Consult guidance when coding these studies to ensure proper reporting.
By Lori M. Shore, CPC, RCC
Radiology has arguably had more than its share of bundling recently. Computed tomography (CT) scans of certain separate body parts are no longer separately payable; endovascular revascularization studies are now grouped into all-inclusive territories; and several renal angiography procedures are now all-inclusive, as well. These changes put a new value on radiology services and challenge coders and clinicians to learn new guidelines. Allow me to explain further.
Abdomen CT and Pelvis CT
Prior to 2011, computed tomography (CT) of the abdomen and CT of the pelvis could be reported, and were reimbursed, separately. CPT® 2011 created new codes (e.g., 74176 Computed tomography, abdomen and pelvis; without contrast material, 74177 Computed tomography, abdomen and pelvis; with contrast, and 74178 Computed tomography, abdomen and pelvis; without contrast material in 1 or both body regions, followed by contrast material(s) and further sections in 1 or both body regions) that bundle the procedures when performed together.
Such bundling has a significant financial impact. For example, per the 2012 Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule Relative Value File, CT of the abdomen with contrast (74160 Computed tomography, abdomen; with contrast material(s)) is valued at 1.27 work relative value units (RVUs), while CT of the pelvis with contrast (72193 Computed tomography, pelvis; with contrast material(s)) is 1.16 RVUs. If reported separately, these codes total 2.43 RVUs. But when these procedures are bundled into the single code 74177 (as they have been since Jan. 1, 2011), the work RVUs are 1.82, or approximately 25 percent lower.
Abdomen CTA and Pelvis CTA
Similarly, CPT® 2012 created a single code (74174 Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing) to bundle CT angiogram (CTA) of the abdomen and of the pelvis. Previously, these procedures were coded independently of one another. As of Jan. 1, 2012, it is no longer appropriate to report these studies separately when they are performed at the same time; you must use the combined code (74174).
Endovascular Revascularization Studies
Endovascular revascularization studies (37220-37235), often done percutaneously by interventional radiologists, were bundled into all-inclusive territories with a hierarchal system in 2011. Any revascularization procedures done in the common, internal, or external iliac arteries are now considered iliac territory. The anterior tibial, posterior tibial, and peroneal are now considered tibial-peroneal territory, and any vessel in the femoral-popliteal system is considered part of that territory. Therapeutic interventions are now inclusive of the higher valued “level.” Angioplasty is the lowest valued intervention, followed by atherectomy (which is also included in the highest level, which includes stent(s) placement). Conscious sedation is also included in these bundles.
Note: For more information about bundling of interventional vascular studies, see “Master the Significant Revisions to 2011 Vascular Codes,” February 2011 Coding Edge, pages 34-37.
In 2012, renal angiography is bundled for both selective (36251-36252) and superselective (36253-36254) catheter placements; conscious sedation is included in these all-inclusive bundles. Intravascular vena cava (IVC) filter codes are also bundled this year into all-inclusive codes for insertion (37191), repositioning (37192), and retrieval (37193):
37191 Insertion of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed
37192 Repositioning of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed
37193 Retrieval (removal) of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed
AV Shunts for Dialysis
Although not an outright code change or bundle, there is a lengthy narrative clarification in CPT® 2012 regarding arteriovenous (AV) shunts for dialysis. The narrative defines the AV shunt as beginning with the arterial anastomosis and extending to the right atrium. All catheter manipulations for diagnostic imaging are included in 36147 Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); initial access with complete radiological evaluation of dialysis access, including fluoroscopy, image documentation and report (includes access of shunt, injection(s) of contrast, and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava). If ultrasound guidance is properly documented, +76937 Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure) may be separately reportable. Additional work needed in the peri-anastomotic segment, defined as the short segment of artery immediately adjacent to and distal to the anastomosis, and the anastomosis itself, is also separately reportable.
Interventions performed within the AV shunt are divided into two vessel segments for coding purposes. The peripheral segment is defined as the peri-arterial anastomosis through the axillary vein. The central segment is defined as including the subclavian and innominate veins through the vena cava. Any intervention in either segment, regardless of the number of lesions treated, is coded as one intervention. For example, if multiple balloon catheters are needed to treat occlusions in the peripheral segment, the venous angioplasty (35476 Transluminal balloon angioplasty, percutaneous; venous and 75978 Transluminal balloon angioplasty, venous (eg, subclavian stenosis), radiological supervision and interpretation) would be reported one time only. The AV shunt is considered to be venous, and the peri-anastomotic segment is coded as arterial. It is permissible to code for stenting work (37205 Transcatheter placement of an intravascular stent(s) (except coronary, carotid, vertebral, iliac, and lower extremity arteries), percutaneous; initial vessel and 75960 Transcatheter introduction of intravascular stent(s) (except coronary, carotid, vertebral, iliac, and lower extremity artery), percutaneous and/or open, radiological supervision and interpretation, each vessel) once per segment.
Now that this narrative on AV shunts has been published, we as coders are responsible for adhering to the letter of the law. Consult the narrative section of the CPT® book for guidance when coding these studies, and be sure to communicate these updates and changes to your radiologists.
Lori M. Shore, BS, CPC, RCC, is vice president of coding and compliance for Medical Billing and Management Service (MBMS), Newark, Del, where she has worked for over 25 years. Lori received her Bachelor of Science degree from Drexel University in Philadelphia, Pa.
May 1st, 2012
Changes make it quicker and easier to code these complex procedures.
By David Zielske, MD, CPC-H, CCIRC, CCC, CCS, RCC
Dramatic coding changes for lower extremity endovascular revascularization have been implemented for 2011:
- Sixteen new Category I CPT® codes (37220-37235) apply to combinations of angioplasty, atherectomy, and stent placement (interventions) performed in lower extremity arteries. The codes describe interventions performed for treatment of stenotic/occlusive disease, and report either open or percutaneous approaches.
- Five new Category III CPT® codes (0234T-0238T) replace the previous percutaneous and open atherectomy codes.
To report the new codes correctly, you’ll need to review the guidelines and bundling issues that apply.
Three Territories Divide Lower Extremity Arteries
The arteries of the lower extremities have been divided into three “territories,” each with separate guidelines and codes describing interventional procedures.
Like the coronary artery intervention codes, the lower extremity revascularization codes follow a hierarchy in which stent placement with atherectomy is considered the highest level of intervention, followed by stent placement, atherectomy, and then angioplasty. Subsequently, angioplasty is bundled to each of the new lower extremity revascularization codes.
1. Iliac Territory
The iliac territory, with three separately billable vessels (the internal iliac, external iliac, and common iliac arteries) allows separate billing of atherectomy, in addition to an angioplasty or stent placement. This is because atherectomy in the supra-inguinal vessels (iliacs, visceral, aorta, renal, and brachiocephalic) utilize Category III CPT® codes 0234T-0238T, which do not have the same bundling issues as infra-inguinal lower extremity revascularization codes.
CPT® codes 37220 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty and 37222 Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty (List separately in addition to code for primary procedure) describe initial and additional iliac angioplasty. Meaning, if angioplasty is the only intervention performed in the iliac arteries on one extremity, use these codes (one for the initial vessel, and up to two additional codes if two additional vessel—not lesion—angioplasties were performed).
If iliac stent placement was performed additionally in one vessel, replace 37220 (initial angioplasty) with 37221 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed, which bundles angioplasty in the same vessel. Code any additional iliac angioplasty procedures in additional iliac arteries with add-on code 37222.
If atherectomy is performed instead of stent placement, use 0238T Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; iliac artery, each vessel in addition to code 37220 for the initial angioplasty. If atherectomy and stent placement are performed in the common iliac artery, use codes 0238T and 37221 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed.
The new supra-inguinal atherectomy codes are coded in addition to any other intervention in the same vessel at the same lesion site. You may bill angioplasty, atherectomy, and stent placement in the aorta or a renal, visceral, brachiocephalic artery, depending on documentation.
2. Femoral/Popliteal Territory
The femoral/popliteal territory is unusual compared to the other two territories because all four vessels in this territory are considered a single vessel for coding purposes. All interventions performed in the common femoral, profunda femoral, superficial femoral, and popliteal arteries are described by a single code. The hierarchy still applies: Stent placement supersedes atherectomy, which supersedes angioplasty.
There are two choices for stent placement in the femoral/popliteal territory: Code 37226 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed describes stent placement alone (with or without angioplasty), while 37227 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed describes stent placement with atherectomy (with or without angioplasty).
For one femoral/popliteal territory, consider all treatments in all vessels as treatment in a single vessel. For all interventions performed in this territory, only one code between 37224 and 37227 should be submitted, regardless of the number of interventions performed in these four vessels. There are no initial or additional revascularization codes for the femoral/popliteal territory; so if an angioplasty is performed in the profunda femoral, an atherectomy is performed in the superficial femoral, and a stent is placed in the popliteal artery, report stent placement with atherectomy, with or without angioplasty (37227).
3. Tibial/Peroneal Territory
The tibial/peroneal codes allow for more than one vessel to be described and coded. Three separately-billable vessels are recognized: the anterior tibial, posterior tibial, and peroneal arteries. The tibial/peroneal trunk is considered part of any distal intervention performed in the posterior tibial or peroneal arteries, while the dorsalis pedis artery is considered continuation of the anterior tibial artery, and the medial malleolar artery is considered continuation of the posterior tibial artery.
Here again, the hierarchy applies: Stent placement with atherectomy supersedes stent placement without atherectomy, which supersedes atherectomy, which supersedes angioplasty alone. Remember: Angioplasty is included in all interventions, if performed.) Code the highest vessel intervention as the initial intervention in this territory, and any other vessel interventions as additional tibial/peroneal interventions. Codes 37228-37231 describe initial interventions while add-on codes 37232-37235 describe additional interventions in the other two tibial/peroneal arteries.
Remember to code each territory separately (except bridging lesions) with initial and additional revascularizations in each territory, as appropriate (the femoral/popliteal territory does not use initial/additional designations). For instance, you can have an initial iliac revascularization and an initial tibial/peroneal revascularization. If you perform a bilateral procedure in the lower extremities, start the coding all over again for the opposite leg with initial revascularization codes for both sides (e.g., 37220, 37220-59; or 37220-50 for bilateral iliac angioplasty).
Include Angioplasty and More in Lower Extremity Revascularization
As already noted, all 16 lower extremity revascularization codes (37220-37235) include angioplasty, if performed.
- Angioplasty (balloon dilation of a stenosis or occlusion) can be performed with a compliant, non-compliant, cutting, or cryoballoon.
- Atherectomy (removal of atheroma) devices include rotational, front-cutting, side-cutting, and photoablation (laser) devices.
- Stent placement utilizes self-deploying, balloon expandable, covered (stent grafts), and drug-eluting stents.
- New codes 37220-37235 also bundle:
- Conscious sedation
- Vascular access
- Catheter placement
- Traversing the lesion
- Imaging related to the intervention (previously billed as the supervision and interpretation code for the specific intervention)
- Use of an embolic protection device (EPD)
- Imaging for closure device placement
- Closure of the access site (which could be by suture for an open approach, or by placement of a closure device for percutaneous approach)
Diagnostic imaging remains separately billable. The imaging must be truly diagnostic, however, and not performed just for confirmation of a lesion or guidance for an intervention. Imaging is bundled when done to measure vessel size, localize a lesion, follow up an intervention, or guide the procedure.
Other interventions in these lower extremity vessels treated with angioplasty, atherectomy, and/or stent placement are separately billable. These include: Intravascular ultrasound (IVUS) (37250, 75945), thrombolysis (37201, 75896, 75898), thrombectomy (37184-37186), and embolization (37204, 75894).
Bill Initial Vessel at Highest Intervention Level
Always bill the initial vessel intervention as the highest intervention level performed within a single territory. If a separate intervention is performed within a different territory, start coding all over again with an initial intervention for that territory, based on hierarchy guidelines (stent placement with atherectomy, followed by stent placement, atherectomy, and then angioplasty).
These guidelines are for treatment of one extremity. If performing intervention on both legs, start coding all over again on the new leg. You may need modifier 59 Distinct procedural service (per CPT® instruction), or modifier 50 Bilateral procedure (per the Physician Fee Schedule Relative Value File), as appropriate, to alert the payer that intervention occurred in both extremities.
Bridging lesions still are considered a single vessel intervention, even if the bridging lesion extends from one territory into another. You still need to have a hemodynamically-significant vessel stenosis to meet medical necessity and code for these interventions.
Example Shows How Codes Have Been Condensed
Compare coding between 2010 and 2011 guidelines and codes, with this example.
Patient with known left external iliac 80 percent stenosis, left SFA 90 percent proximal stenosis, 90 percent mid popliteal stenosis and posterior tibial and peroneal artery occlusions. The iliac lesion is treated with balloon angioplasty alone and the SFA is treated with an appropriately sized balloon however a flow limiting dissection occurred requiring a self-deploying stent. The popliteal artery is treated with a stent graft alone while atherectomy with a laser is performed in both the posterior tibial and peroneal arteries with 70 percent residual stenosis in both requiring 3 mm drug-eluting stents. Closure device is placed.
In 2010, the appropriate codes from a contralateral approach would have been: 36247, 36248, 35473, 75962, 35474, 75964, 37205, 75960, 37206, 75960-59, 35495, 75992, 35495-59, 75993, 37206, 75960-59, 37206, 75960-59, and G0269.
In 2011, the appropriate codes are:
- 37231 Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed
- 37235 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure)
We’ve gone from 19 codes in 2010 to four codes in 2011. Once you master the new codes, you will be able to code these complex procedures with improved accuracy and decreased compliance risk.
David Zielske, MD, CPC-H, CIRCC, CCC, CCS, RCC, is an interventional radiologist and president of ZHealth and ZHealth Publishing in Brentwood, Tenn.
February 1st, 2011
The Centers for Medicare & Medicaid Services (CMS) recently released two special edition MLN Matters articles that disseminate high dollar improper payment and coding vulnerabilities identified during the Recovery Audit Contractor (RAC) demonstration. With the expansion of the RAC program and the initiation of complex medical necessity review in all four RAC regions, inpatient hospitals should notice the information in these provider education articles to avoid unnecessary denials of similar fee-for-service claims submitted to Medicare.
High Dollar Improper Payment Vulnerabilities
MLN Matters article SE1027 lists 17 of the high-risk medical necessity vulnerabilities inpatient hospitals should watch out for. The following claims were denied because the demonstration RACs determined the submitted documentation did not support an inpatient level of care and the provided services could have been performed in a less intensive setting.
- Cardiac Defibrillator Implant (DRG 514/515)
- Heart Failure and Shock (DRG 127)
- Other Cardiac Pacemaker Implantation (DRG 116)
- Chest Pain (DRG 143)
- Misc. Digestive Disorders (DRG 182)
- Other Vascular Procedure (DRG 478)
- COPD (DRG 88)
- Medical Back Problems (DRG 243)
- Nutritional & Misc. Metabolic Disorders (DRG 296)
- Transient Ischemia (DRG 524)
- Other Circulatory System Diagnoses (DRG 144)
- Kidney & UTI (DRG 320)
- Cardiac Arrhythmia (with CC DRG-138)
- Degenerative Nervous System Disorders (DRG 012)
- Atherosclerosis (with CC DRG-132)
- Other Digestive System Diagnosis (DRG 188)
- Percutaneous Cardiac Procedure (DRG 517)
In addition to the list above, the demonstration RACs determined there were three other general categories of denials, which included:
- Medical necessity denials for multiple codes;
- Ambulatory surgical center (ASC) list violations for codes paid at the inpatient rate that should have been paid as outpatient (no complications identified to justify inpatient stay); and
- Other outpatient charges that should have been billed since services were not medically necessary in the inpatient setting.
CMS reminds providers that medical documentation should contain sufficient, accurate information to: 1) support the diagnosis; 2) justify the treatment/procedures; 3) document the course of care; 4) identify treatment/diagnostic test results; and 5) promote continuity of care among health care providers.
Providers should document any pre-existing medical problems or extenuating circumstances that make admission of the Medicare beneficiary medically necessary. Some factors that providers should consider when making the decision to admit may include:
- The severity of the signs and symptoms exhibited by the patient;
- The medical predictability of something adverse happening to the patient;
- The need for diagnostic studies; and
- The availability of diagnostic procedures at the time when and at the location where the patient presents.
Admissions of particular patients are not covered or noncovered solely on the basis of the length of time the patient actually spends in the hospital (see chapter 1, section 10 of the Medicare Benefit Policy Manual on the CMS website).
MLN Matters article SE1028 focuses on four RAC demonstration-identified inpatient hospital coding vulnerabilities, which included:
- Respiratory System Diagnosis with Vent support – (CMS DRG 475) – Principal diagnosis on the claim did not match the principal diagnosis in the medical record.
- Closed Biopsy of Lung (CMS DRG 076, 077,120) – A transbronchial lung biopsy was billed but the medical record showed a transbronchial biopsy was performed.
- OR Procedure for Infections, Parasitic Diseases (CMS DRG 415) – The codes on the claim did not match information in the medical record.
- Coagulopathy (CMS DRG 397/143) – Principal diagnosis on the claim did not match the principal diagnosis in the medical record.
CMS reminds inpatient hospital providers that all inpatient admissions must have the principal diagnosis specifically identified by the attending physician. Secondary diagnoses also must be documented by the attending physician and:
- Clinically evaluated; or
- Diagnostically tested; or
- Therapeutically treated; or
- Cause an increase in the length of stay or nursing care (Federal Register, July 31, 1985, vol. 50, No. 147, pp. 31038-40).
To avoid unnecessary claims denial, CMS also recommends the following “be” attitudes:
Be clear. Providers should ensure that all fields on documentation tools (such as assessments, flow sheets, checklists, etc.) are completed, as appropriate, and legible. If a field is not applicable, providers should use an entry like “N/A” to show that the questions were reviewed and answered. Fields that are left blank or cannot be deciphered often lead the reviewer to make an inaccurate determination.
Be consistent. If an entry is made that contradicts previous documentation, include documentation that explains why there is a contradiction.
Be proactive. Demonstration review staff often noted that providers failed to adequately document significant changes in the patient’s condition or care issues that in some instances impacted the review determination. Ensure any information that affects the billed services and is acquired after physician documentation is complete is added to the existing documentation in accordance with accepted standards for amending medical record documentation.
October 1st, 2010