Ask Dr. Z | Medical Coding Resources (2024)

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All 2024 2023 2022 2021

"From a left radial artery access, the catheter was advanced through the aorta and into the right common femoral artery, and right lower extremity angiography was performed. The catheter was then withdrawn and readvanced into the left common femoral artery, and left lower extremity angiography was performed."

Is it appropriate to report code 36140 for the right common femoral catheterization in addition to code 36246 for the contralateral (left) common femoral catheterization?

Our provider documents CVC's fluoroscopic guidance as "Post placement fluoroscopic image demonstrates good positioning. The fluoroscopic image was archived." Does it need to specifically state placed using fluoroscopic guidance or is the above statement sufficient? Your help is greatly appreciated - Thank you!

Patient has angio with stent performed with IVUS and then is transferred to recovery. During recovery, the patient's condition warrants return to the cath lab for additional angio and stenting with IVUS. For facility billing, as this is one encounter, would the IVUS be appropriate to report with 92978 x 2 with appeal, or should this be reported with 92978/92979? Code 92978 has a MUE of 1.

3D mapping LT Superior and Inferior PV were encircled, and areas of electrical breakthrough were Identified, targeted ablation of these sites were performed to achieve electrical isolation of PV, which did not occur. similarly RT side PV was isolated. During ablation on posterior LA, esophageal temp monitored ablation terminated when temp increased to 38.5 which occurred on posterior wall of LSPV. Isolated firing was seen in the left PVs after isolation, pt cardioverted into sinus rhythm after ablation. A voltage map showed significant scar in the posterior wall and we decided to extend the level of PV to include the posterior wall with 2 lines( posterior line and roof line). Subsequently adenosine was given with the multi electrode mapping in the posterior wall and PVs w/o reconnection seen. Program simulation was negative for arrhythmia . Does this support 93656 with 2 units on 93657 for the posterior line and roof line ablation?

Code 75716 vs. 75710

EX: cases is LLE with run-off. Cath in iliac, angiograph of LLE taken. Finding explains the left & right arteries patent. Since cath was on left only one extremity is credited CPT 74710. Forum in AAPC was mixed opinion. If MD states finding in R side s/b 75716. What’s your opinion?

SECOND REQUEST: How do you bill bilateral pulmonary artery flow restrictor placement with 7Q microvascular plugs into the RPA and LPA?

I found the following from 2019:

"Question: Would it be appropriate to bill 37242 for placement of a microvascular plug in bilateral branch PAs for flow restriction in a patient with cardiac history significant for small left-sided structures and hypoplastic aortic arch? Basically, achieving the same effect as pulmonary banding.

Answer There is a code for pulmonary banding, which this is not. Code 37242 covers placement of vascular plugs in the pulmonary arteries. Although placed bilaterally, I would report the catheter placements and 37242 once to achieve the equivalent of banding. The other option is to report an unlisted code. -Dr. Dunn"

Is the advise the same for 2024?

If provider performed 36224,LT on Monday and found the patient to have a large left Cavernous ICA dissecting 12.6 x 6.7 mm aneurysm and planned for diverter embolization Thursday – then Thursday the provider performed 36224,LT again before performing 61624 – is the 36224,LT still billable for Thursday or no since it was already determined to have an aneurysm and getting treated that day.

I am new to IVR and struggling with surgical marker placements. I have found all sorts of information regarding placement for markers used in radiation therapy, but nothing for markers for pre-operative site localization.

My IV radiologist performed the following

INDICATION: History of Hodgkin lymphoma with prominent left axillary lymph node

demonstrating radiotracer uptake on PET CT.

PROCEDURE: Ultrasound-guided magnetic marker localization. Local anesthesia was administered. Under US guidance, the 14 gauge x 8 cm MOLLI introducer needle was advanced to the target and marker deployed. Post-procedure imaging findings: Echogenic magnetic marker adjacent to the prominent axillary lymph node. No hematoma.

The surgeon later used the MOLLI tracer to localize the area of interest which appeared to corollate with a palpable area within the left axilla during EXCISION TUMOR SOFT TISSUE NECK OR ANTERIOR THORAX SUBFASCIAL <5CM CPT(R) Code: 21556

How would we bill for the marker placement?

We understand codes 93505 and 76937 do not have an NCCI bundle; however, the recommendation was not reporting these together based on the NCCI rationale in your answer to Question 17032. Has your recommendation changed in 2024, or are we still advised not report the ultrasound guidance?

The cardiologists are doing 93505 and 93451 and 33017 and they are wanting to also report the 76937. We haven't found any change is your initial recommendation the same? Our Cardiologists are performing; 93505, 93451, 33017 and are questioning why we can't add the 76937.

For cervical carotid stent placement (37215/37216), do we need to have stenosis in percentage, or is moderate/severe stenosis documentation sufficient? Do we need to have NIHSS score documented in the report?

A. Patients with symptomatic carotid artery stenosis ≥50%; and,

B. Patients with asymptomatic carotid artery stenosis ≥70%.

If they do angiography of the iliacs only following pelvic trauma, for the common/external iliac portion, should we append a -52 modifier to 75710 since imaging is limited to above the knee? I remember seeing an SIR reference on this a couple years ago, but I haven't been able to find it and I want a current opinion.

Median sternotomy was performed and the anterior mediastinum was exposed. There was a large mass involving the right lobe of the thymus which was immediately obvious. The bilateral pleura were opened and the thymus and surrounding fat were removed in their entirety taking care to avoid the phrenic nerve bilaterally. The mass was firmly attached to the pericardium overlying the aorta, however there was a plane for dissection.On the right side, the mass was involved with the right upper lobe of the lung. There was no plane to dissect the mass off the lung, so a wedge of the right upper lobe was taken using a 60 mm blue load Endo GIA stapler. Superiorly the mass was invading into the innominate vein just left of the confluence with the superior vena cava a portion of vein was wedged out along with the mass using an Endo GIA vascular load, however there still was some bleeding from the vein and this was oversewn with a 4-0 Prolene in 2 layers. Mass was removed and sent for frozen specimen. Are 60522, 32097, and 37799 the appropriate CPT codes?

We have a pre Y90 case where no vessels were embolized. The case was strictly for diagnostic purposes. However, the physician uses a TRINAV catheter to deliver 2 mCi of technetium 99MAA to the left hepatic artery. Do we report code C9797, which is normally used for Y90 embolizations?

Would the following be reported with CPT 77080 or 77089?

History: Screening for osteoporosis and bone mass density follow-up.

Comparison: None.

Technical Limitations: There are no significant technical limitations.

FINDINGS: For complete details please see the Clinical Imaging Link in EPIC.

Trabecular Bone Score is 1.372 which is consistent with normal microarchitecture.

IMPRESSION:

IMPRESSION:

Based on WHO criteria, the patient's bone density is classified as osteopenia based on the lowest BMD of 0.819 g/cm2 and a T-score of -1.9. The lowest T score involves the left femoral neck. The L1-4 T-score is 0.5 without inclusion of TBS.

FRAX (not adjusted for TBS): The major osteoporotic fracture probability is 4% and the hip fracture probability is 0.7%.

FRAX (adjusted for TBS): The major osteoporotic fracture probability is 4% and the hip fracture probability is 0.6%.

A follow up DXA scan can be done in two years or sooner if clinically indicated.

One of our providers has recently started documenting that they are using FFR angio. This was documented in one of his reports as “Moderate LAD has a mid/distal myocardial bridge and serial moderate stenoses in the prox/mid vessel which are not obstructive by FFR angio (0.81)” and another report just had “Right dominant coronary arteries with notable but nonobstructive CAD by visual estimation and FFR angio.” When asked to add more details to his operative report, he stated that it was a trial for a new technology. Is 0523T the correct code for this? And if so, what are the documentation requirements for using this code?

Is it correct to code either 33889 (subclavian to carotid transposition) or 33891 (carotid to carotid bypass) when performed the day prior to TEVAR surgery, and related to preparing for the TEVAR surgical repair on a different day?

Since the purpose for either of these procedures is ultimately to prepare for the endovascular repair of the descending thoracic aorta, must the use of these codes be ONLY when performed during the same session as the TEVAR, or would you instead recommend coding 35694 (subclavian to carotid transposition) or 35509 or 35601 (carotid to carotid bypass) if not performed during the same session as the TEVAR repair? If the latter codes are recommended, is it appropriate to report modifier 58 on the TEVAR code when patient returns on different day for this surgery?

The patient normally catheterizes the appendicostomy independently. But this day could not advance the catheter beyond approximately 5 cm. taken to the operating room by pediatric surgery, where they performed a fistulagram and were able to pass the wire into the cecum, however the 8-French modified feeding tube would not track. Reached out to IR for assistance.

Would we use 44799 or 49450 for both procedures below?

The 1st day

1.Fistulogram through appendicostomy

2. Recanalization of the appendicostomy tract

3. Placement of a locking pigtail catheter through the appendicostomy into the cecum

10 days later the patient returned

1. Appendicocecostogram via the indwelling tube

2. Upsize of the appendicocecostomy drain over a wire for a larger tube. Successful exchange of the 8.5 Fr drainage catheter for a similar catheter of 10.2 French size

Thank you in advance

Can you please clarify the code for the following surgery?

"Patient has SVC syndrome and had an occlusion of the superior vena cava. Patient underwent left innominate vein to right atrial bypass 12 mm Gore-Tex; open sternotomy. Clamped the innominate vein both proximally and distally and did an end-to-side anastomosis with the Gore-Tex graft using 5-0 Gore-Tex stitches. We then put a side-biting clamp on the right atrium and made a large opening and then sewed the proximal end of the graft onto the right atrium using running 5-0 Gore-Tex stitches."

How do you report percutaneous sclerotherapy of prominent varicosities in the left labia please? The physician injected a total of 2.5 units of bleomycin into the vascular channels (5 mL volume) under direct ultrasound and fluoroscopic guidance. 36468 or 36470 or 37241? I’m confused with these 3 codes in this scenario. I read that 36468 is for cosmetic sclerotherapy of telangiectasia and spider veins. 37241 is for varicoceles. 36470 is for single incompetent vein. Please shed some light on when to use these codes.

We had a scenario where an MRI brain w/ and w/o study was ordered. On day 1 the MRI brain w/o images were obtained. Due to loss of IV access the images w/ contrast were unable to be completed. No contrast was administered. The patient returned the next day, the study was continued, and the MRI brain images w/ were obtained. Would it be appropriate to still charge only CPT 70553? Would it also be appropriate to report the DOS as the study end date? For hospital billing, the hospital has a choice of reporting either the start date of the procedure or the completion date, correct? The procedure report shows the following: Performed: 06/20/24 1440 - 06/21/24 1220.

We wanted to clarify our understanding that we can bill for diagnostic mammogram (77065, 77066) during breast localization procedures as long as it's not mammographically guided (19281).

We have a patient who already had diagnostic mammogram at an initial biopsy that we billed for, and now patient is coming back for the localization procedure. Can we bill for diagnostic mammogram the second time around?

When a patient has a left heart catheterization performed due to known CAD, atypical chest pain, and abnormal stress test, and the impression states, "CAD stable, unchanged and false positive stress test," would all of these be coded or just the CAD?

Patient has RFA completed on the left AAGSV. One week later returns and RFA is performed on the left PAGSV but also has a post op duplex (93971) of the AAGSV. Provider would like to code for both 36475 and 93971-59 on the second DOS. They state AAGSV and PAGSV drain different venous territories in the leg and should be considered different surgical fields. My concern is they are both in the saphenous compartment. Can you help us with this issue? Thank you

This patient had a fem-fem bypass with basilic vein, which was harvested at the time of surgery. Code 35500 (harvest of upper extremity vein) is an add-od code to just a few procedures, and a fem-fem bypass code 35558 is not one of them. Is there a way to bill for this harvest, or is it included in the procedure?

Our physicians are performing cardioneural ablations in the cath lab with ICE and transseptal puncture on patients with vasovagal syncope. Should we be using the unlisted code for this? Is there a scenario we should use code 93653 for the ablation (e.g., the patient has both vasovagal syncope and a complete heart block)?

During an EPS/ablation procedure if a physician gains access to the left atrium through a PFO (no puncture necessary), can we capture that with 93462? Or would that be considered part of the primary ablation code?

We are needing assistance with the following report:

Decapolar catheter was inserted in seath and advance to lumen of coronary sinus for pacing and sensing of the Left atrium and ventricle. Patient was in sinus rhythm.Catheter placed in pulmonary vein and all veins were isolated with RF. Isoprotereol was started. All 4 pulmonary veins remain isolated. Right sided atrial flutter line was ablated.This is separate and distinct. TVC-IVC isthmus was mapped and ablated. Patient went into atrial tachycardia. It appears it is coming from the coronary sinus, coronary sinus os ablated.

Impressions; 1. Atrial fibrillation, status successful pulmonary vein isolation.2. Distinct and separate arrhythmia, Right side atrial flutter ablation. Bidirectional block was confirmed. 3. Distinct and separate arrhythmia: Atrial tachycardia ablation.

A condensed op report. We are coding this as: 93656, 93655, 93655,93623, and wondering if the pacing and recording of LT vent should be coded (93622). Thank you for your help!

What modifier would I use on 33249 if there was an earlier same day 93654? There's no global, but would I use the -78 modifier anyway?

Patient came in for a heart cath. The reason for the heart cath was I35.0, but CAD (I25.10) was found as a result of the heart cath. Which diagnosis would be first listed?

We are OPPS and have unemployed radiologists who bill separately for the professional component of services. When performing a hip MRI arthrogram with contrast, we have one report for the injection with fluoro written and signed by the performing provider and a second report for the MRI with contrast interpreted by a second radiologist. How do we bill for these services? What does supervision and interpretation entail? Does that refer to the interpretation of the findings of the MRI, or is it the interpretation of the procedure itself, does the procedure need interpretation of the joint and the findings?

The interventionalist sedation portion doesn't document the intraservice time or face-to-face time on the report. The flow sheet has either a level 1 or level 2 sedation. Does it matter if the patient only got level 1 sedation? I cannot find documentation that states the levels that would be considered sedation code 99152.

I know you should not bill for a diagnostic angiography when a previous CTA or MRA was performed unless there is a change in clinical status. However, is it appropriate to bill for a diagnostic angiography if only a CT or MR was performed?

During prostate artery embolizations we are routinely catheterizing additional/accessory prostate arteries arising from separate parents (vesicoprostatic trunk, obturator, internal pudendal). While only 37243 is reported for embolization, would codes 36247 and 36248 for additional catheterized +/- embolized arteries be appropriate?

Also, I understand RS&I is bundled and generally not reported, but what about the instance where a clear shunt is identified and requires additional catheterization/coil embolization to prevent non-target embolization?

I am in the middle of a debate and would ask for confirmation if there is ever a scenario where, in addition to performing a PAE, where CPT 37242 can also be reported for any separate vessel embolization at the same session; for example, "right superior vesicle artery supplying some flow to the prostate was embolized". I understand that only one embolization code is reported per surgical site (CPT 37253) and per guidelines in your Diagnostic & Interventional Reference book CPT 37243 includes non-target embolization at the same session, so CPT 37242 would not be additionally reported, but would appreciate your feedback prior to further discussion with providers and staff.

"A limited, non-contract CT of the pelvis was obtained with the patient in the supine position. An enlarged lymph node anterior to the left acetabulum was identified. Under CT guidance, 19-gauge guide needle was advanced into the lymph node, however, the lymph node was mobile, and removed when the biopsy needle was advanced through it. For this reason, images were obtained prior to each biopsy given the proximity of the lymph node to adjacent vasculature.

Successful CT-guided biopsy targeting a 1.9 cm lymph node anterior to the left acetabulum."

Not sure if this is coded with 38505 superficial?

Is the debridement of the endocarditis vegetations included in the mitral valve repair?

How is the following procedure reported?

"CLINICAL INDICATION: Qalsody administration.

PROCEDURE: After obtaining written informed consent, the patient was placed on the interventional table in the left lateral decubitus position. The patient was prepped and draped in usual sterile fashion. The patient's identity and the procedure were confirmed by the time-out process. Under fluoroscopy, a midline approach to the L3-4 interlaminar space was selected and the overlying skin anesthetized with several mL of 1% lidocaine. A 20 gauge Chiba needle was advanced under intermittent fluoroscopic guidance into the subarachnoid space with return of clear CSF. 10 mL of CSF was collected. 100 mg/15 mL of Qalsody was administered over the course of 3 minutes. The needle was removed and a bandage placed. The patient tolerated the procedure well without immediate complication.

Fluoroscopy Time: 1.0 minutes.

IMPRESSION: Successful lumbar puncture with intrathecal Qalsody administration."

Is it appropriate to code an MRI brain w/wo in addition to an MRI whole body w/wo contrast? See below our Pediatric Division Chief comments.

"The whole body protocol W/WO contrast for cancer predisposition syndromes aka L-Fraumeni includes neck to feet, faster and more limited sequences than if you do a full Chest/Abd and all extremities. The brain is a full brain because of the high risk of brain tumor being higher. This is different than the whole-body WO contrast that includes a limited brain and is used for chronic recurrent osteomyelitis. The WO can all be scanned in one and all dictated in one by the pediatric team. The wo/w will need a separate brain order to be dictated by the neuro team."

What code would you use for the below exam? 22899?

"EXAMINATION: CT-GUIDED INTER-SPINOUS SPACE ENBREL INJECTION AT C6-7.

Clinical history: Prior right to hemorrhagic stroke. Post stroke spasticity with pain. Mild left arm and leg hemiplegia. Right vision loss.

Following detailed discussion of procedural protocol and risks, informed consent was obtained. Patient was placed in a prone manner. Through an anesthetized tract and a sterile field, a 25 gauge bevel tip needle was advanced into the C6-C7, midline, interspinous soft tissues. The needle was removed. Immediately post injection, patient was placed in Trendelenburg position at 20 degrees angulation, for 5 minutes. Patient tolerated the procedure well. Orders were written and verbal instructions given to the patient. CT images were preserved in archive.

Impression: 1. C6-7 anterior spinous soft tissue injection."

"Cannulation and dilatation of left Stenson's parotid duct then injection of radio opaque contrast in left Stenson's duct for sialogram. Left parotid Stensen's duct orifice was cannulated and dilated with lacrimal probes, then subsequently using 24 Angiocath with 4–0 lacrimal probe as a guidewire radiopaque contrast was injected. Findings: The left parotid duct appears mildly and narrowed diffusely but there is no stricture noted and no evidence for obstruction. The ducts fill normally. No evidence for sialolith. No other acute findings are seen."

Is this reported normally with 42550 and 70390, or can we capture the dilatation too?

"Patient has an AVG connected to the SFA and femoral vein, which is infected and abscessed. The AVG is removed (35903). The SFA has stenosis, and an endarterectomy was done at the level (35302). The graft was removed, and the SFA was repaired with a harvested great saphenous vein."

I know the direct repairs of artery/vein are included, but what about when the SGA is harvested for the repair? This seems like a lot of extra work. Is code 35256 also reported?

Patient presented with aneurysmal left brachiocephalic AV fistula.Would codes 37607 and 35236 be correct for this case?

"A small Satinsky clamp was then placed across the large cephalic vein, and the vein was transected just beyond the clamp. Excess vein was then trimmed to allow for a vein patch repair of the brachial artery. This was accomplished with 6-0 Prolene in a running fashion. Next, a counter incision was made in the proximal arm, the cephalic vein was dissected circumferentially, and 2-0 silk ties were placed proximally and distally. The proximal tie was secured, a small venotomy was made, and venous blood was pushed out of the very large and aneurysmal cephalic vein in the arm, creating a flattened decompressed cephalic vein. The more distal ligature was then tied."

For adrenal vein sampling, the physician does right adrenal vein x 6, left adrenal vein x 2, suprarenal IVC x 1, infrarenal IVC x 1, peripheral vein x 1. Under 36500 in the CPT Codebook it says, "For catheterization in superior or inferior vena cava, use 36010." Am I correct to assume that 36010 would go away once the doc subselects the adreno renal trunk since venous sampling includes venography & catheter placements? This case would just be 36500 x 2 and 75893 x 2, correct?

Would the debridement be included with 36832 and not separately reportable?

"Counterincision was created at the arterial limb of the AV access which was was circumferentially dissected, clamped, and divided. This segment was oversewn x 2 using 3-0 Gore-Tex suture in running and locking fashion. Clamp was removed and hemostasis was noted.

Venous counter incision was made at the shoulder over the distal cephalic vein outflow. Vein was circumferentially dissected and clamped an divided. Vein was then suture ligated with 3-0 GoreTex suture.

Incision was made along the access and the aneurysm entered. A large amount of old blood and clot was removed. Vein wall was dissected free. With lg aneurysmal vein removed, there was a lg amt of excess thin, necrotic skin present. Skin and SC tissues were sharply debrided back to healthy bleeding tissues. Total wound are debrided was 600 sq cm (30cm x20 cmx10 cm deep)."

Hello Dr. Z-

Interventional Radiology Scenario:

US evaluation performed and demonstrated 3 small hepatic collections. Under US guidance an 18-gauge needle

was advanced into one of the right hepatic lobe collections. 3 mL of pus was aspirated. Similarly an 18-gauge needle was advanced into another one of the right hepatic lobe collections. 4 mL of pus was aspirated. Finally an 18-gauge needle was advanced into the collection found near the hepatic hilum. 9 mL of pus was aspirated. Needle removed. Manual compression used to hemostasis.

CPT Questions:

Must a cath be left in place to report CPT 49405? Our Coders' Desk Reference notes "A catheter is inserted to drain and collect fluid for analysis. The catheter is removed. In some cases the catheter may be attached to a bag to allow for further drainage" Another source says: "these codes should not be used when a catheter is placed and removed in the same setting".

10160? Does not meet medical necessity per our LCD.

47399 Unlisted?

Thank you in advance for your time and expert review.

Can you please give your opinion on if this should be reported with just one CPT code or with both 64417 and 64418? Does the needle have to be moved in order to report both?

"Procedure: Right suprascapular nerve and axillary nerve block under fluoroscopy. Description: After detailed informed consent was obtained patient brought to the procedure room. Patient placed in the prone position. Patient's shoulder area was widely prepped and draped under sterile condition. Under fluoroscopy guidance suprascapular notch and axillary nerve location was located marked. Skin was infiltrated with 3 cc 1% lidocaine. 25 gauge 3 in needle was introduced between the suprascapular notch for suprascapular nerve and axillary nerve block. After negative aspiration, 5 cc of 0.25% Marcaine with 40 mg of Kenalog was injected into divided doses without difficulty. Patient tolerated the procedure well. Patient taken to recovery for 15 minutes observation. Patient was discharged in satisfactory condition."

How to code attempted deep cervical sentinel node dissection? None found.

"Again, this was on his right chest wall. We then marked it. I checked with the Neoprobe and really did not get a very high reading, got an 18, infiltrated this area with local, then made an incision, then started dissecting down with blunt dissection and some Bovie electrocautery. I went all the way down to the pectoralis major fascia and actually went through it in one spot again using Neoprobe intermittently to try and find any hot node. I cannot feel a hot node, did not see any methylene blue, could not really get any direction on this sentinel node and after exploring this area for awhile, I went superiorly and inferiorly, medially and laterally. I just could not feel anything. I did not want to cause more problems, so at this point, I then closed this incision. I had to gone through the pectoralis major fascia."

For coding for the radiologist's interpretation/billing, should incidental findings unrelated to the signs, symptoms, or condition that necessitated the test be coded if listed in the final Impression and a recommendation for further evaluation was recommended?

Per Coding Clinic, it seems they should not be coded since they are not related to the reason for the test, and is the responsibility of the ordering physician to determine the management of the incidental findings.

The patient had a CT for lung cancer screening (71271). The radiologist noted an incomplete image right thyroid nodule and recommended further evaluation with ultrasound.Should the nodule be coded for the radiologist billing as this is incident to the reason the CT was being done?

I hope I've included enough info. I am just not sure how to code these (or this) stent graft placement.

"Stent graft the right common iliac (into the Dacron of the previous aortobiliac bypass graft on the right side) and the right external iliac from the right groin using VBX stent grafts.

The aforementioned VBX was then brought in the field and passed up the wire through the right groin sheath. A proximal then a distal stent was deployed, with the distal end of the most distal stent being about the mid to distal right external iliac artery. The distal stent was postdilated to 14 mm."

Could you please suggest a CPT code for repair of a right-sided tunneled peritoneal catheter with placement of a new hub of the distal tip of the catheter?