Cardiology Coding Alert

Can you report repositioning with insertion? Here’s the rule.

When you report an inferior vena cava (IVC) filter manipulation, your code choice should specify whether your physician inserted, repositioned, or removed the IVC filter. This approach will guide you to the right code.

Why IVC filters? Your physician will place filters in the IVC in patients who are immobile or bedridden for long periods and develop clots in the leg veins. The filters in the IVC prevent blood clots in the lower limbs from traveling up to the heart and lungs. Your physician will use IVC filters in patients with deep vein thrombosis (DVT) or blood clots. These filters help to prevent clots from traveling through the vena cava vein to the lungs,” says Christy Hembree, CPC, Team Leader, Summit Radiology Services, Cartersville, Ga.

Do not distinguish temporary or permanent filters: You may spot the terms ‘temporary’ or ‘permanent’ filters in the procedure note. Temporary IVC filters can be subsequently repositioned or removed. However, whether the filter is temporary or permanent does not impact the codes you choose from for reporting the IVC filter procedures.

Learn From This Example of Filter Insertion

You may find it easy to spot the insertion of an IVC filter. Your physician may insert a catheter in a vein at the patient’s groin level or the neck and then maneuver the catheter to place a filter device in the IVC. During this process, your physician visualizes the blood vessels through imaging guidance. You report the insertion of an IVC filter with code 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).

“You submit CPT® 37191 for a new permanent or temporary filter that your physician places in the IVC,” Hembree says.

You may read that your provider prepped and anesthetized the patient. Subsequently, your physician will choose a suitable access vein. He may choose to insert a needle into the femoral vein at groin level or the internal jugular vein in the neck based on the number and location of identified blood clots within the venous system. Below is an example of a procedure note for insertion of an IVC filter.

“A thin, long, flexible guide wire and catheter were introduced into the vein. The needle was removed and the catheter was connected to a fluoroscope to obtain digitally subtracted images of the blood vessels. The anatomic structure of the IVC was assessed and the diameter of the target vein was determined. The catheter was removed. An introducer sheath along with the enclosed filter was advanced into the access vein along the guide wire to reach the IVC. With the help of the visual imaging guidance, the filter was gently deployed just below the junction of the IVC and the lowest renal vein. Under fluoroscopy, the deployment and adequate alignment and position of the filter within the IVC were confirmed. The guide wire and introducer sheath were then removed. The images were archived for interpretation. Pressure was applied to the puncture site to stop bleeding.”

Be Specific for Filter Repositioning

When your physician repositions a temporary IVC filter, you submit code 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).

Here is a sample procedure note that can help you confirm the repositioning of an IVC filter.

“The position of the existing filter and anatomy of the IVC was assessed. The position of the filter cone was determined with respect to the caval wall. The filter was checked for any trapped clots and emboli. The catheter was removed and a telescopic filter retrieval sheath and snare were advanced in the IVC along the guide wire. Avoiding any abrasions on the IVC wall, the cone was grasped with the snare and the filter was collapsed into the sheath. Under fluoroscopic guidance, the filter was re-deployed to a new position in the IVC. Position of the filter and alignment were confirmed once again.”

Remember 37193 for Filter Removal

You may read that your physician located the filter, collapsed the filter into the telescopic retrieval sheath, and used the snare to withdraw the filter from the IVC. Your physician may check for any residual clots in the IVC. In this case, you report code 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).

Tip: Do not report filter removal with code 37197 (Transcatheter retrieval, percutaneous, of intravascular foreign body [e.g., fractured venous or arterial catheter], includes radiological supervision and interpretation, and imaging guidance [ultrasound or fluoroscopy], when performed). Code 37193 is specific to IVC filters when your physician removes the filter as a whole from the IVC because the patient no longer needs the filter. “Remember, it is inappropriate to report 37197 because a more specific code exists for the removal of filter,” says Hembree.

What is inclusive in 37191-31793? The code 37191 is inclusive of several services. “These inclusive services include vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed,” Hembree says.

Tip: Do not report code 75825 (Venography, caval, inferior, with serialography, radiological supervision and interpretation) when your physician performs an injection to localize the renal veins before deploying the IVC filter. This imaging is also bundled into the codes for IVC filter placement. “You should not report code 75825 with 37191-37193 if the venography is only used as a tool in placing the filter,” Hembree says.

Bonus Tip: “Only code one procedure (37191-37193) per encounter. Never code the insertion, reposition and/or removal) during the same encounter,” says Christina Neighbors, MA, CPC, CCC, Coding Quality Auditor for Conifer Health Solutions, Coding Quality & Education Department, and member of AAPC’s Certified Cardiology Coder steering committee.