Cardiology Coding Alert

Think outside the box for iliac atherectomy. Are you ready to apply CPT's new revascularization codes starting January 1? Check out these six tips to get you on your way. What's changing: CPT 2011 offers up new codes to help you report services more accurately, including endovascular revascularization, says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle. Specifically, CPT 2011 adds several new codes that represent lower extremity endovascular revascularization, meaning angioplasty, atherectomy, and stenting. Here's how the codes break down:

• Iliac: 37220-+37223 -- Revascularization, endovascular, open or percutaneous, iliac artery ...
• Femoral, popliteal: 37224-37227 -- Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral ...
• Tibial/peroneal: 37228-+37235 -- Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral ...

In this article, iliac artery services are the focus. Look to future articles to discuss femoral, popliteal, and tibial/peroneal services. 1. Watch Procedure and Vessel to Choose Among 37220-+37223 The new iliac service codes are as follows:

• 37220 -- Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty
• 37221 -- ... with transluminal stent placement(s), includes angioplasty within the same vessel, when performed
• +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)
• +37223 -- ... with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure).

Reading through the definitions, you see that the codes for iliac services differ based on whether you're coding a service in an initial vessel or in an additional vessel. Your options also differ based on whether you're reporting (1) angioplasty alone or (2) stenting, with angioplasty if performed. (See the Clip and Save on page 92 for a visual representation of how these new codes break down.) On the other hand: Whether the physician performs the procedure percutaneously, via open exposure, or via a combination of the two will not affect your code choice.The codes are appropriate for any of those methods. 2. Learn How Stent and Angioplasty Affect Coding The general rule for 37220-+37235 is that you should report the one code that represents the most intensive service performed in a single lower extremity vessel. All lesser services are included in that code. Apply the rule: When the radiologist performs a stent placement and angioplasty in the initial iliac vessel, you should report only 37221. That code covers both stent placement and angioplasty (when performed). You should not report 37220 (angioplasty) in addition to 37221 in this scenario. If the radiologist places a stent in an iliac artery but does not perform angioplasty, 37221 or +37223 is still appropriate because those codes specify that the angioplasty is included "when performed." The codes do not indicate angioplasty is required. Exception: The femoral/popliteal and tibial/peroneal codes include options for reporting atherectomy. But iliac coding is a special case. When the physician performs iliac atherectomy in the same vessel as angioplasty or stent placement, you should report one code for atherectomy and a second code for the angioplasty and/or stent placement. CPT 2011 created a Category III code (0238T, Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; iliac artery, each vessel) to capture the atherectomy service on an iliac vessel. 3. Include RS&I and More in 37220-+37223 Expect to see some Correct Coding Initiative edits for the new iliac service codes. CPT guidelines explain that -- in addition to the intervention performed -- the codes include:

• Accessing the vessel
• Selectively catheterizing the vessel
• Crossing the lesion
• Radiological supervision and interpretation for the intervention performed
• Any embolic protection used
• Closure of arteriotomy (incision in the artery)
• Imaging performed to document the intervention was completed.

Report separately: If the physician performs mechanical thrombectomy (such as+37186), thrombolysis (such as 37201, 75896), or both, to help restore blood flow to the occluded area, CPT states you may report those services separately. 4. Tackle Territory Vs. Vessel Vs. Lesion The new codes (37220-+37235) apply to different "territories." Each territory has its own specific set of guidelines. Codes 37220-+37223 fall under the iliac vascular territory. CPT specifies that "the iliac territory is divided into 3 vessels: common iliac, internal iliac, and external iliac." As already discussed, 37220 and 37221 are appropriate for the initial vessel treated. That means they apply to the first iliac artery treated in a single leg. If the physician treats one or two additional iliac vessels in the same leg, then you should choose from +37222 and +37223. Crucial: You may use up to two add-on codes per leg. The reason is that there are three iliac vessels in each leg, and you may report one code per vessel. Be sure you catch that -- because the codes apply per vessel -- you should not report add-on codes for additional lesions in a single vessel. CPT is very clear that "when more than one stent is placed in the same vessel, the code should be reported only once." 5. Check Rule for 1 Intervention in 2-Artery Lesion In some cases, a lesion may extend from one artery into another. If the cardiologist can treat that lesion with a single intervention, then you should choose a single code to report that service. CPT offers the example of stenosis that extends from a common iliac into the proximal external iliac. If the physician uses a single stent to treat the lesion, CPT instructs you to report initial vessel code 37221. You should not also report additional vessel code +37223. On the other hand, if the stenotic lesions consist of two separate iliac arteries divided by a bifurcation with a break in stenosis requiring multiple therapies, then you should report an "initial" code as well as an "additional" code. 6. Look Out for Work in Both Legs The codes state that they are unilateral, which means they apply to a service on a single side of the body. CPT suggests that if the physician treats the identical territory (such as iliac) in both legs at the same session, you should use modifier 59 (Distinct procedural service) to show both legs are involved. This holds true even when the mode of therapy is different in each leg, such as angioplasty in the left leg and both angioplasty and stent in the right leg. Keep alert for payers' modifier preferences, though, as some may prefer you to use modifier 50 (Bilateral procedure), modifiers RT (Right side) and LT (Left side), or some combination of modifiers for procedures on both legs.