Ask Dr. Z

I am really at a loss here. This is more than a straightforward Foley removal to charge as an E&M. Would this go to an unlisted and 77002?

"Ultrasound confirmed the presence of the Foley balloon in place within a contracted urinary bladder. Through the lumen of the Foley catheter, an 8 French dilator was advanced, and contrast was administered opacifying the contracted urinary bladder. Balloon was clearly identified as well. Under fluoroscopic guidance, the Foley catheter was advanced forward. An area in the suprapubic region was then infiltrated with 1% lidocaine. Under direct fluoroscopic and sonographic guidance, a 20-gauge needle was advanced into the region of the balloon and the balloon was punctured successfully. The balloon was deflated. Foley catheter was then removed intact. Patient tolerated the procedure well without immediate complications.”

Is the coil embolization separately billed or included as part of 35151 for the popliteal aneurysm repair?

1. Right proximal popliteal artery to distal popliteal into the tibioperoneal trunk artery bypass with greater saphenous vein

2. Open thrombectomy of the right posterior tibial artery with fogarty balloon

3. Open thrombectomy of the right anterior tibial artery with fogarty balloon

4. Ligation of the right popliteal artery aneurysm

5. Right lower extremity arteriogram with supervision and interpretation

6. Embolization of two separate right popliteal genicular arteries using terumo azur 035 coils.

7. Selective catheterization of two separate genicular arteries

"We then used a navicross and glide wire advantage and selectively catheterized the popliteal artery genicular branch. Two terumo coils 5x11mm were then deployed. We then selectively catheterized a second genicular popliteal artery branch and coil embolized with a 6x17mm genicular branch"

Is it correct to charge 76380 CT limited for a intraoperative 3D CT C-arm study when used during a neuro spine case or orthopedic implant case? Can the 3D code 76376 also be charged?

Procedure was “Hepatic radioembolization preparatory angiogram and Tc99m-MAA administration.” Can we code 36247 catheter placement for MAA administration? CPT Assistant, February 2012 says, “The administration of a radiopharmaceutical is inherent to nuclear medicine studies.” Is catheter placement included in nuclear medicine studies? Selective angiography was done with catheterization at left hepatic artery trunk. Radioisotope: Technetium-99m MAA administration was done from catheter position: Segment 4 branch off the left hepatic artery trunk. Contrast was also used, but it was not mentioned when or how it was given. 78202 and 78830 were done.

Can we code 36247 with 78202 and 78830 without 75726? Or should this be 75726, 36247, 78830, and 78202?

Would this documentation support CPT codes: 93656, 936557 and 93623?

PVI was achieved for all veins with entrance and exit block. High dose isuprel induced 2 separate triggers from the posterior roof near the left-sided veins. A detailed sinus rhythm scar map was created showing patchy scar in this region. Scar modification was performed after which no further PACs were noted. Atrial pacing induced brief typical appearing flutter. Pulmonary vein isolation continued through a 30-minute waiting period.

Please advise.

What CPT code(s) would be billed for the following.

The right tunneled PICC tip was shown to be in the internal jugular vein.

Aggressive saline flush was performed, which was successful in

repositioning the PICC tip to the SVC/RA junction.

Fluoro was used but no contrast

Thanks

The left main coronary has normal takeoff from the left coronary cusp, has mild disease. The LAD is totally occluded. Left circumflex artery has a 70% very distal stenosis. The 2 obtuse marginal branches have 90% stenosis as well, and actually one of them is more like a left PDA. The RCA is a small nondominant vessel and has a 90% proximal stenosis. The left internal angiography demonstrated patent LIMA to LAD. Saphenous vein graft angiography demonstrated patent graft to the first obtuse marginal branch, and graft angiography demonstrated patent graft to the left PDA. Left ventriculography was performed with ejection fraction of 60%. Pullback from the left ventricle to the aorta did not reveal any severe stenosis.

My concernt is there is no mention of placement of catheter in bypass grafts.

Is catheter placement reported with shockwave llithotripsy in the lower extremities? For example, would 36247 be reported with C9764? In the other lower extremity revascularization CPT codes, it is bundled and there is an NCCI edit. But there is no edit for these.

Preliminary Ultrasound of Left breast demonstrates slightly thickened wall, few internal debris within cystic lesion. Ultrasound -guided FNA of the above complex cystic lesion at 5 o'clock position of Left Breast was performed using 18-gauge needle attached to 10 cc syringe. Less than 1 cc of blood-tinged was aspirated followed by insertion of biopsy clip. Specimen was sent to the department of Cytology. Unilateral left mammogram confirmed that the clip is in satisfactory position.

Should we use 19000 or 10005?

Can 19285 & 77065 be coded separately?

The patient comes in for TCPVR procedure with elective right heart/left heart cath and angiograms. Would you code the RHC/LHC and angiograms with 33477?

We are trying to figure out what code we would use for repositioning of lumbar drain with fluoroscopic guidance. The drain was manipulated and slightly withdrawn from the spinal canal. Location confirmed by fluoroscopy. What would you recommend coding? Thanks!

According to AHA Coding Clinic 2nd Q, 2014 - Breast Codes: Biopsy and localization devices, under the Q&A section, the answer to Q #3 states both 19301 and 19283 (in my case 19281) can be coded together if performed on the same breast. What if the marker is placed in the lumpectomy cavity, not in a different location on the same breast. Would it still be appropriate to code both procedures? There is a CCI edit and modifier is allowed, but I am thinking that that is if the lumpectomy and marker placement was done in different locations on the same breast.

Would this be 35226 or 37799, or would it be something else entirely since technically its repair of a previously placed right common iliac to right external iliac bypass graft?

Approximately 3 mm x 4 mm defect in the proximal 3rd of the bypass graft in the posterior lateral aspect. After debriding the friable portion of the artery, there was too large of a defect for immediate primary closure and so after mobilization of the bypass graft and trimming of the edges of the artery for more sustainable tissue, we performed a end-to-end anastomosis of the existing bypass graft in a primary fashion.

“I did not feel comfortable repairing this without additional exposure and mobilization, so then I transected the artery to obtain a circumferential evaluation of the artery, CryoArtery. After additional debridement I felt comfortable reattaching each end in end-to-end fashion with 5-0 Prolene suture in simple interrupted fashion in its entirety.”

Physician billing - Pt had a LHC w/ stent for anteroseptal MI and later in the same day, patient develops a high degree AV block so returns to the cath lab requiring a temporary wire placed same day, same provider but separate encounter. There is a 0-edit between the cath and the temporary pacer so the -59 modifier cannot override the edit. Does that mean that even in a situation such as this, the pacer is not billable?

Would you report code 10030 or an unlisted chest code for this report?

"CLINICAL INDICATION: Subcarinal cystic structure. Under CT guidance, a 17 gauge coaxial introducer needle was placed into the subcarinal cystic structure via right posterior approach. A 0.038 guidewire was inserted through the cannula, and the cannula was removed. The tract was serially dilated, and a 10 French pigtail drainage catheter was ultimately placed into the cystic structure. Fluid was manually aspirated through the catheter, and the catheter was attached to a drainage bag. The catheter was secured to the skin with a Percu-Stay device. Fluid was sent off for cell count, cultures, and cytology. IMPRESSION: Uncomplicated CT-guided drainage with catheter placement of mediastinal cystic structure."

Our radiologist is performing needle placement only via fluoroscopy for a cervical spine injection. The pain management provider is actually giving the injection. Can the radiologist bill anything for the fluoroscopic needle placement only?

Can you please clarify whether the Penumbra (Indigo) is still considered aspiration thrombectomy or is it now considered mechanical thrombectomy. Previous responses stated it is aspiration, but our Cath Lab disagrees. The Mechanical Thrombectomy E-Learning Module states the only device that is appropriate for use with 92973 are the AngioJet devices. There are many MTD devices shown in the module, are none of them other than Angiojet coded with 92973? Of note, the Optum Guide to IR has an example that codes a Penumbra thrombectomy as mechanical.

Code G2066 was billed with 93298 for remote loop recorder device interrogation; however, code G2066 is now deleted. What code is replacing G2066?

The cardiologist I code for have and in-office cath lab and perform LE resvascularization and a few other procedures there. My question is with meds given, are they allowed to code also 96374?

Common meds are

Versed

Fentanyl

Protamine

Zofran

Benadryl

Flumazenil

From right side femoral access,  catheter was placed in infrarenal aorta above bifurcation and performed angiogram, and catheter was placed in left external iliac for left leg runoff. Findings state aorta patent with iliacs and complete left leg findings. Can we report code 75625 in this case? Not sure whether significant portion of aorta was imaged since he said catheter was placed above bifurcation.

How would you code the axillary cutdown when the Impella is removed? Is this billable?

This is another persistent afib patient returning for repeat ablation.

" A voltage map revealed pulmonary vein isolation from prior ablation procedure. In this context we decided to extend the line of isolation. Radiofrequency applications with 25 to 45 watts were delivered around the left and right pulmonary veins to achieve wide antral circumferential isolation. Entrance and exit block was confirmed bilaterally. High esophageal temperatures were noted while ablating the posterior aspect of the RPVs. Applications were interrupted once the temperature reached 38.5 C in the esophagus. After pulmonary vein isolation was achieved, pace capture at 10 mA x 2 ms was performed along both lesion sets. Additional radiofrequency energy was applied at the areas of capture."

If the pulmonary veins were identified as isolated from a prior ablation is the extension of the line of isolation in the presence of persistent afib still reported as 93656?

Is it appropriate to report 36569 when an RN, employed by the hospital (Vascular Access Team), places an PICC? There is no physician involvement, other than the reading of a post procedure chest x-ray.

They are using ultrasound and had wanted to report 36573, but, don't believe that to be appropriate due to lack of physician supervision and interpretation. Do you agree?

In a case where the patient was scheduled for an upgrade from dual PM to BiVi PM, the doctor was not able to implant the LV lead. I’m coding 33225-74 because it is specific to why patient was on the table, because additional supplies and time was used, and because the doctor states “concern for complications” and aborted the procedure. The doctor then added a new RV lead and exchanged the dual PM so I’m also coding 33207 and 33233. Do you agree with my codes? Also, if the patient is for a brand new BiVi PM and doctor cannot place the LV lead and just places the dual PM, should I be coding 33225-74 as well? I have been just coding for a dual PM insertion. I’m interested in your thoughts. Thanks!

Physician placed an AFX 2 with a Proximal extension Vela 25-75. Is the correct CPT coding for this a 34703 and 34709 for the proximal extension?

What should be coded for the following?

A four-quadrant sector transducer scan reveals that there is only some a small amount of ascites fluid in the right perihepatic space, no fluid seen in the left upper and left lower quadrants of the abdomen and also in the right lower quadrant and hypogastric region respectively. Therefore we elected not to perform a repeat paracentesis at this time. Instead we elected to perform closure of the prior peritoneal cavity tract which had resulted from the prior ultrasound guided paracentesis performed a few days ago. Therefore we embarked on performing a circ lage suture to pucker the tract followed by skin to skin apposition with adhesive skin glue. Using sterile technique and 1% local regional anesthesia with buffered lidocaine for total of 10 cc. This resulted in complete cessation of fluid coming out. We then performed a dry dressing.

Impression :successful management of a peritoneal ascites leak coming from the prior site of peritoneal fluid drainage

Need Dr. Z's opinion with this op report :) Thank you in advance!

An arteriotomy was made mid common femoral artery extended across the femoral bifurcation to the origin of the superficial femoral artery which was widely patent. Occlusive highly exophytic plaque was at the femoral bifurcation. An endarterectomy plane was identified, taking care to preserve the abrupt termination of the plaque at the origin of the profundofemoral artery. We endarterectomized from the proximal superficial femoral artery retrograde to the level of the inquinal ligament w/a penfield elevator. At the origin of the profundofemoral artery I divided the plaque with Potts scissors, resulting in preservation of a nice ostium. I tacked down the plaque at the origin of the profundofemoral artery w/7.0 prolene sutures and passed the plaque off as a specimen. The 8 mm graft was spatulated to match and end to side anastomosis completed with 5-0 prolene sutures.

Then the op goes on to discuss completion of the axillary to bifemoral bypass.

Can you please clarify if we should use 19285 or an unlisted code for an ultrasound guided needle localization of right axillary lymph node? CLINICAL HISTORY: Patient is seen for an ultrasound guided Pintuition Seed localization of a malignancy and tissue marker in right axilla. FINDINGS: The patient was positioned on ultrasound table and the right axilla was prepped and draped in the usual sterile manner. High resolution real time ultrasound imaging was performed. The malignancy and tissue marker to be localized was identified in the axilla. Ten (10) cc of 1% lidocaine was utilized for local anesthesia. The localizing needle was inserted and the needle tip was advanced through the lesion using real time ultrasound guidance. A Pintuition Seed was then deployed through the needle and the localizing needle was removed. A post localization mammogram was performed confirming accurate localization of the lesion. CONCLUSION: Successful ultrasound guided Pintuition Seed localization of a malignancy and tissue marker in the right axilla.

Can you advise me as to what the correct CPT charging would be for 4D CT angiography? I understand the charging for 3DCT angiography for S&I is 76376 and 76377 as to whether this was reviewed on an independent workstation. I cannot find any information concerning 4D CT charging.