Ask Dr. Z

Our physician performed a port check 36598 includes contrast injection and fluoroscopy, then decided to removed it 36590, and place a new port via new access 36561, 76937, 77001. Our edit is saying 36598 conflict with 77001 and modifier not allowed. Can we bill for the port removal 36598?

I need your expertise on this case. Patient went in for TEE and stress echo; the procedure was performed on separate encounter. Can the facility report C8930, C8929 if contrast was used? Or if only the stress used contrast and the TEE did not, can we report C8930 and 93306? Per NCCI, modifier is allowed on TEE 93306 or C8929 when supported reported with stress echo. Some payer is denying for the reason CO 97 -Pmt included in allowance for another svc/px. What is your input on this?

Pt presented to ED for dizziness, CT Scan with contrast performed. at same visit Pt received IV push of Zofran what would be the correct X modifier to use for 96374?

It has been ACR and your recommendation to use unlisted 76498 for MRI WB citing AMA Clinical Examples in Radiology Spring 2009. In a recent AMA CER Winter 2024 Q&A on the appropriate code to report a whole-body CT or MRI, the CPT codes for the relevant body parts of interest should be reported. When appropriate to report, modifier 52, Reduced Services, could be applied to designate a limited degree of anatomical overlap of the imaging range with the advice to check with local payers on the use of mod-52. What is your guidance on this?

Code 0338T is listed as a base code for IVUS code 37252, but 0339T is not listed as a base code. Do you recommend coding IVUS if performed with 0339T?

I have a cardiologist who is asking to charge 93312 and 93355 for his part in a Watchman procedure. He performed a baseline TEE and TEE for guidance, per his report. I see in CPT codebook that these cannot be billed together.

Since an interventional cardiologist performed the Watchman (33340) procedure, should code 93355 or 93312 be reported for the non-interventionalist?

Please help! I am just learning ASC coding. Our provider was "intending" to perform an angioplasty of the SFA in the ASC setting. However, the provider was never able to get the catheter past the contralateral external iliac and down into the SFA to attempt to cross or work on the SFA lesion. Per the provider documentation, all that can be reported is code 36246 for the catheter placement in the contralateral external iliac artery. Are we able to report code 37224-74 for the ASC (the patient did have anesthesia)? Is it okay that the provider's and ASC's CPT code would not match in this particular case? I have researched but cannot find a definitive guidance on this issue. 

Are the posterior segment VIII branch of the right hepatic artery and the medial segment VIII branch of the right hepatic artery hepatic artery two different artery branches?

If an IVUS catheter is placed in a renal artery for measurements to determine what size Paradise ultrasound catheter to use for therapy, can the IVUS be charged/coded? There is no NCCI edit that CPT 37252 and 37253 cannot be coded with 0338T or 0339T. Re Cor said this is a grey area and could not advise whether to charge or not to charge for an IVUS. What is your recommendation?

Would you please provide some clarity as to when it is appropriate to use code 55706? CPT Assistant, November 2010, Volume 20, Issue 11, page 5 states that it must be performed under general anesthesia, 35-60 samples are obtained, and a previous negative standard prostate biopsy was performed. I have a provider insisting that these guidelines are outdated and per clinical standards she should be able to use this code when moderate sedation is used, 20 cores are obtained, and no previous standard prostate biopsy needs to be performed. She states it is the technique, not the type of anesthesia or number of cores that defines this. All the other guidelines are met, including the use of a template and a transperineal approach.

In 2021 you advised using unlisted code 64999 for renal hilar blocks. Has that advise changed since 2021? Can we code these with CPT 64415 or any other category I code?

If we place a drug-eluting stent in the native LC (C9600) and a drug-eluting stent in SVG to OM2 (C9604), how would we code angioplasty to SVG to OM3? Code 92938 is add-on to 92937, but would that still apply in this case, or should I just code as 92921?

Our urologist and radiation oncologist work together on brachytherapy cases, and we’ve been coming documentation within the Radiation Oncologist reports that supports “transrectal ultrasound probe is inserted into the rectum to visualize and measure the volume of the prostate using planimetry “does this meet documentation and medical justification to report CPT code 76872? We should also take in consideration that he (Radiation Oncologist) is also reporting the transrectal guidance (CPT code 76965) for these cases which bundled with 76872, based on CCI edit.

What is the correct way to report this procedure?

"INDICATION: Hydronephrosis. Acute kidney injury.

TECHNIQUE: The pre-existing retrograde biliary drains used as ureteral stents were prepped and draped. The catheters were then cut and catheters removed under fluoroscopic guidance.

FINDINGS: Bilateral retrograde ureteral stents were removed and completely intact. The stents were externally accessible via the urostomy.

IMPRESSION: Successful removal of bilateral retrograde ureteral stents."

Should I report code 37218 for the following?

"A Seldinger needle was used to gain access to the carotid artery with placement of a wire directed into the descending aorta. A 6 French dilator was used to upsize the channel and facilitate placement of an 8 French sheath. Angiography was performed, showing evidence of a greater than 90% stenosis at the origin of the innominate artery. The patient had previously been anticoagulated. Subsequently, a 7.0 x 20 mm balloon was advanced to the area of high-grade stenosis, and angioplasty was performed. Angiography was performed, and ideal stent location was determined. Secondary to the near bovine anatomy ability to not cover the origin of the left common carotid artery was limited and obtained good results into the innominate artery. An 8.0 x 19 mm Omnilink stent was positioned to cover the area of atheroma and stenosis and deployed at 10 atm. This resulted in good apposition."

If a lesion is treated in the right coronary artery with a stent (C9600-RC), and the RPDA is treated with a drug-coated balloon, would the PDA be 0914T or 0913T?

If both were treated with DCB would it just be 0913T alone?

If the left hepatic and middle hepatic arteries are both selected, would the coding be 36247 and 36248, or would it be only 36247 for the middle hepatic being the farthest artery selected?

Is both color flow and spectral analysis documentation required to report code 76820 as it is for duplex CPT codes?

What is the appropriate CPT code for CT-guided bilateral T9, T10, and T11 intercostal nerve cryoneurolysis? Would it be 0442T or 64999? I saw a previous post that suggested 0442T, but I also saw some other guidance that possibly unlisted code 64999 may be assigned.

Would you code 33264 for CRTD gen change and then 33271 for the new subcutaneous lead that was attached to the existing defibrillator lead using a Y connector? The patient already has an existing CRT D with three leads.

An incision was taken and extended down to the level of the device, which was removed. The pocket was then fashioned to accommodate the new device. A trocar was then taken and extended down to the posterolateral aspect of the lateral chest and a defibrillator coil was then delivered to this area and the delivery sheath peeled and a coil secured with suture. A Y connector was placed between this as well as the proximal SVC coil and the defibrillator was now replaced with a new device. The pocket was then inspected, irrigated and closed.

A physician performs a left heart cath, and the report states, "We then crossed the aortic valve and measured pressures." Is that statement enough documentation to code the LHC, or does there need to also be documentation of what the measurement numbers were? Here there were no LV or LVEDP measurements documented, just the statement pressures were measured.

Patient had a chronic right lower lobe lung infection with cavitated necrotic right lower lobe. The note states, "The chest was entered approximately under the periosteum of the ninth interspace. The cavity was palpated and delineated. I then resected three ribs for a segment of approximately 5 inches to fully unroof this region. It did appear to be approximately ribs 8, 9 and 10, although it was difficult to know for certain. The region was gently debrided. Clearly the cavity was foul and infected. There was no obvious bronchopleural fistula that could be visualized. The skin edges were turned down using a combination of #2 and #1 Vicryl suture." The code we came up with is an unlisted code of 21899 but can't determine the best comparable code for the procedure performed. How would you code this service?

Patient had an EVAR for aortic and iliac disease. We billed codes 37236 and 37221-50. Arteriotomies on both sides were closed and patched. Then, patient required an endarterectomy due to no distal signal in leg due to skin flap in femoral artery. Is code 35371 billable in this scenario?

"The ultrasound was brought back to the field and used to interrogate the bilateral common femoral artery arteriotomy site. No evidence of fistula or pseudoaneurysm were noted, and good pulsatility was seen in the arteries distal to the site of repair. Distal signals were checked, noted to be better on the right and absent on the left. Skin incisions were closed utilizing 4-0 Vicryl. Dermabond was placed over the incision line. I cut down on the left CFA. I opened the CFA and noted a large flap in the CFA. The CFA was endarterectomized and a bovine pericardial patch was placed with a 5-0 prolene. Hemostasis was obtained. There was an excellent signal in the CFA. Incision was closed in multiple layers with 4-0 vicryl and dermabond to the skin."

When agitated saline is used in transthoracic echo, should this procedure be reported with code C8923 or 93307?

Would this procedure be coded as 0441T or 0442T or would it be an unlisted code?

IMPRESSION:

Percutaneous right sciatic nerve block.

Percutaneous cryoablation of a neuroma located at the distal most aspect of the right sciatic nerve, at the level of the amputation.

Pre-procedure diagnosis: Phantom limb pain

Indication: Pain control

The patient was positioned prone. Initial imaging was performed.

Target #1:

- Maximal diameter (cm): 0.9

- Location: Amputation stump.

Under Ultrasound guidance, the needle was advanced adjacent to the sciatic nerve. Approximately 8 mL of bupivacaine 0.5% and 40 mg of triamcinolone was injected around the neuroma.

Under CT and ultrasound guidance, the ablation applicator(s) were advanced and positioned within the target(s). For each target lesion the applicators were placed and repositioned as necessary to achieve the desired ablation zone.

Thank you

On the following procedure I am looking for clarification. Per question ID 20868 & 21945 a left bundle (HIS) lead wouldn't be reported as a ventricular lead.

CPT assistant Bundle of HIS pacing lead with no atrial lead present CPT Assistant, March 2022 Page: 12 Category States that a HIS lead is a ventricular lead and should be coded as such. With that information for the below report would you do 33264 with 33225?

OP Note:

Upgrade of a dual-chamber ICD lead system to dual-chamber biventricular pacing ICD lead system by placement of a nonselective left bundle pacing lead via left subclavian pre-pectoral non-thoracotomy approach using ultrasound guidance for vascular access and utilizing nonselective left bundle pacing technique as the "left ventricular" lead.

Our provider performed an US pelvis (transabdominal only) with pelvic duplex. We reported codes 93975-26 and 76856-2659. Later the same provider performed an US appendix limited, and we reported code 76705-26. Is a repeat procedure modifier required with code 76705?

On pages 677-678 of the 2025 Diagnostic & Interventional Cardiovascular Coding Reference, it states that non-selective add-on pulmonary angiography code 93568 may be reported in addition to selective add-on code 93569 (unilateral) or 93573 (bilateral) when a percutaneous pulmonary artery angioplasty (92997, 92998) is performed. Why would a non-selective code be separately reported with a selective code?

I was wondering if an LV/CS lead was placed with a pacemaker or ICD, then the thresholds were unsatisfactory so it was changed to a LBB lead or RV septum lead, if we should bill a 33225-53 or just the 33225?

I have seen conflicting answers. I have read that I should add the 53 when completed and then changed to LBB or RV septum. Recently though I have seen on an AAPC magazine test that,

"When a procedure is fully performed but the outcome is unsuccessful, code the procedure as completed because the procedure was not reduced or aborted in any way."

Could you please advise on which way I should be billing this for my providers?

Patient had a planned CABG, MAZE W/ Atrial Clip & PFO closure. Since the PFO closure was planned and not an incidental finding is there a CPT code that we can bill for this. Since this was not a percutaneous procedure 93580 would not be supported possibly an unlisted code 33999 compared to 93580? Or would this be included within the primary procedures?

Obtaining smooth diastolic arrest an atriotomy was performed through Sondergaard's groove & retractor was placed w/ excellent visualization of the mitral valve. Did close small PFO compromising visualization due to back bleeding. P 2 prolapse with a torn cord medial half of the anterior lateral papillary muscle. Placed sutures from trigone→trigone increased exposure. Fastened 4-0 Gore-Tex & anchored them to the corresponding papillary muscle. 5-0 Gore-Tex then passed through the chorda loops free edge of the prolapsing P2 segment. Patient's previous anatomy high risk for Sam postoperatively I intentionally made the posterior leaflet more tethered down in the ventricle.

How would you code for a case where the side port of an intrathecal pump is aspirated under fluoroscopy but no contrast is used? I believe an old Q&A suggested 61070 with 77003 but based on the add-on code edits it doesn't seem like that is an option any longer.

Can we report code 76377 with below dictation?

"The obtained rotational 3D angiogram images were reviewed and processed on an independent working station.

Super Selection and Angiogram: Left Common Carotid Artery, 3D projection, series 10.

There is a Spetzler Martin grade 4 AVM left parietal arteriovenous malformation fed by dominant enlarged left M2 branches, likely rolandic and anterior parietal artery with early venous drainage into enlarged vein of Trolard and superior sagittal sinus in anterograde fashion. There is also deep drainage into internal cerebral veins into the vein of galen and straight sinus. The nidus approximately measures 3.2cm x 2.6cm x 2.25cm. No intranidal aneurysms or flow related aneurysms identified."

We have a stand-alone workstation for 3D ribs (VITREA). We are able to send our thin images to VITREA, and it will process 3D ribs and send it to PACS. The radiologist will look and read these 3D images. Is this something we can charge for using the 3D code 76376 or 76377?

An IC provider performed 93461 and had difficulties performing an access closure (due to diffused heavily calcified common femoral artery-the perclose device failed, they tried a footplate bit it kept getting stuck, then they tried a Minx7 french but that ruptured, lastly they tried an Angio-seal which still failed). Should 93461 get modifier -52 since the patient had to have the last device removed by vascular? Vascular also performed an artery repair with endarterectomy in addition to the device removal. The entire cath was successful other than closure.

My doctor did both TCAR and TF carotid stenting in the same session on the same side (left). Can both of these be reported as 37215-LT x 2 since they were done with different techniques from separate access sites? For sake of space I've only sent the conclusions: "Successful TCAR with dual stent deployment for symptomatic calcified L ICA disease. Due to severe ostial LCCA stenosis and slow flow into the stents, a secondary transfemoral LCCA stenting was performed with distal protection. No immediate complications."

Patient had drug-coated angioplasty of both popliteal and SFA. Is this still only coded once as 0913T?

Since the T12-L1 level is considered a cervical/thoracic paravertebral facet joint level for treatment with neurolytic agent, would the following procedure be reported with codes 64633-50 and 64636-50 (rather than 64634-50?)

"Procedure Performed: Bilateral T11, T12, and L1 MEDIAL BRANCH NERVE TO TREAT T12-L1 and L1-2 FACET LEVELS Radio Frequency Ablation under Fluoroscopic Guidance.

After negative aspiration for blood, CSF, or air, each needle was stimulated at 2 hertz for motor and 90 hertz for sensory without any problem and no radiating pain. 0.5 mL of 1% preservative-free lidocaine was placed at each level. Next, a lesion was made at 80 degrees Celsius for 90 seconds at each level without any problem. Then 40 mg of triamcinolone (total) was injected in divided doses at each level (condensed to save space)."

Can you please provide education on the radiology portion of this procedure? Bone marrow biopsy/aspiration is CPT 3822-LT. Having an issue with the radiology codes. Radiology is coding 77002 & 76377. Thinking it should be 77012 & 76376. Question is also do we have a "base code" for 76377? Would 76377 be coded with 77002 or 77012? This is for facility coding. 

"Patient on fluoroscopic table. Cone beam CT was performed to clarify the biopsy path. 3D rendering was performed under physician supervision, not requiring image post-processing on an independent workstation.

Skin prepped, under local anesthesia with fluoroscopic guidance, Arrow on control power bone access needle was placed into left iliac crest. Aspiration of bone marrow & bone plug aspiration was performed. CT exam was performed using one or more of the following dose reduction techniques, automated exposure control, etc.

Fluoroscopic time: 0.75 minute."

"Patient has an indwelling left sided nephrostomy tube. Contrast was injected performing a nephrostogram. This demonstrates the presence of a long segment area of narrowing at the ureteral intestinal anastomosis at 8 diverting ileostomy. Patient is post cystectomy and partial ureterectomy with ureteral intestinal anastomosis. The existing nephrostomy tube was removed catheter was placed into the distal ureter near the area of narrowing. Glidewire was then used to traverse the area of narrowing into the diverting ileal loop. Kumpe catheter was advanced into the diverting ileal loop and the catheter was removed. Under fluoroscopic guidance an 8.5 French by 22 cm nephroureteral stent catheter was placed with the distal tip coiled in the diverting ileal loop and the proximal loop formed within the renal pelvis."

Would this be 53899 or 50688/75984 or 50434?

In 2022 the code descriptor for 11981 was revised to include the terms bioresorbable and non-biodegradable. Is it now appropriate for physicians to report code 11981 for these antibiotic pouches placed during pacemaker implants and pacemaker generator change outs?

What CPT code would be used for an MRI of the soft tissue of the lower back? (The 2025 book only mentions an MRI soft tissue of the upper back being coded to the MRI chest codes.)

Provider utilized the Javelin IVL catheter in the coronary artery. Per Shockwave website this product is for peripheral use not for coronary. Would I still be able to bill 92972 on this case since the catheter was utilized off label?

Can you report EGD with biopsy with enteroscopy codes?

When is it allowed to bill 75710 and 75820 together?

Do you code the following report as 93925 and 93922?

US ARTERIAL LOW EXT BILAT WITH ABI (XPD)

PVD

TECHNIQUE:

CF Doppler common pneumatic cuffs

Rt CFA peak systolic velocity 143 cm/second biphasic waveform, profundus femorals 61 cm/second biphasic, SFA proximal 72 cm/second biphasic, SFA mid 36 cm/second monophasic, SFA distal 41 cm/second monophasic, pop 30 cm/second monophasic, posterior tibial 42 cm/second monophasic, dorsalis pedis occluded

Lt CFA 142 cm/second biphasic, profundus femorals 56 cm/second biphasic, SFA proximal 55 cm/second biphasic, SFA mid 116 cm/second biphasic, SFA distal 102 cm/second biphasic, popliteal 40 cm/second biphasic, posterior tibial 44 cm/second monophasic common dorsalis pedis 34 cm/second monophasic

Rt brachial pressure 185 mm Hg, ABI 0.3 also some noncompressible vessels

Lt brachial pressure 129 mm Hg, ABI 0.82

Imp:

Rt low extremity spectral broadening abnml waveforms segmental areas of occlusions and

severe disease w/ ABI 0.39. Lt low extremity spectral broadening abnml waveforms and mild disease w/ ABI 0.82

Per documentation, patient has peritoneal abscess. Abdominal drain was placed, but now there is no drainage from past few days. IR provider had removed the drain bedside and dropped the charge for E/M, but asking coder to bill for drain removal. Is it billable? If it is what is the code?

Patient was brought to the OR due to a right femoral artery pseudoaneurysm. There was a hematoma in the issue and at the anastomosis of the previous bypass with old and new blood. Using question ID #16039 it appears we will code this as a ruptured repair 35142 due to the active bleeding at the anastomosis. Is there any new guidance on this?

"Hematoma RT groin entered; subcutaneous tissue the hematoma was encountered and was removed. A large amount of hematoma both old and new clot was removed at the base of the hematoma of the right limb of the aortobifemoral bypass was identified and the toe of the graft was noted to have been disrupted with the sutures no longer intact. Bleeding coming from the native vessel, most likely from circumflex iliac branches. The foot of the graft on the femoral artery was completely removed by cutting the Prolene sutures. Hemostasis obtained & decision to put a jump graft was made. Some of the clot was sent for culture."

We occasionally perform bedside gastrostomy tube checks outside of the radiology department where an RN or MD injects contrast, and then a supine KUB and x-table lateral are immediately taken. The two images are done consecutively.

The description for code 49465 does not specify a modality, only "radiological evaluation". Would the imaging process described above meet the criteria for this code?

Would this be unlisted code 37799 or embolization 37242? If using an unlisted code, what would be a comparable code?

"Patient with history of prior venous intervention now has large arteriovenous malformation with large neck involving right common femoral artery and right common femoral vein. Surgeon uses an Amplatzer Duct Occluder II device with positioning of each disc at either side of the AV malformation with excellent seal." 

When coding for the facility, can we report diagnostic angiograms, catheter placements, US guidance, 3D etc., or is this one code C8004 all-inclusive? If all-inclusive, can we report code 75726 when imaging the SMA or other families that do not include the liver?