used to place the catheter in the left subclavian artery. Over an exchange length wire, that catheter was replaced with a LIMA 5 French catheter, and left internal mammary artery angiogram was performed. Then, I went in with a pigtail catheter, and left heart cardiac catheterization was done."

Do you still recommend using code 37246 for lower extremity PTA for treatment of a thrombus? The physician documents a thrombus causing an 80% stenosis of the popliteal artery.

"There was separate thrombus resulting in 80% stenosis of the native distal (P3) popliteal artery and the tibioperoneal trunk. An additional 3000 the lesions were administered corresponding to a total of 100 units/kg. The lesion was angioplastied with a 3 x 200 mm followed by a 4 x 150 mm and a 4 x 60 mm Armada balloons. The final angiogram showed good results with less than 20% residual stenosis and only a minute amount of residual thrombus. The heparin effect was reversed with protamine.

Conclusion: This is a patient with acute thrombus of the native distal (P3) popliteal artery and tibioperoneal trunk treated with balloon angioplasty."

What is pass-through code to go with C1761?

The IR physicians are wanting to bill code 96365 for the prophylactic antibiotics done prior to procedure for lung chemoembolization. The IR physician places the order, but the RN (hospital setting) performs the administration and the IR physician isn't present.

My understanding this isn't a billable service for the IR physician even though they place the order. Can you please clarify or confirm? Thank you

Is it ever appropriate to report 76942 at the same session as 76937? (hospital/facility coding)

Example case in IR: Port-A-cath placement for cancer at same session as thigh muscle US guided core biopsy for soft tissue mass.

All required elements are documented for reporting ultrasound guided access for the port placement. Would it be appropriate to report 36561, 76937, 77001-XS (NCCI edit with 20206) for the port along with 20206 and 76942-XS (NCCI edit with 36561, 76937, 77001) for the muscle biopsy? The -XS modifiers clear the NCCI edits, but there is still the 3M edit stating, "Do not report 76937 with 76942." My rationale is that I'm reporting them for completely separate procedures performed from different access sites and performed on different anatomy areas. Is that the correct thought process for this scenario, or is it just a never ever report 76937 and 76942 together no matter what?

Patient presented with both AAA and iliac aneurysm. The physician placed an iliac branch endovascular graft in the internal and external iliac artery followed by an iliac extender graft. After this was deployed the physician started the AAA repair with a Gore main body with bilateral limbs. Would you code for the AAA 34705, iliac 34707, and 34709 since this was a completely separate repair from the AAA? If this repair had been performed with just an extension graft would you only use 34079?

Procedures performed were 37187 and 37212 with cardiopulmonary bypass for capturing thrombus in the filter. Would the cardiopulmonary bypass be included in the mechanical thrombectomy procedure since it was used as a filter to capture thrombus?

We have a patient who presented for Watchman procedure. The device was inserted, but "PASS criteria unable to be met despite repeat TS and new device: clinical decision was made to remove device". Would the correct code be 33340-74? Or 33340 with removal of foreign body?

On the previous day, patient was brought to cath lab emergently for STEMI, and an IABP was placed along with stents in LAD and D1. The following day, patient was brought back to remove the IABP and a relook at the left vessels; both stents are patent. We are billing for the 33968, but can we also bill 93454 for a relook with no new indications?

We have been coding sacrum biopsy as deep bone biopsy, as it is a part of a vertebral body. In May 2023 CPT Assistant, AMA is suggesting considering it as similar to a bone biopsy of a spinous process, which is superficial. But in Fall 2022, AMA is suggesting in their Clinical Examples not to use 0200T and 0201T codes in conjunction with 20225 when performed at the same time. So, AMA was considering sacrum as a deep bone in that scenario. What are your thoughts?

Please clarify catheter placements for a flossing technique access for example access into internal jugular vein and common femoral vein for snare for through and through. Would this be two catheter placements or one catheter placement of the furthest point? Depend on scenario? 

Findings:

Cholecystostomy tube evaluation demonstrates contrast filling around large gallstone. No opacification of the cystic duct. Extraluminal contrast through the drain tract exiting the skin.

PROCEDURE SUMMARY:

- Drainage catheter check under fluoroscopic guidance

- Additional procedure(s): None

Pre-procedure

Consent: Informed consent for the procedure including risks, benefits and alternatives was obtained and time-out was performed prior to the procedure.

Preparation: The site was prepared and draped using maximal sterile barrier technique including cutaneous antisepsis. Drainage catheter check and removal. The patient was positioned supine. Initial imaging was performed with contrast injection through the indwelling tube.

- Initial imaging findings: Poor opacification of the gallbladder lumen. No opacification of the cystic duct. Extraluminal contrast along the drain tract, exiting the skin.

I am aware the removal was not done, so we can't code for removal but the cath check and contrast injection we can?

Would you suggest unlisted code 93799 or 33225-74? 

"The coronary sinus was cannulated with an EP catheter and a contrast injection through the sheath showed that the vessels were very tiny there was a lateral vessel and there was a middle cardiac vein however both were really timely. We were able to get out into the lateral vein with a whisper wire however the lead would not advance. Using a subselection tool we were unable to get the Glidewire very far past the mouth of the main body of the coronary sinus. Same thing happened with the middle cardiac vein. We can get to the septal portion of the middle cardiac vein however despite attempts a Glidewire and whisper wire would not advance out sufficiently to allow coronary sinus lead placement. All of the veins were very small and spidery. It was clear that a coronary sinus catheter could not be placed. The original device was left in place."

"Patient brought to cath lab emergently. A 100% occluded vessel was located in the LD, RC, and LC. Our culprit lesion was in the LD and treated with a stent. The LC was treated with an Aspiration thrombectomy of the OM2. No angioplasty or stenting was preformed in this vessel. Then the RC an attempted angioplasty was preformed since they were not able to cross the lesion they are planning on brining the patient back at a later time."

We know that the aspiration is included in the primary intervention of the same vessel. In this case would we be able to bill code 92941-LD with 93799-LC for the thrombectomy that was completed in the LC?

"Aspiration thrombectomy of OM 2. Thrombus was visualized in the distal arm to causing a 100% occlusion/TIMI 0 flow. Following the intervention of the LAD, the Choice PT was reintroduced and used to cross the thrombotic lesion. Aspiration thrombectomy performed using priorityONE 6 French aspiration catheter."

Need clarification on how to code the following: Our EP doctor brought a patient in for a CRT-D generator change. Patient has only two leads. One in the RV and the other in LV. Physician office thinks 33228 is more appropriate since there are only two chamber/leads used. I thought CPT assistant clarified that a multi-lead is system with leads in three or more chambers OR a CRT -device. Would 33229 not be the more appropriate code to use?

"After angiography hemorrhage was noted from the ETT. This was treated with frequent suctioning, PEEP, exchanging the ETT, reversal of heparin, nitric oxide, temporary RPA balloon occlusion (7mm diameter x 2cm long Tyshak 2 balloon with RLL wire position, this was the lung field where infiltrates were noted), and transitioning to a Servo ventilator. The decision to end the procedure was made. Serial ABGs and ACTs were repeated as the bleeding was controlled. Patient oxygenation was never poor but ventilation was and it slowly improved as the bleeding was controlled. We estimated EBL out the ETT of about 50ml. All catheters and right-sided sheaths were removed and hemostasis was obtained with direct pressure prior to the application of a Safeguard. The LFV sheath was exchanged for a 5 Fr x 8cm CVL, which was sterilely dressed." 

Looking for guidance on how to code the hemorrhage treatment and ventilator?

Our radiologists are sometimes doing a bone marrow aspiration along with a bone lesion biopsy. The patient is scheduled for a bone biopsy for FDG avid lesion (20220 or 20225), but during the biopsy he also does a bone marrow aspiration at the same site. Should this be charged/coded as 38222 or 20220/20225 based on the indication of bone lesion?

The patient has a gastric lap band with a port , they came to IR for an adjustment. The radiologist accessed the port on the band under fluoro and aspirated a small amount of fluid from the port to deflate the band. He is coding 76000 for the fluoro but what can we use for the access if anything?

How do you code conversion of a nephroureteral stent to an internal ureteral stent?

"The pre-existing left nephroureteral stent was injected with contrast, which demonstrates appropriate position of the proximal pigtail in the renal pelvis and the distal pigtail in the urinary bladder. A wire was advanced through the NU stent with the tip in the urinary bladder. Over that wire an 8 French x 24 cm internal ureteral stent was deployed with the distal pigtail in the urinary bladder and the proximal pigtail in the renal pelvis. Contrast was injected, confirming adequate drainage of the left renal pelvis to the urinary bladder. The cannula was removed.

IMPRESSION: Uncomplicated internalization of an 8 French x 24 cm internal ureteral stent."

What catheterization code would be used for the following? Is this considered non-selective or selective?

Access was obtained in the right axillofemoral graft near the anterior superior iliac spine with the underlying inguinal ligament and iliac crest available for compression, using a micropuncture kit. This was exchanged for a 6 French sheath over a Bentson wire. A kumpe catheter and wire were advanced into the subclavian artery and angiogram images were obtained.

Angiographic Findings:

- successful access of the right axillofemoral graft with acute thrombus

- Patent right subclavian, axillary, and proximal brachial arteries and main branches

- Acute thrombus throughout axillary graft.

I found a similar case on question ID 4047 but it is outdated (2012) with now deleted codes. Thanks!

Dr. Z - We have a case where the patient presented with acute MI. The patient was taken emergently to the cath lab. During the LHC, it was discovered the the patient had 100% occlusion in the mid-RCA secondary to ISR, duration of occlusion unknown. The patient also had 99% mid-LAD stenosis. We attempted intervention on the RCA CTO, using a Pilot 50, but the wire was going into the subintimal space, and further intervention on the CTO was stopped. Attention was turned to the LAD, and PCI/DES was performed. I bill for the hospital side. Would we code this as an attempted CTO, 92943-74, RC and C9600-LD, or would the hierarchy rule not apply since the patient was taken emergently to the cath lab for acute MI, making our codes C9606-LD and 92943-74? Thank you.

We performed a PVI ablation for atrial fibrillation. Following the PVI, we ablated the floor line and roof line (box set). “During this, the patient went into atrial fibrillation." Next, we performed a vein of Marshall ablation on the “mitral isthmus flutter”, followed by a CTI. We think this is coded with 93656 (PVI), 93657 (box set), and 93655 x2 (VOM for atrial flutter and CTI). Do you agree with these codes?

FINDINGS:

1. Injection of the right inguinal lymph node demonstrates connection and leakage into the space surrounding the JP drain in the right lower quadrant. Glue/lipiodol was injected, which filled up two of the afferent channels from the accessed lymph node.

2. Images from the catheter injection demonstrate no significant cavity.

3. The catheter was draining clear straw-colored fluid.

Impression: Lymphatic leak into the space surrounding the the right lower quadrant drain status post successful lymphangiogram with glue embolization, drain exchange, and alcohol sclerosis of the space surrounding the drain.

I have coded 37244, 38790, and 49423. I am hesitant to report code 49185 because it sounds like one site that is communicating, and there is an edit between codes 37244 and 49185. Would it be appropriate to report code 49185 with a modifier here?

Can they bill C-codes if provider using this equipment at the hospital, or can they only be billed by provider when he owns obl?

MD states "flow reversal" is the distal embolic protection when I emailed for clarification:

Procedure(s): Left carotid stent placement with flow reversal (TCAR).

He does not specifically dictate in his narrative distal embolic protection, but there is a supply used on the case. Does "flow reversal" documentation meet the guidelines to code 37215?

We were just recently made aware that code 75565 now has allowance to be billed more than once per session/encounter. CEU for this is 4 now, we just wanted to confirm this can be done for example twice per session/encounter if properly documented - as long as they are clear to the coder on which vessels were mapped that is the most important?