Ask Dr. Z

Please suggest. Indication: Esophageal varices bleeding. Paracentesis performed. left common iliac vein access , iliac venogram , IVUS performed to determine If the patient is a candidate for DIPS placement in future. US guided to puncture to get splenic access. After venogarm selection of gastric vein , gastric venogram, selection of 5 different branches supplying varices , embolization of them. I know procedure is 37244. Please suggest codes for this catheter placement? Can we report IVUS? cath placement for that? Thank you

How do you code the injection in right L5 transverse process injection?

Patient was diagnosed with discitis/osteomyelitis. IVR doctor placed drain under CT guidance into left paraspinal soft tissue. CT confirmed drain was placed adjacent to an area of discitis and osteomyelitis with gas in psoas musculature. Also, deep conscious sedation was provided by anesthesiologist. We are not sure what to code, 10030 or 64999. If it's unspecified, what code do you think we can compare it to?

Would cardiologist report code 75756 when only IMA angio performed, no cath?

Physician Charges

Percutaneous abdominal fat pad biopsy. CPT 22999 or 17999?

Organ targeted: Soft Tissue, abdominal wall

Biopsy side: Left

Fine needle aspiration: No

Core biopsy:

1. Biopince 16 gauge 13 - 23 mm, 5 samples

Has the AMA published an explanation as to why a central venous catheter or device termination location must be documented? How must the catheter/device tip location be identified/documented? For example, confirmation by CT scan the next day.

We have a new vendor that is taking our MRI images of the heart and using their software to do a detailed review for cardiotoxicity. The study is Myostrain and asking us to bill 75557. The study does not require function studies. Do you have to perform function studies to code/bill 75557?

If the injection of Tc99 is given for a liver tumor, are we billing 79445 with 37243 or just the 79445?

Axillary bi-fem bypass was performed for infected aortitis Then through separate incisions an open lap was performed with excision of the infected aorta/iliac arteries. Would the excision of the infected aorta/iliacs be included in with the bypass procedure, or is it separately billable? If billable, how would you code this?

"Once we completed the axillary bifemoral bypass, we decided to resect the distal infrarenal aorta, aortic bifurcation, entire right common iliac artery, and proximal left common iliac artery. The tissue was sent for culture and pathology. We then performed further debridement along the left iliac vein and distal vena cava, confirming that all infected retroperitoneal peritoneal tissue was removed. We oversewed the right and left common iliac cuffs with a Blalock stitch, using 3-0 Prolene suture. The aortic cuff was oversewed in a similar fashion. We confirmed hemostasis. We then thoroughly irrigated the retroperitoneum with both saline and Betadine solution."

Per your response for question ID #11629, if embolization via spinal arteries is done for a vertebral body met, this should be coded as 37243. However, we are getting some pushback from one of our providers stating they feel 61624 is more appropriate when the vertebral body metastasis is compression and/or invading the spinal cord since now it's affecting cord, which is CNS. Could you provide some insight?

CPT Assistant (November 2020) states that a patient does NOT have to be in Afib if patient has persistent or paroxysmal Afib in order to code 93657 (additional Afib ablation), although the code still reads Afib should be remaining. So if PVI is complete and a linear carina line is required, can we code for the 93657 when the patient is not still in Afib after PVI is complete? Also, if the carina line is performed for "right PVs were difficult and required carina line for isolation", could that be reported with 93657 or not since it sounds like they are still isolating the PVs?

"Patient upgraded from dual ICD to biventricular ICD. Surgeon was unable to access the coronary sinus for the LV lead. The CS sheath was withdrawn to the right atrium, and wires were advanced to the heart. Over remaining wire the pacing sheet was advanced to the right atrium. Then, the wire and sheath were advanced to the right ventricle, and the sheath was positioned into the high basal RV septum approximately 2 cm distal to the aortic valve. Lead was tested, which demonstrated a septal paced morphology with a wide QRS. The lead was then screwed deep into the septum."

We have 33264 for the upgrade, but since the surgeon is attempting LV lead (and that is the intent) but has to come into the septum, would you report code 33225 or 33999?

Question: A 74-year-old patient with history of coronary artery disease (CAD), who is status post coronary artery bypass graft (CABG), presented to the emergency room with complaints of increasing chest pain over the last three days. The patient described intermittent chest pain lasting for approximately 20 minutes that started as back pain and bilateral shoulder pain, then radiated to the center of the chest. A proximal stenosis of the vein graft to the obtuse marginal branches with extensive thrombus was seen in the distal graft, which was likely the culprit lesion causing a non-ST elevation myocardial infarction (NSTEMI). It was noted that the patient also had severe native multi-vessel disease, and the other vein grafts appeared to be patent. In this case, is it appropriate to assign a code for CAD with angina for the severe native multi-vessel disease that resulted in the MI?

The answer is to code I21.4 as principal with I25.10 as additional. Why wouldn't you code I25.810 instead for the stenosis of the vein graft? Should I code both I25.10 and I25.810?

Hi Dr Z,

Which CPT code can be billed for following procedure.

This is facility billing

Left forearm arteriovenous graft declot

Fistulogram and central venogram

Balloon angioplasty of AV graft, venous inflow, and outflow basilic vein with 7mm x 60mm Dorado balloon, 6mm x 40mm Lutonix DCB, 8mm x 60mm conquest balloon

Findings: there is a Left forearm AV fistula with a PTFE interposition graft. There is significant stenosis > 75% in the inflow anastomosis between the vein and the graft. There is severe > 75% stenosis at the outflow forearm basilic vein.

Thank you in advance

Physician states he utilized a 6 French cath for engagement of the RCA. It was difficult to engage the ostium and he attempted to use side holes. More stable support was achieved with AL 0.75 cath. Engaged without difficulty. Lesion was crossed utilizing 014 Prowater guidance. At this point after crossing the lesion attempted to cross the severe stenosis in the proximal RCA. He was unable to cross. Subsequently exchanged for 1.2 x 12 threader dilation sys. and PTCA was performed in the mid lesion with some improvement. Then attemped to dilate with 2.0 x 6 sprinter dilation sys. and was unable to cross utilizing the 2.25 x 12 resolute onyx stent. What is the correct way to code this? Code the attempted RCA stent with modifier 74? The angioplasty was successful but if you go with charging the PTA instead of the stent to the RCA, can you still change the supply charge for the stent? I understand you should charge was actually done, but how does your facility not lose the cost of stent that was attempted.

Can you please advise the appropriate professional fee codes for insertion and removal of the iTind (temporary implanted nitinol device)? I've seen guidance saying unlisted codes should be used. Should unlisted codes be used for both the insertion and then later when removed also send an unlisted code?

Some have mentioned that 53855 would be appropriate for the insertion and 51701 for the removal at a later date. Can you explain why those codes may not be appropriate? I've seen facility code of C9769 referenced for this procedure.

We are seeing physicians insert the RV component of a dual chamber leadless pacemaker system as a single chamber pacemaker instead of a single chamber leadless pacemaker. There is no plan to add the RA component in the future. There is nothing in CPT Assistant indicating whether or not these should be coded based on the type of device used (0797T) or the type of pacing it is intended to perform (33274). Should this be coded as a single chamber leadless pacemaker (33274), since there is no intention of adding an RA component later, or should they be coded based on the type of device inserted using 0797T?

Patient had prior diagnostic CTA and here for pulmonary thrombectomy. Provider did right heart catheterization with selective bilateral pulmonary imaging with bilateral thrombectomy. Do we bill 93451 and 37184-50 along with 93573? Can we bill for 93573 since prior diagnostic CTA done, or we just bill for 37184-50, 36014-50?

Architectural distortion is frequently seen on breast imaging and biopsies. I've seen support for both R92.8 and N64.89. Which ICD-10 is most appropriate?

When two separate nodular areas located on the same lobe of the lung are resected and sent for frozen section followed by lobectomy (during the same session) of the same lobe of the lung, can we bill for each of the separate nodules - 32668 x 2? Or can we only report 32668 x 1 since they are both located on the same lobe of the lung?

"Plan was to place an AC pascal clip on the medial aspect of A3-P3. However, there was significant difficulty in advancing the clip through the intended orifice. Multiple different trajectories were attempted as well as attempting to cross with the clip elongated.

After a multi-disciplinary discussion (CT surgeon, interventional cardiology, structural imager), plan was made to attempt plugging of the orifice.

Successful plugging of the intended orifice on the medial aspect of A3-P3 with an 18 mm PFO occluder with improvement of the mitral regurgitation from severe to none."

Can we use 33418 in this situation?

Physician services coding question: Physician A (neurointerventionalist) performs the lumbar puncture and Physician B (oncologist) performs the Spinraza injection. Would we assign 62328 or 62329 for Physician A? I'm recommending that the people who code for Physician B assign 96450-52 since their physician only injected the Spinraza. I've seen 62328 suggested for our physician's portion but this seems more therapeutic than diagnostic.

Does code 93319 require a congenital diagnosis when billed with 93312, 93314, 93315, 93317?

If a doctor documents high-grade stenosis or subtotal occlusion when an angioplasty is performed for a dialysis fistulogram, is this enough to code for the angioplasty? I know that the percent of stenosis is required, but I am not sure if those terms are acceptable as well.

I have a provider who is using adenosine to check for additional arrhythmias. As a coder, I'm not seeing in his documentation that it supports the additional code, and it looks like he is doing this to confirm adequacy of the ablation. The provider states that the documentation below supports 93623. Do you feel this supports adding 93623?

"The ablation catheter was then placed in the left ventricle, and adenosine was administered in two separate doses to achieve transient AV block. Left ventricular pacing was performed without evidence of an accessory pathway. There was no evidence of latent conduction in either the left or right-sided veins."

Successful IVUS-guided PTCA and recannulization of LAD CTO performed due to under-expanded stents. I spoke with the physician, and there was no intention of placing a new stent, just wanted to recannulate/open and expand existing stents in the artery. Would code 92920-22LD be appropriate? I'm trying to cover for the time spent on the CTO piece.

Left common and external iliac artery stenoses were so severe that there was difficulty getting just a Kumpe catheter to track over the bifurcation this required pretreatment prior to placing a sheath across the aortic bifurcation. This was done with a 5 mm balloon. Combination of wire and CXI catheter were used to traverse the stenoses and occlusions entering luminally distally into the distal popliteal artery. The diseased segments were treated with 3 mm balloon followed by a 4 mm shockwave balloon. Followed by stent column of 5 mm stent from the proximal popliteal artery to the proximal femoral artery. Right common and external iliac artery. These were treated using a 5 mm shockwave balloon the common iliac artery was additionally treated using a stent. Left common and external iliac artery t were treated using the 5 mm shockwave balloon. The left common iliac artery also had a stent placed. Left external iliac artery is treated using a stent. My codes C9765-50 and C9765-XU. Thank you for all your help.

Can you bill insert CPT 33967 and 33968 on same DOS?

Why do we get edit for fluoro and ultrasound guidance but NOT for CT guidance when coding 64530?

CT surgeon came to case for mediastinal exploration, control of hematoma, removal of foreign body, and ligation of left atrial appendage due to Watchman perforation of left atrial appendage. Cardiopulmonary bypass was initiated. It was found that the Watchman device had perforated and was completely out of the left atrial appendage but was still attached to the deployment catheter. The catheter was used to re-snare and bring the Watchman into it. The catheter was backed out of the heart. The LAA was ligated and sutured. 

Surgeon reported codes 35820 and 33268, but also wants to bill for removal of foreign body, which would be the Watchman/catheter. Please advise if backing out of the catheter with Watchman re-snared would qualify for removal of foreign body. We considered 33515 for cardiotomy with removal of foreign body, but this was documented as a repair by removing the LAA. Please advise. 

Patient was referred for diagnostic right renal angiography with pressure gradients and possible renal artery stent for fibromuscular dysplasia of renal artery, after having a CT scan showing "The right renal artery stents are widely patent even the 1 in the branch vessel. However there is a subtle abnormality just proximal to the most proximal right renal artery stent that could represent an underlying severe stenosis or web from FMD."

Per procedure report, "the catheter was placed in the abdominal aorta via right common femoral artery with injection. Patent arterial vessels without significant disease: abdominal aorta, left renal, left common iliac, right renal and right common iliac. The catheter was placed in right renal artery via right common femoral artery with hemodynamics. No pressure gradient on pull back from inferior branch of right renal artery into the aorta. No renal artery hypertension." What is the appropriate coding for this diagnostic case?

Patient with an extravascular ICD (new code set 0571T-0614T) presents for relocation and DFT testing. The extravascular ICD was relocated to a sub-serratus position. "Further dissection was performed to achieve space in the sub-serratus position where the generator was relocated to. Positioning was confirmed on lateral fluoroscopy and was also more posterior than the original placement." DFT testing was also performed. Please advise on appropriate coding for this case. Would you suggest an unlisted code?

A CT head w/o and CTA head were ordered and performed at the same time for same reason for exam. If there is a finding in the CT head w/o, would it be appropriate to code for both?

What codes would you use for a contrast enhanced mammogram done in a hospital setting? We've seen advice to use the mammogram codes 77065/77066, G0279 and the Qxxxx for contrast plus 76499. Is this correct? How about 96374 for the injection?

We have 93657 and 93655. Questioning if the dissociated PV potentials ablated that is noted here would meet criteria for code 93657.

"DX persistent A fib/typical A Flutter. CTI ablation 5:30-6:00 position of the TV annulus. Line interrogated and block confirmed. Geometry created of LV and pulmonary veins. Low voltage areas over posterior wall. Four vein pulmonary isolation done; first pass achieved right side isolation. Linear carina ablation. Gaps ablated in the region of the left posterior carinal region. After isolation, block confirmed. Dissociated PV potentials noted in the bilateral pulmonary veins. Lesions of posterior wall were contained to 5 seconds or less. Impedance drop of 10 ohms, current delivery and FTI index was closely monitored."

The patient had a dual chamber ICD upgrade to a CRT-D. Alongside the documentation of the LV lead insertion, there is this additional documentation:

"We noticed that the atrial lead was pulled back, and therefore slack was added and two additional Ethibond sutures were utilized to tie down the sleeve of atrial lead. The leads were connected to a new pulse generator."

Is this enough to report 33215 reposition of previously implanted pm/defib lead?

Can 3D post-processing be coded with kyphoplasty and vertebroplasty procedures? Currently there are no NCCI edits. Would this be considered included “procedural guidance”?

Per the SIR, 3D post-processing “requires documentation of diagnostic uncertainty prior to initiation of the procedure as well as the subsequent imaging findings and their significance. Determining the best approach to a lesion is not diagnostic imaging; determining whether a lesion exists is.” Per the NCCI Policy Manual Chapter 9.D.15, 3D rendering shall not be reported for mapping sites of biopsies or needle placements. Would 3D post-processing be considered “mapping” for kyphoplasty or vertebroplasty since it is already known the vertebra needs treating?

If 3D post-processing can be reported, what type of documentation is required to support billing for this service? We are thinking if 3D is performed prior to intervention then yes, and if during or after then no since bundled, but there are differences in opinion between physician and coders on this and we are seeking clarification.

Procedure Repositioning

Repositioning of PD catheter under Fluoroscopic guidance

Injection of contrast, intraperitoneal

Interpretation intraperitoneal contrast injection

Removal of fibrin plug from pd catheter.

The swan-neck PD catheter was accessed. Infusion of contrast into the peritoneum was performed which demonstrated good flow into the abdomen. Infusion of 500 ml saline was performed by slow drainage. A plug was dislodged from the catheter following manipulation with guidewires and drainage took place.

How would I code this?

I have a patient that came in with a LT Paraophthalmic artery aneurysm. Dr. States that they Did a selective LT Subclavian artery catheterization and angiogram was performed, LT External carotid artery using roadmap technique viewing the Occipital, Middle Meningeal, superficial temporal, and internal maxillary. He also did the LT Internal Carotid under roadmap technique. Multiple runs in multiple views noting the LT Ophthalmic artery region at this point he used 3D rotational angiogram to obtain a better eval. This was reconstructed on a separate workstation. At this point a phenom microcath was cathed into the Ipsilateral M2, pipeline flex was deployed a second pipeline was placed to ensure stasis given the ophthalmic artery came off the neck of the aneurysm.

Am I correct in my coding? 61624, 75894, 75898, 76377, 36225, 76937?

I don't feel coding the 36224 ,36227, 36228 would be valid and that they would be inclusive of the 61624.

Please advise......Thank you

When a cancer patient has non-malignant pleural effusion and the fluid has not been sent off for any testing, would the first listed diagnosis be J90 followed by the cancer code? We know that when it is a malignant effusion the cancer is coded first, but we're unsure on the sequencing when the fluid is non-malignant.

Does the catheter have to be moved to add 37185? Say they catheterize the RLL pulmonary artery (36015-RT), then they perform 37184-RT, then he says persistent defect noted in the right main PA on angio and performs thrombectomy on the right main PA without mentioning catheter movement? Can 37185 be added?

Also, is it considered pullback if after the right side procedure then he selects the LLL PA (36015) and does thrombectomy 37184-LT, then he states he slightly retracts the flowtriever to the Left Main PA & another aspiration is performed (37185-LT)? is that 36015-59LT again or 36014-? What would the cath placements codes also be?

A stent was placed in the left internal carotid/common carotid artery bifurcation to allow for reinforcement of the internal carotid artery as a means of protection at the time of planned future surgical resection of the tumor. The artery is normal without evidence of ulceration or stenosis. Which stent CPT code is most appropriate: 37216, 61626, or an unlisted code? 

We have conflicting information on whether an assistant surgeon is allowed during a Watchman procedure. Encoder pro says that only 62 modifier is allowed. However, Codify says 62, 80, and 82 are allowed.

We have a surgeon who places right femoral trialysis catheters, but he does not confirm where the tip of the catheter terminates. When I asked him he said post-op placement imaging for femoral catheters is not needed; he said there is no way to definitively confirm catheter placement in the iliac vein on plain film without cross-sectional imaging like a CT/MRI. In these cases do we report code 36556-52?

I think I'm getting myself confuse with code 37241 and 61626.

Is 61626 more appropriate for this procedure? CPT instructions state, for non-CNS and non-head and neck embolization, see 37241-37244. Is neck lymphatic malformation a non-CNS and therefore 61626 should be used instead of 37241?

"TECHNIQUE: Right face and neck were prepped and draped in sterile fashion. Ultrasound was used to evaluate the lymphatic malformation and access into the malformation was obtained using a 21 gauge needle. Contrast injection venography confirmed location. Sclerotherapy was performed under fluoroscopic guidance. Three additional sites were selected and again access into the malformation was performed using a 21 gauge needle under ultrasound guidance. Location was confirmed with contrast injection. Sclerotherapy was performed under fluoroscopic guidance.

SCLEROSANT: Doxycycline 100 mg (4 mL) diluted in 1:1 ratio of Omnipaque and Bupivacaine for a final concentration of 25 mg/mL."

Patient with an EV-ICD presents for relocation and DFT testing. The EV-ICD was relocated to a sub serratus position. "Further dissection was performed to achieve space in the sub serratus position where the generator was relocated to. Positioning was confirmed on lateral fluoroscopy and was also more posterior than the original placement." DFT testing was also performed. Please advise on appropriate coding for this case. Would you suggest an unlisted?

Have there been any updates to not being allowed to code albumin infusions (96365) with a paracentesis (49083)?

In coding clinic 1st quarter 2024, there was a question and answer for angina with MI. "Assign code I21.4, Non-ST elevation (NSTEMI) myocardial infarction, as the principal diagnosis. Assign code I25.10, Atherosclerotic heart disease of native coronary artery without angina pectoris, for the multi-vessel native CAD, as an additional diagnosis. It would be inappropriate to assign a code for angina in the setting of an MI." Can you explain why we would not code angina with a MI? This seems like new guidance. In the Coding Guidelines 1.C.9 Atherosclerotic Coronary Artery Disease and Angina it mentions "If a patient with coronary artery disease is admitted due to an acute myocardial infarction (AMI), the AMI should be sequenced before the coronary artery disease." but does not mention anything about angina with the CAD in this statement. What are your thoughts on angina with MI?

Patient with thymic tumor. Successful particle embolization of the right superior thyroid artery feeding the thymic tumor. Would you report code 37243 since the tumor is in the thymus or 61626 because the feeding artery is in the neck?

A patient undergoes coronary IVUS in the cath lab. The physician states in his report, “IVUS was used for stent sizing.” No additional information is provided (other than identification of the specific artery evaluated). Is this sufficient documentation to support coding the IVUS?