Cardiology Coding Alert

CPT 2001 has introduced several new codes, many of which are separately billable, to describe endovascular repair of abdominal aortic aneurysms (AAA) procedures that formerly had to be billed using a single unlisted procedure code (37799, unlisted procedure, vascular surgery). In addition, two new radiology codes may also be billed with the procedures under certain circumstances.

Endovascular repair involves the introduction of a collapsed prosthesis through arteries in the groin (either femoral or iliac). The prosthesis is advanced into position under fluoroscopic guidance, after which a balloon inflates it to full size and metal clips on the distal and proximal ends of the device latch on to the inside of the artery. According to Diane Elvidge, CPC, senior reimbursement specialist with Princeton Reimbursement Group in Minneapolis, cardiologists are increasingly performing these procedures.

Applying the New Codes

The first three codes in the endovascular AAA repair subsection describe variants of the same procedure. Code 34800 (endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using aorto-aortic tube prosthesis) describes placement of an endovascular tube graft in the aorta from a single groin incision. Because the anatomy of most patients is not suitable for this type of graft, it is not placed frequently.

More often, the aneurysm will extend to the very distal aorta or into the proximal common iliac arteries. Because no adequate normal distal portion of aorta is available to accept a tube prosthesis, the physician will instead place a bifurcated graft. Two codes describe such a graft. Code 34802 (endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using modular bifurcated prosthesis [one docking limb]), the most frequently performed of these three procedures, uses a modular design in which the main aortic prosthesis is attached to two short docking limbs in both iliac arteries. The other bifurcated graft, 34804 (endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using unibody bifurcated prosthesis), describes the placement of a one-piece prosthesis specifically designed to the dimensions of the patient.

In addition to the endovascular repair, the physician may perform one or more other procedures to complete the treatment. For instance, an occlusion device may be placed (34808, endovascular placement of iliac artery occlusion device [list separately in addition to code for primary procedure]) to block off a stenosed or otherwise diseased iliac artery that cannot be treated with an endosvascular graft. This procedure, in turn, requires a vascular surgeon to place a femoral-femoral prosthetic bypass graft (34813, placement of femoral-femoral prosthetic graft during endovascular aortic aneurysm repair [list separately in addition to code for primary procedure]) to maintain the patients blood flow to the affected leg.

Note: Codes 34808 and 34813 are add-on codes and may not be billed on their own.

Additionally, depending on the patients anatomy and the severity of occlusion (from plaque, for example), direct vascular access may be required to initiate the endovascular repair, says Kathleen Mueller, RN, CPC, CCS-P, an independent vascular surgery coding and reimbursement specialist in Lenzburg, Ill. In such cases, either the femoral or the iliac artery is exposed to facilitate the introduction of the sheath required for endovascular AAA repair. If the femoral artery is entered, 34812 (open femoral artery exposure for delivery of aortic endovascular prosthesis, by groin incision, unilateral) is used. If the physician exposes the iliac artery, 34820 (open iliac artery exposure for delivery of endovascular prosthesis or iliac occlusion during endovascular therapy, by abdominal or retroperitoneal incision, unilateral) should be coded. Both codes are payable separately. For example, Mueller says, if a modular bifurcated endovascular graft is inserted via an open iliac exposure, both 34802 and 34820 should be billed.

Note: The descriptors for 34812 and 34820 specifically note that these codes are unilateral. Often, however, both femoral or iliac vessels are accessed to position the endovascular prosthesis better. In those cases, modifier -50 (bilateral procedure) or modifiers -LT (left side) and -RT (right side), depending on the requirements of your carrier, should be appended to the appropriate code. Code 34812 should also be billed with modifier -50 attached if a femoral-femoral bypass graft prosthesis (34813) is placed because both femoral arteries are dissected during this procedure.

Coding for Placement of Extensions

If the prosthetic device is not long enough and post-operative angiography discovers a leak, an extension may be required. Typically, such an extension is placed during the same session as the original AAA repair. Sometimes, however, the leak is not discovered until the procedure has been completed. In both cases, 34825 (placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic aneurysm; initial vessel) should be used for placing the extension. If more than one vessel requires an extension, use 34826 (placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic aneurysm; each additional vessel [list separately in addition to code for primary procedure]).

Note: If more than one extension is placed in the same vessel during the same operative session, only one code may be reported.

If a leak is discovered and the extension is placed during the postoperative period of the original procedure (34800, 34802 and 34804 all have 90-day global periods), the AMA recommends attaching modifier -78 (return to the operating room for a related procedure during the postoperative period) to 34825 or 34826. If the procedure is staged, however, modifier -58 (staged or related procedure or service by the same physician during the postoperative period) should be used instead, according CPT.

Note: The last three codes in the CPT section, 34830-34832, describe open repair of AAA following unsuccessful endovascular repair. Cardiologists are unlikely to perform these procedures.

Related Procedures May Be Billed Separately

All of the endovascular AAA procedures described above begin with the introduction of guidewire catheters and an aortogram or other angiography to advance the endovascular prosthesis into position.

The placement of the catheter for this purpose is separately payable, as is the aortography or other angiography performed to map out the patients anatomy so the prosthesis can be correctly implanted. If the catheter is placed nonselectively (i.e., into the aorta only), 36200 (introduction of catheter, aorta) should be billed. Sometimes, however, the physician may require a closer look at the renal arteries to ensure the prosthesis does not obstruct the renal arteries. If such a selective catheter placement is performed, 36245 (selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family) is billed instead.

Note: Although 36200 and 36245 are unilateral codes, if catheters are placed on both sides, modifier -50 or modifiers -LT and -RT should not be appended. The catheter on the second side is included in the endo-vascular repair because it is performed to aid in the placement of the endovascular prosthetic device.

Two new radiology codes for interpretation of the angiography performed with the endovascular repair may be billed if the physician performs the supervision and interpretation (S&I) of the angiogram. Code 75952 (endovascular repair of infrarenal abdominal aortic aneurysm or dissection, radiological supervision and interpretation) should be used if the angiogram is performed in connection with the placement of the endovascular AAA prosthesis, whereas 75953 (placement of proximal or distal extension prosthesis for endovascular repair of intrarenal abdominal aortic aneurysm, radiological supervision and interpretation) should be billed in with the placement of a prosthesis extension.

Note: Radiology S&I codes, including 75952 and 75953, may be billed by the physician only if a radiologist is not present and the physician documents a separate radiology report.

Although the introduction to the endovascular AAA subsection in CPT 2001 states that codes 34800-34826 include vascular access and all catheter manipulation, vascular access and catheter placements are separately payable in certain circumstances. According to CPT, any vascular access and mapping prior to the procedure performed to identify the patients anatomy is separately payable, Elvidge says. Any angiograms or x-rays taken during the procedure to aid in the inflation of the prosthesis once it is placed at the site of the aneurysm, however, are included in the endovascular repair codes [emphasis added].

Realize Increased Reimbursement With New Codes

This new group of codes could mean significant payment increases for endovascular AAA repairs.

For example, a 65-year-old man is diagnosed with an AAA and the cardiologist decides he is a candidate for endovascular repair (34802). During the procedure, however, severe stenotic disease is observed in the femoral artery, and the cardiologist is unable to pass the prosthetic sheath. Therefore, both femoral arteries are opened to place the catheters and deliver the prosthesis (34812). After the prosthesis is placed, angiography reveals leakage at the site of one of the devices docking limbs, and an extension is required.

Until the introduction of the new codes, all the endovascular procedures during this operative session would have been coded using 37799, Elvidge says. In addition, codes 36200 and 75630-26 (aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision and interpretation-professional component) could also be billed.

Now, however, this session would be billed as follows:

34802
34812-50 (or 34812-LT and 34812-RT)
34825
36200
75952-26

According to HCFAs 2001 fee schedule, 34802 is valued at 35.27 relative value units (RVUs), while 34812 is worth 9.94, and 34825 is worth 19.09. Because the 34812 was performed bilaterally, an additional 4.97 RVUs (50 percent of 9.94) can be added to the RVU total. If HCFAs national conversion rate is applied, this adds up to more than $2,600 for the procedures described by the three new AAA codes (or about twice as much as the typical payment for 37799 in these circumstances).

Recognize Bundled and Billable Procedures

The balloon angioplasty performed to inflate the aortic prosthesis is a component of the main endovascular repair code (34800, 34802, 34804). Therefore, codes 35452 (open aortic transluminal angioplasty) and 35472 (percutaneous aortic transluminal angioplasty) should not be billed in addition to any of these AAA repair codes. Any angioplasty or other interventional procedure performed during the same session but unrelated to the repair should be considered a distinct service that may be billed separately, however.