Renal Angiogram Coding

Question:

Is catheterization separately reported with renal angiograms?

Answer:

No. The renal angiogram codes, see table below, include all catherization.  The codes are selected by order of catheterization and as unilateral or bilateral.  Also, remember that a flush aortogram is included in the renal angiogram codes and not separately reported.

CPT Code	Description
36251	Selective catheter placement (first-order), main renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, andflush aortogramwhen performed; unilateral
36252	bilateral
36253	Superselective catheter placement (one or more second order or higher renal artery branches) renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture, catheterization, fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, andflush aortogramwhen performed; unilateral Do not report 36253 in conjunction with 36251 when performed for the same kidney.
36254	bilateral

*This response is based on the best information available as of 01/09/20.

Unspecified vs. Uncertain Behavior Skin Lesion Diagnosis Code

Question:

Can you refresh my memory on when to use the diagnosis code for skin lesion “uncertain behavior” vs “uncertain behavior”?  I know one is to be used before we get pathology results and one is for after, I just don’t remember which is which.  If you could give me the ICD10 codes that would be great too.

Answer:

You’ll use an “unspecified” diagnosis code when you do not have a final path report – D49.2 is for unspecified behavior lesion of the skin. Use the “uncertain” behavior diagnosis code when histologic confirmation whether the neoplasm is malignant or benign cannot be made by the pathologist.  Look up the path report diagnosis in the ICD-10-CM Index to if you have a path report.  Use D48.5 is for uncertain behavior of the skin.

*This response is based on the best information available as of 01/09/20.

Diagnosis Code for “End of Life” DBS Battery

Question:

What would be the appropriate diagnosis code (ICD-10-CM) for “end of life battery” when we have to change the generator in a deep brain stimulator patient. I have gotten mixed responses previously whether or not to bill “mechanical complication” vs “encounter for adjustment”. Or are both of these incorrect?

Answer:

We recommend using the original diagnosis for why the deep brain stimulator was placed in the first place (e.g., Parkinson’s). It is expected that a battery will last only so long so replacing it is not considered a “complication” when replacement is needed. You could also report Z45.49 (Encounter for adjustment and management of other implanted nervous system device) as a secondary diagnosis code but it would not be the primary diagnosis. The primary diagnosis is the patient’s condition that warranted the neurostimulator. This advice actually applies to spinal cord stimulator and vagus nerve stimulator battery replacement.

*This response is based on the best information available as of 12/19/19.

Measurements for Excision of Lesion Removal

Question:

Our coder sometimes uses measurements listed in the pathology report for lesion excisions, because the measurements are unclear or missing in the procedure note. Is this ok?

Answer:

No, for several reasons. Once removed, tissue(s) shrink so don’t depend on the measurements listed in the pathology report as it will most likely be smaller than the actual excision. And It is always necessary to have the measurements of the excision documented in the procedure note. So, if you have Question:s or need documentation clarification, ask your provider for help so he/she can amend the note prior to billing if necessary.

Excision means lesion plus margins (the narrowest margin), not just lesion itself. CPT 2019 gives us several illustrations on page 83 of how to calculate for these codes, so make sure to share this information with your coder and provider.

*This response is based on the best information available as of 12/19/19.

Trigger Point Injections Coding: Muscle or Muscle Group

Question:

One of our Providers recently completed Trigger Point injections toBilateralThoracic ParaspinalsandBilateralTrapeziusin the same setting for a patient. When we bill for this procedure do we counteachside(Left and Right) of these procedures as a muscle group to be billed out as 20553 OReacharea(Bilateral or unilateral) of these procedures as a muscle group to be billed out as 20552?

Answer:

Trigger points are by muscle(s) injected; 20552 is 1-2 muscles, 20553 is more than 3 or more muscles.  He injected 4 muscles (2 paraspinal and 2 trapezius) so the code billed is 20553. Additionally, these codes are not reported bilaterally with a 50 modifier or with an RT/LT. Report by the number ofmusclesinjected.

*This response is based on the best information available as of 12/19/19.

Coding for ICG Imaging

Question:

Can you give guidance on CPT 15860 as it pertains to colorectal surgery?

My surgeons have been using this code when they use the isocyanine green fluorescence imaging either with the robot (Firefly) or open (SpyPhi).  They are saying this code is relevant because they are assessing vascular flow in a graft (it’s technically a graft of autologous tissue to replace the removed bowel).

Answer:

The infusion of ICG dye as imaging to assess perfusion is inherent to the procedure and not separately reported.

*This response is based on the best information available as of 12/19/19.