David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: My IR providers feel that if a patient has a GJ tube that migrates into the stomach and they fix it, it is considered a conversion and not a replacement. They are stating that because it is in the stomach, it is acting as a G-tube rather than a GJ tube, and therefore it is a conversion. Would this be a conversion or a replacement? Answer: This is a replacement. Some are easy; others are hard. This is not a conversion. Report code 49452 if they remove a

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: Co-surgery with urologist. Summary of vascular report: "I completely excised the tumor, leaving a very small rim of tumor in the cava. Once the left kidney was off the field, I was then able to place clamps in the renal vein, in the cava above and below the tumor, and finally was able to excise the rim of cava that was invaded with tumor. We were able to completely resect the tumor from the cava. We attempted a primary repair, but it was evident that a mismatch in

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: Is this indirect portal venogram billed with 36481 in addition to the hepatic veins selection? "US-guided RIJ vein access, hepatic fourth order vein selection. Transcatheter venous pressure measurement, indirect portal venogram. RIJ vein was accessed under continued US guidance. A single US image of access was obtained for documentation. A wire was advanced into a fourth order branch of the right hepatic vein, and a 5 French catheter was passed. The wire was removed and pressure measurements taken, both wedge and free. Right atrial pressure was measured. The

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Recently, the American Hospital Association (AHA) was asked to clarify their response to a question previously posed to them (See Coding Clinic for HCPCS, Fourth Quarter 2021) regarding CPT code assignment when iFR studies are performed. Unlike FFR studies, iFR studies do not require the use of a pharmacological stressing agent (e.g., adenosine). Herein lies the issue: What is the correct method to code for a procedure that does not precisely match the CPT code description? Each code is described as follows: +93571 Intravascular Doppler velocity and/or pressure

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: What should I charge for when the Provider places a coronary sinus (CS) lead in a single permanent pacemaker (PPM)? "The MD attempted to place a PPM lead (C1898), but given severely dilated right atrial (RA) and suspected scar, several different sites within the RA were assessed for adequate sensing of the p waves. No p waves were sensed. Therefore, the RA lead and sheath were removed. A Medtronic Left Ventricular (LV) lead was placed in a posterior lateral vein of the left ventricle, adequate pacing was confirmed,

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: Can code 0715T for coronary IVL (Shockwave) be reported with C9600-C9608 for coronary interventions performed with the use of drug-eluting stents? Or is its use limited to 92920, 92924, 92928, 92933, 92937, 92941, 92943, and 92975? Answer: For now, we are reporting with non-DES and DES. Due to one set of codes being from the CPT Codebook and the other set being HCPCS II, there certainly may be add-on code edits that kick out 0715T with DES (until that is addressed by CMS and AMA). Complete Interventional Radiology

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: If an aorto-bi-iliac graft is used for an iliac artery aneurysm only, would you report code 34707 or 34705? Answer: Initially code to the pathology (aneurysm), then to the device (ABI endograft). Codes 34705 and 34707 are used to report endovascular endografts for treatment of aneurysm, pseudoaneurysm, traumatic disruption, etc. (not stenosis). We would report 34705 here. If an ABI endograft was placed for stenosis, code to the stenosis first (37236, 37237), not the device.   Complete Interventional Radiology and Cardiovascular Coding Detailed information on a broad range

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: Radiofrequency ablation for atrial fibrillation (pulmonary vein isolation), additional radiofrequency ablation for atrial fibrillation (roof line), additional radiofrequency ablation for atrial fibrillation (posterior line with isolation of posterior wall), additional radiofrequency ablation for supraventricular tachycardia (mitral annular line), additional radiofrequency ablation for supraventricular tachycardia (cavotricuspid isthmus line), additional radiofrequency ablation for atrial fibrillation (CFAE lesions along coronary sinus). Would the correct coding of this procedure be 93656, 93657 x 2 (box-roof line and posterior wall then CAFE lesion) and 93655 x 2 (mitral annular line and cavotricuspid)? Does it

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: Will you please advise on coding for the following case: No heart cath done, only angiography. Angiography: Descending aorta: pigtail catheter placed in the proximal DAO shows the aorta to the level of the transverse arch and both the left and aberrant right subclavians are visualized. This shows the level of the two anterior DAO collaterals for selective angiography. There is a suggestion of additional subclavian or IMA collaterals, but this is not well seen. Collateral #1: No injection only findings documented Collateral #2: Selective injection with findings Collateral

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: "After cardiac ablation procedure had been completed, attention was then turned access closure. Given large size of the transhepatic sheath required for ablation, with direct communication with the systemic vasculature, access site embolization was necessary to prevent hemorrhage on sheath withdrawal. Then after diagnostic venogram of the right hepatic vein performed. Venogram demonstrates brisk central outflow from the right hepatic vein to the IVC, with the site of venous access identified as mild luminal irregularity at the sheath tip encountered on slow sheath withdrawal. Embolization of the venous access

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: What would be the appropriate CPT codes for CT cystography performed for bladder evaluation? The codes I came up with are 51600 and 74430. Answer: If the contrast was administered intravascularly, this would meet the criteria of a with-contrast exam, and possible codes would be 72193 or 72194. If the contrast was administered via a catheter placed into the bladder, this would be defined by codes 51600 and 72192. Remember, when a code description contains the verbiage "with contrast", contrast material must be administered: intravascularly (situated in, occurring in,

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: Our techs in Radiology take C-arm fluoro imaging in operating room to assist surgeon, then the radiologist dictates findings. Can Radiology charge one of these codes for the ERCP images (74330, 74328, 74329)? Also along those lines, could we charge for cholangiogram, uretherogram, etc. for images taken in the operating room then dictated by radiologist? Answer: From a facility (i.e., hospital) billing perspective, as an institution, the facility may code/bill for services rendered. Billing of OR services can be tricky, as there are other surgical procedures (and CPT codes)

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: "Patient brought to ASC cath lab, prepped, draped and local anesthesia was administered. The left axillary vein was cannulated using fluoroscopic landmarks. 2 guidewires were inserted through the needle to establish IV access. A micropuncture needle was used & the micro sheath was advanced into the vessel and used for electrode placement. The left infraclavicular pocket was opened with an incision over the previous one. The pocket appeared normal. Patient developed progressive SOB after being placed on the table for the procedure with 02 saturation dropping to low 90's

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: How would you code this case? 36221, 36902, 0237T? Pre/post op diagnosis: left AV fistula inflow stenosis. Description: The right common femoral artery was accessed using a micropuncture needle. This was exchanged for 5 French sheath using Seldinger technique. A pigtail catheter was advanced into the ascending aorta and arch angiogram was performed. Please see above findings for details. Next the left subclavian artery was selectively catheterized and a left upper extremity angiogram and left upper extremity fistulogram was performed. 5 French short sheath was exchanged for 5 French

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: The cardiologist performed a TEE, and his documentation states that he performed color flow, but there's no mention of spectral Doppler. Would you bill 93312-26 and 93325-26, or would you include 93321-26 for the documentation of the regurgitation and wall motion? Study details state: "A complete echo was performed using complete 2D and color flow Doppler. During the study the esophageal view was captured. The probe was inserted by the cardiologist. There was no probe insertion difficulty. Anesthesia performed sedation. Irregularly irregular rhythm was present during the study. The

The following decision was released by CMS effective October 28, 2021. The main focus of this document and decision was that there will no longer be a National Coverage Determination (NCD) for this procedure and instead, coverage or non-coverage will be made at the local level by the Medicare Administrative Contractor (MAC). Additionally, based on this change, when reporting code 37184 for pulmonary thrombectomy, modifier GZ will no longer be needed. The document in its entirety can be found at: NCA - Transvenous (Catheter) Pulmonary Embolectomy (CAG-00457R) - Decision Memo (cms.gov) As this NCD is effective October 28, 2021, ZHealth

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: Which code would you use for incision and debridement of the infected port pocket? "The port pocket incision and neck dermatotomy site were reopened. Using manual pressure, purulent contents were expressed from the incisions. The pocket was copiously irrigated and anterior antegrade and retrograde fashion using normal saline. The port pocket was debrided. The incisions were packed and were then left open and packed with iodoform gauze." If unlisted, which unlisted code would you suggest and what will be the comparable code for it? Answer: Report the appropriate debridement

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: Hoping you can help us resolve a dispute over medical necessity for use of arch study code 36221. Because the code describes diagnostic imaging, I assume that we need documentation of indications and findings to use it. Without an indication, I assume it is just a guiding shot to find the orifice of the subclavian or innominate for angiography of the arm. Cath lab staff wants to apply this code without indications (i.e., trauma to the arm only). Is a history of PVD enough? What if there is no

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: I read where even though no catheter used CT and MR angiograms are considered catheter based. If a patient has a CT angiogram at 800 and it shows Active contrast extravasation in the pyelocalyceal system in the midpole of the LEFT kidney. Later that day the patient is taken to IVU and has a left renal angiogram, segmental left renal angiogram and embolization. The doctor notes in his dictation the left renal hemorrhage noted on CT angiogram. In this case I don't believe the angiogram done by IVU would

by David Zielske, MD, CIRCC, COC, CCVTC, CCC, CCS, RCC Question: Patient has AF and atrial flut­ter. After completion of success­ful PVI, the physician performs a typical atrial flutter ablation. Three-dimensional mapping and conventional catheter mapping were performed using this abla­tion catheter and the left atrial coronary sinus decapolar cath­eter. Multiple radiofrequency lesions were administered, re­sulting in gradual slowing of the atrial flutter with eventual termi­nation. The ablation catheter was then placed in the lower lateral right atrial wall, and pacing was performed from the coronary si­nus catheter from coronary sinus. Conduction times across the ca­val tricuspid isthmus were noted