Anesthesia Coding Alert

The insertion of a transjugular intrahepatic portal systemic shunt (TIPS or TIPSS) is a procedure usually performed in a radiology setting with anesthesia. There is no specific code for TIPS from the surgical standpoint, which can make coding the anesthesia portion a challenge.

The TIPS procedure is often performed on patients whose livers have become so scarred from conditions such as hepatitis or cirrhosis that the organ no longer filters blood efficiently. As a result, the blood pools in it. A TIPS procedure is performed when other options such as sclerotherapy have failed to control that congestion of blood.

Under general anesthesia, a catheter is inserted in the jugular vein and manipulated into the portal vein system to place a shunt. This device ensures that the portal vein stricture or stenosis is opened and blood flow is unobstructed.

Carriers Have Different Requirements

Because coding guidelines for the procedure are highly regional, it is important to work with your local carrier and be familiar with local policies regarding TIPS.

Some carriers have local codes they want providers to use when reporting TIPS, and others have local medical review policies (LMRPs) on the subject. Indianas Medicare is typical of many, says Scott Groudine, MD, chairman of the government, legal and economic affairs committee of the New York Anesthesia Society and an anesthesia specialist in Latham, N.Y. Since there is no specific CPT code for TIPS, the policy lists several options for coding the surgical portion of the procedure, depending on the physicians involvement. Two codes used most often under this policy are:

35476 transluminal balloon angioplasty, percutaneous; venous

37205 transcatheter placement of an intravascular stent(s), (non-coronary vessel), percutaneous; initial vessel

Other carriers suggest coding for TIPS with 37799 (unlisted procedure, vascular surgery). However, Mary Klein, CPC, coding specialist with the anesthesia billing group Panhandle Medical Services in Pensacola, Fla., says, Using an unlisted vascular procedure code is risky for anesthesia because it requires sending an operative report with the claim as support. Carriers can be very picky about paying these codes, and the documentation you get from the radiologist may not be sufficient to convince the carrier to pay you 10 base units for TIPS.

Vessel access and integral components of the procedure (such as selective catheter placement, venous system; first order branch [e.g., renal vein, jugular vein] [36011], percutaneous portal vein catheterization by any method [36481] or percutaneous transhepatic portography with or without hemodynamic evaluation, radiological supervision and interpretation [75885 or 75887]) may or may not be considered part of the primary procedure code 35476. In areas, such as Indiana, where these components are considered part of 35476, they should not be billed separately. However, most payers in other areas allow for the diagnostic procedures to be billed separately from the therapeutic procedures, says Cindy Parman, CPC, CPC-H, principal and co-founder of Coding Strategies Inc., an anesthesia coding consulting firm in Dallas, Ga.

Klein agrees that some carriers will allow billing with 36481 (percutaneous portal vein catheterization by any method). Our radiologists use CPT code 36481 to report TIPS, she says. As a coder, this one makes the most sense to me because it describes the procedure most accurately.

Crosswalk Time

Once the anesthesia provider knows what code the surgeon uses to report the procedure, it can be crosswalked to the appropriate anesthesia code and billed with the appropriate number of base units and time. The following anesthesia codes should be filed for TIPS, depending on the surgeons code:

35476 becomes 01921 (anesthesia for angioplasty), billed at eight base units plus time;

37205 becomes 01844 (anesthesia for vascular shunt, or shunt revision, any type [e.g., dialysis]), billed at six units plus time;

37799 (becomes 00350 (anesthesia for procedures on major vessels of neck; not otherwise specified), billed at 10 units plus time; or

36481 becomes 00532 (anesthesia for access to central venous circulation), billed at four units plus time.

Codes 75960-26 (transcatheter introduction of intravascular stent[s], [non-coronary vessel], percutaneous and/or open, radiological supervision and interpretation, each vessel; professional component) and 75978-26 (transluminal balloon angioplasty, venous [e.g., subclavian stenosis], radiological supervision and interpretation; professional component) are also included in the Indiana policy as surgical coding options for TIPS. However, these two codes are used in conjunction with other procedure codes and only indicate the radiologic supervision and interpretation of the other primary procedure rather than the actual performance of the procedure. Neither of these codes has a corresponding anesthesia crosswalk code; thus they and may not be accepted for TIPS-only procedures.

Crosswalking code 37799 to 00350 is the one to be careful with, Parman cautions. The use of 37799 assumes an invasive procedure, not a percutaneous one such as TIPS, which is less complicated. Therefore, the base units are too high for a TIPS. If the surgeon files with 37799, the anesthesiologist should document what was performed, and be prepared for reimbursement less than 10 units since TIPS doesnt really merit that. Of course, with the use of an unlisted CPT code, the operative notes will be reviewed by the payer and changes will be made to the anesthesia code if necessary before reimbursement is made, Parman says.

Other Factors to Consider

Obviously, it is important to work closely with the surgeon and his or her staff to know which code is reported for the procedure so the anesthesia professionals involvement can be coded consistent with that. This is especially important in cases like TIPS, when the reimbursement for anesthesia can fluctuate so much depending on the crosswalked code.

Patients who are undergoing TIPS usually have medical conditions that classify them as P3 (a patient with severe systemic disease) or P4 (a patient with severe systemic disease that is a constant threat to life). Because of this, anesthesia providers can receive additional compensation.

Most carriers allow one additional unit for P3 and P4 patients and two additional units for the P5 patient, Klein says. But Medicare and other federal or state-funded programs such as Medicaid wont recognize these modifiers and dont allow any additional payment for them.

The Qualifying Circumstances section on page 34 of CPT 2001 lists additional add-on codes that can be used to help document that the case was more complicated than usual, either because of the patients health or other circumstances.

What About 37140?

CPT code 37140 (venous anastomosis; portocaval) is a perfect example of why anesthesia providers should check with their local carriers about accepted codes for TIPS. Physicians in some areas, such as California, often use this code to report the procedure. That means the anesthesia provider crosswalks to code 01922 (anesthesia for non-invasive imaging or radiation therapy) and bills for the corresponding seven base units plus time.

But other states, such as Indiana, do not allow coding with 37140 for the surgical portion of TIPS. As their policy says, code 37140 involves open surgical portosystemic shunting and must not be billed for this percutaneous procedure. The Nationwide Medicare carrier in New York also considers using 37140 for TIPS to be incorrect.