Cardiology Coding Alert

Presented by Jim Collins, CPC, CHCC

The following supplement to Cardiology Coding Alert is the transcript of a teleconference presented by The Coding Institute. To obtain the slides for the conference, please log on to our Online Subscription System at http://codinginstitute.com/login and open the PDF version of the current issue, and the slides will be contained therein. If you're not sure how to use the Online Subscription System or need help opening the issue, please contact our customer service department at 1-800-508-2582 or service@medville.com, and one of our representatives will be able to assist you.

The speaker for the teleconference, Jim Collins, CPC, CHCC, is the Chief Executive Officer of the Cardiology Coalition, a professional society dedicated to advocacy efforts for cardiologists and the billing proficiency of cardiology practices.  Mr. Collins has over twelve years experience as a physician reimbursement consultant and limits his practice to cardiology related issues (procedural auditing, E&M auditing, revenue cycle optimization, staff training and physician training.) He is the Consulting Editor of Cardiology Coding Alert and is a seasoned national speaker on cardiology documentation and reimbursement.

Thank you Mandy and good morning to everybody out there listening in.  This is a two-hour conference that is going to be geared specifically to peripheral vascular billing and we are going to try to take you through all of the very critical issues that you need to understand in peripheral vascular.  Of course with this topic, we could spend 2 or 3 days on it if we really wanted to get into the little specifics about each of the difference types of services that could be provided and coverage issues and the correct coding initiative edits and so on.  It is really not going to be possible in a two hour conference, but we should be able to cover everything that you need to really get up to speed on accurate coding of these services, point you in the right direction and give you some guidance that you can use to code these services to the maximum allowed amount and also within all the applicable regulations. 

Understanding The Clinical Side Can Make Coders' Work Easier

With peripheral vascular services, I think it is critically important that people understand a little bit about the clinical side of these services as far as what the doctor is doing and why they are doing it, because when billing out these operative reports and reading through them to try to assign codes, it is very easy to get lost in the process.  Understanding a little bit about the clinical side should help you out considerably.  So, the first thing I want to stress is what peripheral vascular disease is.  In short, it is the narrowing, clogging and hardening of the arteries.  It is very similar to coronary disease except that it is in vessels that are outside of the coronary distribution. 

When we have patients that present with symptoms of peripheral vascular disease, a lot of times it is going to be in their lower extremities and that is going to be indicated by patients who have cold feet, bluish feet because they are not getting circulation in those areas.  They might have sores that do not heal appropriately in their lower extremities, in the feet and in toes.  We actually see patients that come in with gangrene on their toe tips, and their fingertips because the flesh is actually starting to die at the most distal points of their body after it is deprived of oxygenated blood for a certain amount of time. 

The problem that causes this blockage of arteries in the peripheral system has many factors.  One of the big ones is of course, cholesterol levels.  When patients have a lot of low density cholesterol in their body, in their blood stream, it is going to start depositing itself all along the pathways and that is going to create road blocks.  It is going to keep the blood from going where it needs to go, to do its actual function.  Due to several other contributing factors such as genetics and if people drink alcohol and smoke cigarettes and so on, all these are going to be factors that also contribute to peripheral vascular disease.

Patients' Symptoms Will Depend On Where Peripheral Disease Is In The Body

On page# 2 at the top, you can see that this is a disease that affects a little bit over 10 million people in United States currently.  When people get above the age of 50, one in twenty of those people have peripheral vascular disease to the point that they really need to have some sort of help or else they are going to have a decreased quality of life.  Of course when we have patients who have peripheral disease in their lower extremities, that basically means the lower extremities are not going to have the oxygen and the nutrients to supply the leg muscles with the fuel that they need to operate.  When a patient tries to go up a flight of stairs, they are going to have an intense cramping feelings in their lower extremities.  When they sit down, the cramping is going to subside as the muscles' demand for oxygen is reduced and that is what we call claudication.

So when we have these patients who have peripheral disease, depending upon where it is, they are going to be coming in with different problems.  If the patient has disease in the arteries that supply their head with blood that means they are going to not be able to maintain consciousness, they are going to be a little bit less responsive to verbal stimuli, they might actually pass out if they have extensive carotid artery disease. 

When we look at trying to identify these patients and accurately assess their peripheral disease, one thing that we need to do is figure out which patients to do studies on, and there are a lot of non-invasive tests that might be performed on a patient before we actually proceed on to do an invasive study, which is commonly referred to as peripheral angiography.  The non-invasive studies are going to include your ankle brachial indexes, your indices and also ultrasound studies of the lower extremities, carotid arteries.  Once we figure out that this patient does have a strongly suspected peripheral vascular disease, we are actually going to go inside of their body with a catheter so that we can do contrast angiography of the areas that we want to study.  This is where we start talking about invasive studies of the peripheral systems. 

When we do these invasive studies, we make a hole in the patient's body typically. it is going to be in their groin area.  We puncture in there and we use a series of guidewires and catheters so that we can navigate through the patient's arterial system.  And what we are going to do is inject a contrast agent through these catheters.  If you look on the top of page #3, you can see a picture of what angiography is going to be looking like.  The catheter is essentially positioned up at the top above the image there and contrast is injected.  As it flows downstream, it is going to be completely flood the vessel that we are trying to look at and tell us what the shape is.  This contrast agent is special, because it illuminates similar to how metal illuminates when we put it underneath an x-ray; and by flooding the vessel and then looking in it with a moving x-ray outside of the patient's body, we can see exactly what those downstream territories look like.
 
You can see on the left hand side of your page there is an arrow that is pointing to an area that has probably 95% blockage in the artery.  As you can imagine the patient's muscles and whatever else is down below that area of obstruction is going to be deprived of oxygenated blood and that is going to cause all these symptoms, which will essentially bring patients into our office. 

Peripheral And Coronary Imaging Will Be Increasingly United In The Future

One of the first things of course, that is the challenge for us is to kind of marry the two worlds of peripheral vascular billing with diagnostic heart cath--and I know not everybody on the call today is in cardiology practice, but those that are in a cardiology practice, one of the biggest challenges that we have to deal with is first, merging the two worlds from a coding and regulatory perspective; and then also getting paid for these services because a lot of payers do not understand the different regulations that apply and you start seeing typical heart cath bills going out with your five bread and butter codes that might go on a diagnostic heart cath.  And then we also have peripheral studies put on there as well. 

This is not something that is going to go away.  Peripheral imaging and coronary imaging are going to be united in the future more so than it is now for a number of different reasons.  One of the big reasons is that it is a natural fit. 

Patient Base And Physician Skill Level Overlap

When we look on the bottom of page 3, where I have all these main reasons why we are merging these two fields of medicine, the natural fit comes into play in two perspectives.  First, they have the same patient base.  If the patient has coronary artery disease, they are going to be seeing a cardiologist, the cardiologist goes in and does diagnostic studies of the coronary arteries.  These patients have coronary artery disease because they have the same ingredients in their blood as what causes peripheral disease.  So they have high levels of low density cholesterol in their blood, they have got the family genes that help facilitate that, they might be smokers, they might drink an excessive amount of alcohol and so on. 

If these patients have coronary disease, there is going to be an extremely high correlation with the fact that those patients are also going to have peripheral vascular disease.  So, there is a natural fit with the patient, there is also a natural fit with the physicians, because if a physician can go into a groin artery, thread the catheter all the way up through the aorta, up to the aortic arch inside of the heart and into the coronary arteries--which are essentially wrapped around a beating human heart--and do these studies, there is really nothing that is going to be stopping them from doing the same exact studies in the renal arteries which are only half the distance from the access site as the coronary arteries are.  And these vessels in the peripheral systems are also not going to be wrapped around a beating object, especially not in a human heart.  They are going to be relatively stable whether they are in the lower extremities, the upper extremities, the renal arteries or the carotid arteries, these vessels are relatively stationary when you compare them to how the coronary arteries beat.  So the patient base overlaps and the physician skill level also overlaps. 

There are also financial reasons why we would have cardiologist doing peripheral studies.  One is that it is really financially beneficial to the health care system.  If we can bang out two studies, the heart cath and a peripheral study at the same setting, it is going to basically save us two different patient admissions to the hospital, it is going to save consultation fees, it is going to save diagnostic workup that leads to the angiography, then so on, it is going to enough saving a tremendous amount of money.  Also if we can catch these diseases before they spread to the point where patient would naturally be referred to a vascular surgeon or an interventional radiologist, we are actually going to be able to save that patient's body from deteriorating. 

So if we can catch the patient's peripheral disease when, say, it is in renal artery and the peripheral disease is only at 85% blockage, we are going to be able to go in and intervene on those arteries percutaneously and save that patient from extensive renal disease, which could actually cause them to go in to renal failure and have to go on the transplant list and then on to dialysis which is a tremendous amount of money impact on this system.  The same reasons that we can prevent this disease from proliferating and spreading itself to the point that the patient gets to where they are causing permanent damage to the body, that is going to be very beneficial to the patient as well.  We can essentially save the patient that whole downhill slope of deterioration, physical stress and mental stress and damage to the body if we catch this disease before it progresses to the point that it starts causing the damage. 

How To Bill Medicare For Non-Selective Renal/Iliac Angiography

When we first start doing peripheral studies at the same time as the heart catheter, one of the main studies that we will be doing is a nonselective study and on the top of page #4, a couple of codes have been developed specifically for non-selective studies at the time of heart cath.  These are codes G0275, G0278, they are HCPCS codes as opposed to CPT level I codes.  These only apply to Medicare patients and at the time of a heart cath if they receive non-selective studies.  So there are three hoops that we have to jump through before we bill G0275 for non-selective renal angiography or G0278 for non-selective iliac artery angiography.  The three hoops again--it has to be a Medicare patient, they have to be in there having a diagnostic heart cath performed, and they also have to have these studies performed non-selectively.  If those three hoops are not met then we do not actually have to bill these G codes. 

The codes, when they were first introduced, were ambiguous in the fact that they did not clarify if these were intended to be used for selective versus non-selective studies.  There was a lot of concern at time--we had speciality societies involved and CMS and OIG--that we all had to deal with rather aggressively right after these codes first came out.  They came back a few months after the whole process started and said 'no these codes were intended just to be used for non-selective studies.'  And that is an important decision and important clarification because these services at that time paid only about $12 dollars each.  Currently they pay around $14 each but it is still a lot less money than would be generated if the doctors did selective studies. 

So at the time the codes were first introduced, they did not say whether they were selective or non-selective.  A couple of months after they came out, CMS clarified that they were intended to be used for non-selective purposes only and the code definitions were changed mid year.  When the 2005 CPT came out, which was effective on January first of this year, the code definitions were changed to be what they show at the bottom of page # 4 and if you read through them, you will see that they do not include that word 'non-selective' anymore so they somehow deleted out the definition component that clarified that these were for non-selective studies only.  On the top of page #5, you can see that through the Cardiology Coalition, which is the advocacy organization that I am working with, we were able to get CMS to clarify that for the time being, these code should be used just for non-selective studies of the renal iliac arteries at the time of heart cath.

For Now, Do Not Bill G0275,78 Without An Indication To Do A Peripheral Study

We have also made a proposal to CMS that they cover these non-selective $14 procedures for patients that have documented coronary artery disease.  In essence, there is a huge overlap in patient base.  There are a lot of financial benefits to the healthcare system.  There are tremendous healthcare benefits offered to the patient.  If we know they have coronary artery disease, if we can go ahead and do a screening study of their peripheral arteries based on the fact that they have coronaries, we should be able to facilitate a lot of these benefits.  Currently, Medicare is looking at that proposal, it is not definite at this point, they have not said whether they are leaning towards it or not, but for the current time we should not be billing G0275 or G0278 unless we have an actual indication to do a peripheral study on these patient.  An indication might be a noninvasive study that suggests the patient has renal artery disease or lower extremity disease.  The patient might have refractory hypertension, malignant hypertension, renal vascular hypertension.  These are all indications that will pave the pathway of medical necessity to be able to prove that these G0275, G0278 studies are actually clinically indicated and appropriate to bill. 

If we do not have an indication for them at the current time, we should not be billing for these studies whatsoever.  And again, a doctor may choose to do a study that is not covered by Medicare, but it is inappropriate for them to bill it to Medicare.  Right now, CMS is still looking at that proposal as far as coverage indications, but they have told us that it is appropriate to bill for these studies only if they are non-selective.  If the doctor goes on and does a selective study of the renal or iliac arteries, then we should be billing for those with a traditional peripheral study codes, which we are going to be talking about for the remainder of this teleconference.
 
Beware Of CCI Edits For Many PV Services.

The example of those is at the top of page 6.  If we were to do a unilateral renal study, selective at the time with heart cath, we should be billing 36245 for the catheter placement, 75722 for the radiologic imaging of those services.  The Correct Coding Initiative edits are going to become impacted because there are a lot of these peripheral codes that are going to be bundled into the heart catheter placement codes, which I have got at the bottom of page #6 for you.  The ones in bold, are really just the ones that are inappropriate at this point.  As you can see, the 36245 right now we have to use a 59 modifier or we could use a left or right modifier on that to get around the Correct Coding Initiative edits.  But since CMS has clarified that these selective studies should be billed in addition to the heart cath, it really makes that CCI edit--and also the ones 75722 and 75724--really just an administrative burden, rather than anything that is going to be bring a benefit to the Medicare system.  So one of the efforts of the Cardiology Coalition is working on, it is actually get those three edits actually removed from CCI and that is something that it looks like that should be possible because there is really no benefit being achieved from those. 

And other one of things that we will talk about on coronary studies before we move on to talk strictly about peripheral--and this is really just more of a housekeeping thing to get out of the way so we can focus purely on peripheral stuff, and that is the reimbursement amounts that are generated.  If you look at the top of page #7, you can see that when we do a left heart cath, what we have to do is to make access to the patient's lower extremity, flexibly catheterize two vascular families that are wrapped around the beating human heart all the way at the top of the aortic arch.  When we do that we get approximately $375, this is just a rough national amount.  Of course, it is going to be impacted based on your carrier and your geographic adjustment factors.
 
Huge Reimbursement Disparity Exists Between Left Heart Caths And Bilateral Renals

When we do a bilateral renal study, we are still going in and selectively catheterizing two vascular families, however like I said earlier the target arteries are half of the distance from the access site as the coronary arteries are.  These arteries are relatively stationary when you compare them to the coronary arteries and also the end-organ is much less sensitive.  If we were to absolutely botch up a diagnostic heart cath, the patient is essentially going to die, because they cannot live without their heart.  If we are completely botch up renal angiography, the patient still has a chance on dialysis and also with the transplant list and also in addition to that, the patient can of course, live with just one kidney as opposed to having two kidneys.  So, the end-organ is much less sensitive.  However as you will see in these reimbursement amounts we get approximately 20% more money for doing a bilateral renal study than we do for heart catheter.  Again, that is one of the advocacy efforts the Cardiology Coalition is working on right now: to get CMS to recognize that there is a huge disparity in the reimbursement amount and the relative value units for these services and try to get the diagnostic heart caths brought up to where they really should be in reimbursement. 

Payers May Need To Be Educated On Complexity Of Peripheral Vascular Studies

Next, we will talk about just strictly peripheral vascular billing issues and ignore the fact that we are doing heart cath with these.  The big thing to keep in mind with heart caths is if it is a non-selective study, you need to use those G codes.  If it is a selective study, you are going to bill the same codes that we are going to talk about during the remainder of this conference; however you have to take into account the Correct Coding Initiative edits.  A couple of people that are attending today wrote in saying, "our payers are not reimbursing us for these services".  What you really need to do is to figure out the correct combination of modifiers and keep in mind your 93510 is going to bundle in codes that do not really make a lot of sense.  You just have to reference the Correct Coding Initiative edits and make sure you put a modifier on to bypass those edits when appropriate.  That is going to get you paid, and then even with that, you are going to have some carriers actually adjudicating these claims without understanding that it is appropriate to bill for the selective studies in addition to the heart cath codes.  So you may actually have to educate your payers in a lot of these cases.  Peripheral vascular studies are the most complex areas in billing right now.  The insurance companies and your Medicare carriers do not understand these rules nearly as much as most of us who are on this conference call today do. 

So on the top of page #8, we have got some of the things that we have to take into account when we were doing peripheral studies.  We have to extract a lot more detail out of these reports than we do in most procedural reports.  We have to really identify where the access site is because in a lot of cases that is going to impact our billing.  We have to understand the direction that the catheter is being moved in.  We have to understand how many different vascular families is that position in and what diagnostic studies are performed, what interventions were done, what sequence the interventions were performed in.  When we actually get into really billing for these, we have to understand what the doctor's intent was when doing intervention.  We also have to take in to account all the different modifiers that apply--Correct Coding Initiative edit modifiers, the 26 modifier for a radiologic code, if we are doing these in facility and so on.  So there is a lot of data that we really have to extract from these reports. 

Because of that, it is important that your doctor understands how to document these things, what is important in the document, and they actually take the time to do it.  A doctor gets in the habit of documenting a heart cath in a certain efficient fashion and then they start doing these peripheral studies, which to them, in many measures, is a walk-in the park compared to a complex coronary procedure.  So they might not document as extensively as they do for the heart cath.  If they want to get optimum reimbursement, if they want to get paid multiples of what they would for a heart cath procedure, they have to get very specific on where they came into the patient's body, where they specifically positioned the catheter and each of the different diagnostic images that they are taking and assessing. 

The First Set Of Coding Rules Is Specific Only To Catheter Placement

The coding rules that apply to peripheral studies are really fractionated.  When we look at these we have to break it out into essentially three or four different boxes.  The first box is specific to catheter placement.  It is not necessarily a complex set of rules, it is just a goofy set of rules that apply to catheter placement, that does not apply anything else in peripheral vascular.  So to really understand peripheral vascular billing, what you need to do is when you read through a report, push yourself away from it and try to go through and say, "just where did the doctor place the catheter?"  Apply all the rules that apply to catheter placement and code those services separately, then go through it a second, maybe even a third time.  Go back and figure out, what diagnostic images did the doctor take?
 
The first set of rules is specific just to catheter placement and when we try to apply the catheter placement box rules, we really cannot think about the diagnostic imaging, we cannot think about the intervention, we cannot think about a lot of different things.  We really need to just read through the report and say, whether we do it in our head--whether we document it on a piece of paper like a diagram--you have to really specifically say, where did the catheter come in to the patient's arterial system and where did it go, every single different point within the arterial system.  Without doing that, you are not going to be able to code these things accurately. 

The second set of rules is specific just to the diagnostic imaging.  So we are going to go through and talk about those rules and again, the imaging rules, the diagnostic imaging, which a lot of people call the radiologic supervision interpretation or just an S&I--these rules do not correlate with, do not reconcile with the catheter replacement set of rules, which is going to be that first set of rules that we talked about.  And then after we talk about the imaging pieces, we are going to talk about the intervention rules and there are actually really two different sets of intervention rules--one is for regular peripheral vascular procedures, which essentially means anything outside of the carotid or vertebral arteries.  Then there is a the second set of rules that applies to the carotid and vertebral interventions and they are really unique from the box of rules that are specific to interventions in like the renal, lower extremities and so on. 

So we are going to do first and let us talk about the first set of rules.  After this, we are going to take a 10-minute break so that you can ask questions if you want to.  I know this is a two-hour conference--like I said,  the different rules that apply are really fractionated, they do not correlate with each other, so I do not want try to give you all the rules that apply and then open it up to questions because we will have questions coming from all across the board.  So we are going to focus on the first box of rules, which is catheter placement.  We will take a break after that for 10 minutes to allow you ask questions that are specific to catheter placement.  When we come back, we will talk about the diagnostic imaging, the interventions, and then we will open up for second set of questions at the end of the conference.

Non-Selective Cath Placement: Movement Towards Or Into Aorta From Any Access Point.

The first thing to understand in the first set of rules at the bottom of page #9, is what non-selective catheter placement is.  In short, if we were to take a whole lot of material and boil it down to its most basic core, non-selective placement is when we go in to the patient's arterial system from any access site and we move the tip of the catheter towards the aorta or actually into the aorta--that is going to be non-selective catheter placement.  It is important to note that when we go into the aorta, any position that we go into the aorta, whether it would be just at the tip of where we actually enter the aorta or at the point at the most proximal point of the aorta, which is going to be aortic valve--if we go all the way up there, we are still going to be considered a non-selective catheter placement and it is not going to change our coding at all. 

If we are billing for a non-selective study, the catheter placement codes that are going to apply are listed at the top of page #10 for you.  The one that you are going to be using most commonly, most frequently is going to be the 36200 and this is the one that applies to catheter placement into the aorta, no matter where in the aorta we go, no matter how many different stops we have in the aorta. 36200 says 'we are placing at the tip of the catheter from any access site in the patient's body into the aorta.' 

The other code that you will be using a lot from the top of this page #10 is 36140.  This says that we are making access into an extremity artery, but we are not actually crossing into the aorta.  So 36140 would be, for example, if we went into the patient's right groin area, we might move the tip of the catheter towards the aorta, but not actually into it--that is going to be 36140.
 
We can also go into the patient's extremity artery and move away from the aorta and as long as we do not go through a bifurcation, we are still going to be able to use 36140.  The main difference in going towards the aorta or away from it is what the doctors might reference as retrograde versus antegrade.
 
Antegrade Or Retrograde Does Not Change 36140--As Long As The Aorta Is Not Crossed

If we go retrograde, that means we are going into the patient's artery--let's just say we are going in to the patient's right common femoral artery, which is just an artery in the right upper leg.  And if the tip of that catheter is pointing towards the aorta, it is basically pointing into the flow of blood so it is going against the flow of blood.  We call that a retrograde stick.  If however we were going in and pointing the tip of catheter down towards the patient's toes in the right leg, that is going to be an antegrade stick.  If we go antegrade or retrograde, it really does not change the code, the 36140, it is going to be the same code.  The big difference is to understand that it is going to be non-selective if we do not cross into the aorta, it is going to stay 36140 and if we do cross the aorta, it is going to be 36200. 

The other codes that are on the top of page #10 do not get reported nearly as frequently as the 36200 and 36140.  The one code that you might be billing occasionally is 36145 and this is when the doctor catheterizes an AV shunt which is going to be something that is in the patient's body that allows blood to communicate between the arterial and the venous system to increase circulation, which is going to be typically used on a dialysis patient.  It is just a procedure that done by a surgeon make an opening in the arterial system and an opening in the venous system to kind of connect those two to help in circulation.  If we are going in and catheterizing that--36145. 

The other codes you really are not going to be seeing that frequently if ever:  the first one is 36100 is a direct stick into a vertebral artery, or a carotid artery, which does not happen a lot.  36120, the retrograde brachial artery stick.  That is not going to happen too frequently, however it might for some vascular surgeons that are doing upper extremity studies without actually crossing into the aorta and then the 36160 code which is a translumbar stick in to the aorta.  It really is not going to be happening, probably not ever in most cardiology groups and in most vascular surgeon groups, even. 

How To Spot A Selective Catheter Placement

In order to go from being non-selective, which would be one of these codes that we just talked about, to becoming a selective catheter placement one of the few things has to happen.  The first thing is that if we are placing the tip of the catheter into the aorta, what we would actually have to do is to leave the aorta and go into a different vascular family.  It is really important to understand what a vascular family is--it is essentially going to be a network of arteries that connects to the aorta at a single location. 

If you want to look at the next page, look at the bottom of page #11 and then we will come back to the page #10 here.  At the bottom of page #11, you can see a diagram that shows what the arterial system looks like in the upper body of the patient and you can see that there are different branches--the question mark looking artery that is right in the middle of the patient's chest is what we call the aorta.  At the most proximal tip of that end of question mark at the top, that is where the patient's heart is going to be, that is going to open up right from the left ventricle.  As you can see at the top, there are three different vascular families.  The vascular family is one attachment to the aorta and then as you can see, the blood is going to flow from that attachment to the aorta and distribute to this network of arteries that kind of carries blood out, down the patient's right arm, up to the right side of the patient's head.  That is going to be considered to be one vascular family.  And if you look to the right of that you can see another vascular family that carries blood up to the left side of the patient's head, next to that is another vascular family that carries blood down the patient's left arm and also up towards their head on the left side.  These are three different vascular families.

Again, a vascular family is something that is a network of arteries that have one common attachment to the aorta; so if we go into the aorta and we leave the aorta to go into a vascular family, which is going to be of course different than the one we came in from, different than our access site, that is going to become a selective catheter placement--the second we leave the aorta.  We are going to see the tip of the catheter go into the patient's right common femoral, we go up into the aorta, if we were to go down into the patient's left lower extremity, the second we leave the aorta to go down into the left lower extremity, we are going to become selective.  This is going to be what they call 'first order selective' at that point.  That is one way we could become selective. 

When Moving Away From Aorta, Each Bifurcation Increases The Level Of Selectivity

Another way we could become selective is if from an access site, instead of going towards the aorta, we actually go away from the aorta.  This is what we talked about a minute ago when I said instead of doing a retrograde stick, we actually do an antegrade stick, so that when the catheter goes into the patient's body, it is actually going with the flow of blood as opposed to against the flow of blood.  If we move that catheter downstream through the patient's arterial system, we are going to come to point in the road where there is a bifurcation.  A bifurcation just means that there is a fork in the road and the tip of the catheter is either going to have to go left or right.  If we go left or right, the second we navigate that split in the road, we are going to become selective.  And the second we go through that first split in the road, we become first order selective.  If we come to another split in the road and we go through it, whether we go left or right, we are going to become second order selective.  We come to another split in the road and we decide to go left or right and actually go through it, then we are going to become third order selective.  And this is really where the complexities of peripheral vascular billing really start to kind of present themselves.  It is not that it is that hard of a concept to grasp, it is just that we really need to be able to figure out exactly what level of full selectivity we are at, which really requires you be able to read through the operative report, correlate it with some sort of a diagram and actually go through and count, how many times did I come through a split in the road?  That is going to dictate what level of selectivity you are. 

On the top of page #11, you can see the codes that apply selective catheter placement.  At this juncture there are three different codes and they are broken out into two different kind of groupings of codes.  The first is 36215, 36216 and 36217.  These are for selective catheter placements that are performed in a vascular family that branches out from the aorta above the patient's diaphragm.  The 36245, 36246, 36247 are for selective catheter placement in vascular family that branch out below the patient's diaphragm.  When we look at these codes, you can see that the codes are essentially the same, 36215, 16, and 17 and 36245, 46 and 47.  They all start with 362, they all end on 5, 6 or 7.  The 5 is always going to be the first order, the 6 second order and 7 is always is going to be third order and the third order one actually says 'third order or more selective,' so if we actually have a 4th or 5th order selective code,  that 36217 code is going to apply to it.

A "Flawed Rule Of Thumb" To Keep In Mind When Coding Selectivity

Now one of the rules of thumb that will help you code these things out accurately is actually a flawed rule of thumb, but it is one that is going to apply 99.9% of the time.  What I want you to do is to understand the general rule, and I will explain what the exception to the rule, and then kind of put the exception to the rule on the back burner because it is not going to apply hardly ever. 

The flawed rule of thumb that I want you to follow is within each vascular family that the doctor selectively engages we want to have one code and only one code from the top of page #11--the codes ends in 5, 6, or 7.  Make sure that if the doctor goes into one vascular family up into the aorta and goes off into 2 or 3 different vascular families.  If we go into three different vascular families, we know that there are going to be three codes that end in 5, 6 or 7 from the top of page #11.  And the rule of thumb that is going to apply again in 99.9% of the time; it is a flawed rule thumb, but is one that is going to help you tremendously in accurately assigning codes. 

Like I said, in each vascular code we only want to have one of these codes assigned.  We want to make sure it is the highest order selectivity code, so if the doctor goes into two different territories in the same vascular family--one is a third order selective, the other is a second order selective--we are going to want to use the code that ends in a 7, the third order selective code.  That is the right way to bill it and it is also the way to get optimal reimbursement.
 
Now the one exception to this rule.  I kind of have this diagrammed down at the bottom of page #11 and this is going to be really rare.  It is going to be the case where we go in to a patient's extremity artery and we are moving towards the aorta, but we are not actually going into it for these first two studies.  What we do is we go into (you can see that there is an access site on the bottom left hand side of that diagram on page 11) the access site in the patient's right brachial artery, the catheter is moved upstream, so this is one of those retrograde sticks, and we are moving up the flow of blood and we are going selectively into the right vertebral artery and then coming out and going selectively into the right common carotid artery.  This situation is going to be one in which we will actually have two codes that end in a 5, 6 or 7 within the same vascular family and the reason being is that just the way the codes are structured.  The 36215 is each first order branch within a vascular family.  We are coming in retrograde from that patient's right brachial artery.  The second we take a left hand turn to go up into right vertebral, we are actually moving away from the aorta and we are going through a bifurcation and that is going to make us first order selective. 

We do the same thing when we come out of that, we go up into the patient's right common carotid artery.  Again, we are going away from the aorta through one bifurcation--that is another first order selective catheter placement code.  This is a really rare exception.  Typically if the doctor wants to study the patient's carotid and vertebral arteries they are not going to be coming in from that vascular family, they are going to be coming in from a lower extremity artery.  Usually what I see in practices is if the doctor is using a brachial artery stick, what they are doing that for is because the patient has lower extremity peripheral vascular disease and the doctor wants to diagnose those lower extremity arteries, but because the disease is so advanced, they cannot actually thread a guidewire and a catheter through the common iliac arteries in the patient's lower extremity.  So instead of doing that, they come in from the patient's brachial arteries.  That is going to be what you are going to see more times than not.  So this one exception to the rule is one that it is really really rare, but it is an important one to know just so that you do not get kind of thrown off the track the few times that you do see it.  But the rule of thumb that you need to follow is that within each vascular family the doctor selectively engages, make sure you have one of these codes that ends in a 5, 6, or 7, and make sure it is the highest order selectivity code in that vascular family.  It is absolutely critical that you do that because this is where dollar for dollar most of the money gets lost in peripheral vascular billing--it is not understanding that within each vascular family, you are going to have one of those codes ending in 5, 6, or 7. 

Do Not Bill Both Selective And Non-Selective If Only One Access Site Is Used

When we look at billing out for these procedures, another rule of thumb that is always going to apply is that if we only have one access site on the patient, which is one place where the catheter accesses the arterial system, we are only going to have selective or non-selective, we will never have both.  There is no situation in which we should have one access site and be able to bill out a non-selective, whether it be like 36140 (catheter placement in the lower extremity) or 36200 (catheter placement into the aorta) in addition to a selective catheter placement code--one that ends in 5, 6, or 7.  If we go selective from that access site, that selective catheter placement code is going to include everything from the point the catheter makes entry to the patient's body to the point the catheter is at the highest level of selective catheter replacement code.  Any other non-selective stops along that route are going to actually be included in this selective catheter placement code.  And this is something that clearly was contradictory a few years ago, but it is something that has been clarified in writing. 

You can actually look at the bottom of page #12, the top of page #13 and really see where the definitive guidelines were established.  The CPT book clarified it, the administrators of the Correct Coding Initiative edits and CMS clarified it at the bottom of page #12, and also the Society of Interventional Radiology clarified this position.  Rather than read those all to you, I am just going to put those out in your handouts for you, and allow you to read through those things verbatim and see that this is the rule of thumb that, three years ago, it would have been a flawed rule of thumb, but now it is definitive and it is a solid rule of thumb that you can follow: if we have one access site we are only going to be selective or non-selective, but never both at the same time.

A lot of times when we do these peripheral studies, the doctor will actually go into different territories within the same vascular family and to illustrate this, I want you to jump ahead again just one page and then we will jump back to page #13 here.  If you look at the top of page #14, you can see that we have an access site in the patient's lower extremity.  You can see the arrows that are illustrating the path that the catheter took to get up into the patient's right vertebral artery. 

The First Set Of Rules For Billing 36217, Ultimate Catheter Placement

To come up with this 36217, what you basically do it is this:, as soon as we go into the aorta we are at 36200, which is the catheter placement into the patient's aorta; the second we leave the aorta to go into that innominate artery, we are going to be becoming a first order selective catheter placement, which would be a 36215.  So we are going to lose that 36200 because it was en route to the first order catheter placement.  When we come to that bifurcation, we have to decide, do we want to continue to go down the patient's right upper extremity or do we want to go up towards the patient's head up into the common carotid artery?  The doctor chooses to take a left hand turn.  The second he pushes the catheter through that fork in the road, we become a second order selective catheter placement, 36216.  And we are actually going to lose that 36215 first order selective catheter placement, because the second order catheter placement was actually the final destination.  The first order was in route to it. 

At that point, the doctor continues down the patient's right upper extremity, takes a sharp right hand turn to go up into the right vertebral artery.  The second we leave that subclavian artery and go up into the right vertebral artery, we become third order selective--that is going to be code 36217.  That 36217 includes the 36215, 36216, 36200, all these codes are really in route to it.  If we were to stop at six different positions along that pathway that is indicated by the arrows on the top of page 14, it is not going to impact our catheter placement billing--our first box of rules. 

When we start talking about the second box of rules, most of those are going to be separately billable from a diagnostic coding perspective; those are going to be the diagnostic images that are taken, not the catheter placement.  The first box of rules, we are talking about catheter placement.  Anything along the route to get to that 36217 is included in the 36217.  We could stop one time, we could stop 15 times, it does not impact our coding because the 36217 includes everything from the access site to the point that the tip of the catheter is up in the right vertebral artery. 

Going Off The Beaten Path Within The Same Vascular Family

Now one thing that happens occasionally is that the doctor will actually go off of that beaten pathway.  So the arrows that are listed there from the access site up to right vertebral, think of that as the beaten pathway.  When we bill for 36217, we are getting paid for the whole course of the journey along that beaten pathway.  If the doctor, however, were to come out of the right vertebral artery through the two bifurcations that he just traveled and take a right hand turn through that one bifurcation, to go up into the patient's right common carotid artery, the second we go up in that right common carotid artery we are at a position that is not along the beaten pathway.  And that is the position that is separately billable. 

However, this is in the same vascular family as that 36217 that we just billed for.  The 36217 is going to be the one code that ends in a 5, 6 or 7 within this vascular family that we can bill for.  To get paid for the positioning of the catheter up into the right common carotid artery, we actually have to use a different code and that is going to be code that ends in an 8.  So let's flip back to page #13 now.  You will see at the bottom of page #13, we have got codes 36218 and 36248.  These codes say we have already billed for a code that ends in a 5, 6 or 7 within this one vascular family and now we what we are billing for is going off into a different branch of the vascular family that was not in route to the code that we just billed for.  So it is a code that is going to generate additional reimbursement for the doctors.  Again however, the doctor has to clearly indicate that he or she first went to this more selective catheter position and then came back and went to a different branch of the vascular family before you can accurately assign these codes ending in 8.

With Good Documentation, 36218 And 36248 Can Be Billed An Infinite Number Of Times

One of the little things in my head, which is kind of goofy to most normal people, but I think the rules that we have mentioned about one code that ends in a 5, 6 or 7 being billed in each vascular family--these codes that end in an 8, you can actually bill a couple of different times in each vascular family.  So in my mind, I took the 8 and I turned it sideways and we end up with the infinity symbol, so even though the code that ends in 5, 6 or 7 can only be billed one time in each vascular family, these codes that end in 8 can be billed essentially an infinite number of times as long as the documentation reflects that that is the service that was provided. 

Again on page 14, a glance back at these diagrams to get the concept in your head that when we bill that 36217 for the right vertebral artery that pays it for everything along the beaten pathway.  If we are going to bill another catheter placement code in that same vascular family, we have to go off of that beaten pathway and in those cases, we are going to use the code that ends in the infinity symbol, the code that ends in an 8:  36218 above the diaphragm, 36248 below the diaphragm. 

Modifiers Show That Catheter Placements Are In Different Vascular Families

The next thing to keep in mind when we are billing out for these things is that our catheter placement codes are actually CCI edit impacted.  What that means is that if we were to bill a first order catheter placement in one vascular family and a second order catheter placement in another vascular family, there is a set of CCI edits, that says you cannot bill a first order selective catheter placement above the diaphragm and a second order catheter placement above the diaphragm on the same patient for the same day unless you tell us these are in different vascular families.  They are going to automatically assume with their electronic edits that if we bill a first order and a second order that the second order was something that was the final destination and the first order was actually in route to it.  What we need to do to get around the Correct Coding Initiative edits and get our claims paid is to actually indicate on the claim form that these were in two separate vascular families, otherwise they are going to pay the higher order one and deny the lower order one--they are going to actually bundle it into the other one. 

To do this, we have to use one of the Correct Coding Initiative edits modifiers and those are all listed at bottom of page #15 for you.  I tried to make them bold, but they look as if they are actually in a lighter color, they are the LT, RT and the 59.  The LT just says this is in a vascular family on the left side of the patient's body.  The RT says the right side of the patient's body, and the 59 is kind of the generic modifier that says this procedure is separate and different from this other procedure.  The rules that you need to follow are really summarized on the top of page 16 and those are essentially, if you can use the right or left, use them, if not, then fall back on the 59.  Do not just put the 59-modifier on every single claim form because it is generic.  In order to code correctly, we need to be able to code to the ultimate level of specificity and that applies to whether we are doing procedure coding, diagnosis coding or modifier coding.  And if you know that we had a catheter placement in the right vertebral and one in the left vertebral, slapping an LT and an RT on the appropriate codes are going to be much more specific then using a 59 modifier on both of them.  However, if the left and the right modifiers do not work, then you can go ahead and put on the 59.  The reason why you need to do those again is because they are going to assume that your catheter placements are all within the same vascular family unless you tell them with modifiers that that is not the case. 

The Right Way To Use The Modifier 51 For Multiple Cath Placements

On the bottom of page 16, we are in a really goofy transition time when it comes to modifier-51.  The modifier 51 is the multiple procedure modifier.  Historically, we would have to put down any of these codes that are modifier 51 impacted, which are going to be your catheter placement codes, they would want us to put the most expensive one first on the claim form with no modifier on it, and then sequence the second and third one or maybe the fourth one after it and put the 51-modifier after each of those.  What they would do at the claim adjudication point is pay us 100% from the first line item and then 50% for each of the second, third and fourth line items that have the 51 modifier attached onto it.  The concept is that we are going to do a first order catheter placement in one vascular family and a second order in another vascular family, each of those codes that we will be billing for includes the preop and the postop, obtaining vascular access, then also getting all the equipment out of the patient's body and obtaining hemostasis after the procedure.  The 50% reduction basically compensates the government, compensates our payers for that economy of scale, if you will.  They call it a multiple procedure reduction saying that the doctor is doing two procedures in one operative session.  They are actually going to be able to reduce their payment because there is not as much work--there is not twice as much work just because we are doing two different catheter placements. 

The reason why we are in a goofy transition is because Medicare told all payers that they need to adjudicate these claims appropriately regardless of how they are submitted.  Whether we use a 51 modifier, or if we accidentally do not use a 51 modifier, or if we put like a 50 modifier, which says a bilateral catheter placement, which we might use if we do a bilateral renal selective catheter placement--if we put a catheter in the right renal artery and then in the left renal artery selectively, we could actually just use the 50 modifier to say we did a first order catheter placement bilaterally. 

If Payers Require -51, List The Highest Reimbursing Catheter Placement First

What CMS told payers--which I put on the top of page #17 for you, I put the web page where they actually communicated this because you know, all of this stuff that I am giving I want you to feel absolutely secure in applying.  Medicare told carriers to actually apply those multiple procedure reductions regardless.  I have talked with cardiology groups across the country and the majority of the groups that I have been talking with on this specific issue say that their carrier has told them not to put the 51 modifier on it, because it is just bogging down their system.  Most Medicaid agencies however still want a 51 applied and then when we go to private payers, it is just a hodgepodge of findings.  So that is the concept behind the 51 modifier.  If your carrier still requires it or if you have Medicaid that requires it or other payers, you need to put the highest reimbursing catheter placement first and then you sequence the other ones in descending RVU order and put the 51 modifier in the multiple procedures.

What we are going to do now is go through a quick case study and then we are going to take a 10-minute break for questions and please if you have questions, make sure you only ask questions that are specific to catheter placement.  When we move on to the next subject, it is going to be good to answer those questions as they come up in those individual areas. 

The first example that I want to give you just to kind of show you how these different rules of thumb apply, is illustrated on the bottom of page 17.  It is written out like the operative report might reflect.  On the top of page 18, I have actually got a diagram with arrows pointed to the different places that the catheter is selectively positioned.  So you might actually benefit from looking at page 18 as I read the sample operative report for you, so you can see exactly where these arrows came from.  It says there is a right femoral artery access, selective catheter placement--and the keyword here is of course, selective catheter placement--into the right common carotid artery, the right vertebral artery, the left common carotid artery and the left vertebral artery.  There was also a study of the aortic arch performed with a separate injection from the aortic arch position. 

Now when we look at these things, the first thing to bang out is of course the 'separate study' of the aortic arch performed from the aortic arch position.  That position, when we move through the aortic arch, say we do a study at that point and diagnostic--from a catheter placement perspective, it is not going to be billed because we ultimately move the tip of that catheter on to do selective catheter placement.  And the rule of thumb here is that if we go selective from one access site, we cannot bill non-selective for it.  So the last sentence that I had in the operative report really does not impact billing whatsoever, when we talk about this first box rule which is your catheter placement. 

Are Arteries Being Catheterized Above Or Below The Diaphragm?

We will start with the hardest vascular family first.  You can see at the top of page 18 there are four different arrows for the different arteries that were selectively engaged, right vertebral, right common carotid, left common carotid and left vertebral as you look from the left to the right on your diagram.  And the first vascular family is of course the one that houses the right vertebral and the right common carotid.  This is the toughest one because, as you will see, these are both in the same vascular family.  Rule of thumb #1, if we are in the same vascular family, we are only going to have one code that ends in a 5, 6, or 7.  The first thing I like to do and say well all these catheter placements are above the diaphragm, so they are going to be ending in a 15, 16, or 17.  For those of you who need a reference for the diaphragm, just think of that being just above the renal arteries.  So if we are catheterizing the renal arteries below, consider that to be code ending in 45, 46, 47; above that point consider it to be 15, 16, 17. 

These catheter placements which are essentially a four vessel head study are all above the diaphragm, so all go in 15, 16, 17.  The catheter placement into the right vertebral is going to be a third order selective catheter placement.  We determined that by just saying from that aortic arch position we are going to take a right hand turn to go up into the innominate artery and at that point it would become first order selective.  We are going to come to that split in the road and will have to determine do we want to go to the right and travel up toward the patient's head or do we want to go left down towards the patient's right upper extremity?  And the doctor chooses at this point to go left.  At the second we cross through that bifurcation, we become second order selective and that is going to our 36216 code.

Then we are going to take that right hand turn, which is going to be a relatively sharp right hand turn to go up into the right vertebral artery.  The second we engage that right vertebral artery we change from being second order selective and we start to become third order selective, which is 36217.  So kind of keep that 36217 in your head. 

Then we look at what else the doctor did in that same vascular family?  You could see there is another arrow that points to the right common carotid artery.  To get to that position from the aortic arch we are going to take that right hand turn at the innominate and become first order selective 36215.  We come to that split in the road and instead of going left we actually have to go to the right and that is going to be a second order selective as soon as we go through it--36216.  Now within the same vascular family we have got a second order selective and a third order selective.  The code that we are going to actually apply--because we only want to have one code that ends in a 5, 6 or 7 in each vascular family--we going to want to apply that 36217 code because that is the highest order selective catheter placement within this one vascular family. 

Did The Doctor Leave The 'Beaten Pathway'?

Get that picture your head of what the beaten pathway looks like and then you say well, you know what, the doctor went off into the right common carotid artery and that is not along the pathway that we just got reimbursed for with our 36217.  This is where the bell should be going off in you head for that code that ends in the infinity symbol, the 36218 code.  So within this one vascular family we are going to have a 36217 and we also are going to have a 36218 for the right common carotid. 

Then we look at the other vascular families and these are actually much simpler.  The next one over is going to be the left common carotid artery.  When we go from our aortic arch position up into the left common carotid artery, we only have to take one turn so it is going to be 36215 at that point.  The other catheter position is going to be in the left vertebral artery.  To go to that point we have to take a right hand turn out of the aorta and then we are going to take a left hand turn up into the vertebral.  So that is actually a second order because we have to navigate two separate turns.  One is going to be to leave the aorta to go into that vascular family.  The next is going to be take a sharp left hand turn to go up in the left vertebral artery--36216.  So when we look at the diagram such as this and we map it out based on what the operative report tell us we have got 36217, 36218, 36215, and 36216. 

Make Sure The Payer  Knows If Catheter Positions Were In Separate Vascular Families

Then you have got to say Medicare does not trust us or the Correct Coding Initiatives are set up to bundle these services together essentially.  If you look at it you can see that they are going to consider that 36215 to be in route to the 36216 and the 36216 to be in route to the 36217.  They are essentially going to deny those two and pay us just for the 36217 unless we tell them that these three catheter positions were in three separate vascular families, which is indeed the case. 

And then we have got the RT, the LT and the 59, which one can we utilize?  We can put the RT and the LT on basically each one of these codes.  We have the right vertebral, left vertebral--this is on the top of page 19--we put the RT on the code for the right vertebral, which is 36217.  We put the LT on the left vertebral, which is 36216.  Then we also put an RT--that goes with the right common code 36218 and the LT on the left common code 36215.  Now at this point I want to point out that the RT on the 36218 is not 100% necessary because that is not an add-on code.  It is not actually going to be impacted by the CCI edit but it does not hurt put it on there.  It is more specific than leaving it off, and it kind of helps coders kind of map these things out just like that when we start saying LT on the left and RT on the right one--it is not going to really hurt anything.
 
The other thing that may not be necessary is that 59 modifier that we have on the 36215, which is the last line item.  I put that on there because I have seen a lot of claims such as this get denied and the payers come back saying, 'well we know you did a 36215 on the left and you also did a 36216 on the left, (which is the code just above it) but these two might have been in the same vascular family that happened to be on the left hand side.'  So the 59 modifier in this situation will say, 'yes 36215 was on the left.'  The 36216 was on the left but they were separate lefts--they were separate vascular families that happened to be in the left side of patient's body--and putting that on there for those payers who are going to be questioning those claims should help to streamline your process. 

At this point Mandy, I would like to open up to calls for about 10 minute just so people can ask questions about the catheter placement billing.  Again please keep your questions specific to catheter placement.  We are going to talk next on the diagnostic imaging in the interventions.  So Mandy are you there?

Yes sir.  Ladies and gentlemen I would like to remind you that this portion of the teleconference is also being recorded.  If you have a question at this time please press *1 on your touch tone telephone.  If your question has been answered or you wish to remove yourself from the queue please press pound.  Please limit yourself to one question at a time so that everyone may have a chance to participate.  If you have another question you may reenter the queue by pressing *1. 

Q & A Session:

Our first question comes from Billy Hamilton of Cardiac Disease Specialists.  Please state your question.

Question:  Hi, when our peripheral vascular physicians are doing a heart cath for Medicare, a lot of times they try to say that they are doing aortograms with run-offs - that's 75630.  But when I read the report I notice that they are doing a renals and they mentioned there might be mild diffused aortic atherosclerosis in the aorta, and then they put the iliac femorals...Am I correct if there is medical necessity, like hypertension or renal peripheral vascular disease history, to code those as the G0275 and the G0378 rather than 75630 with the 59 modifier, cause it does allow...

Answer:  That is absolutely right.  If the doctors are basically doing non-selective renals, non-selective iliacs, G0275, G0278 are going to be the most appropriate.  One other thing that I have seen happen a handful of times, which really presents a unique scenario and one that there is no efficient way to bill for and get paid for but is one where you have to stand your ground and fight for--is that sometimes that the doctors will be assessing strictly for aortic aneurysm, abdominal aortic aneurysm.  And I have seen a handful reports in which the doctor does a heart cath during the point of pushing the guidewire and the catheter up to do the heart cath they experience abnormal territory in the abdominal aorta and when they come out with their pigtail catheter they will actually position it below the level of the renal arteries, inject the contract and what they are looking at is just the abdominal aorta.  In those situations we have really got a leg to stand on to tell the payer, 'look we did not do a non-selective renal angiography.  We clearly positioned the catheter below the renal arteries.  This should be reimbursed at the code that we would use for a regular abdominal angiogram, which is going to pay us probably four or five times as much money as the G0275.' 

But if your doctor just positions the catheter above the renals and does non-selective renals and then they watch the contrast flow down into the lower extremities, I would agree with you completely, that G0275 and G0278 would be most appropriate.  But be on the lookout for those times when the doctors are truly assessing for abdominal aortic aneurysm as opposed to renal arteries.  When you submit your claim, I would almost guarantee it is going to get denied; but on appeal I can almost guarantee it will get paid.  First level of appeal or second level of appeal.

Question:  One more part of that, this is only for Medicare those G codes right?

Answer:  Yes it is.

Question:  For commercials, and they say that they are doing exactly that.  Would it be okay to put the 75630?

Answer:  Yes it would be.

Question):  Okay.

Answer:  Anybody but Medicare you want to use the 630 code; and the big thing there, which we will talk about next so I do not want to get too much in the depth--but make sure it shows the abdominal plus the lower extremity through the femoral arteries.  You got to have iliac and femoral arteries and we will talk about that next so don't get hung up on that.  But you are absolutely right if it is non-Medicare the doctors are doing abdominal plus the run off then use the 75630 code.

Question:  Okay, an aortic aneurysm is the only reason you can think of where they can go ahead and bill 75625?

Answer:  Right.  If that is all they are assessing for, then that is all you are going to want to be billing for.  Even with Medicare if it is non-selective--the big thing that helps is showing that it is below the renal artery because then they really do not have a leg to stand on to say, 'well this is really non-selective renal angiography.'  If they know you are below the renals, this was an indicated procedure, you illustrated the patient had an aneurysm in their abdominal aorta and here is the follow-up and plan.  That makes it rock solid.

Question:  That is very good.  Thank you very much.

Our next question comes from Susan of Hilton Head Heart.  Please state your question.

Question:  Actually this is Dennis from Hilton Head Heart.  Can you hear me?  We have a question about one of my doctors who does bilateral lower extremity angiogram and it is specifically due to the code of 36140, that non-selective placement.  They have been told in the past--which I have been trying to refute, so I am glad we did come to this particular audio conference--it has been told to them by some that even if it is not Medicare, although it is AMA's and CMS' positions, if it is a commercial carrier then they can go ahead and bill for that 36140?

Answer:  You are talking at that they do a selective study?

Comment:  Correct.

Answer:  You know I do not think it is safe move at all because it is something that is established in the CPT book, which applies to everybody.  The fact that CMS has clarified it,  the Correct Coding Initiative and the Society of Interventional Radiology--I mean those clarifications are truly specific to Medicare but if you really look at what rules and guidelines non-Medicare payers follow, they are really basing it on what Medicare follows and the one reference about what is in the CPT book, which is back on the bottom of page 12, it says 'selective vascular catheterization should be coded to include introduction and all lesser order selective catheterization used in the approach.' 

So if we are going into the patient's right lower extremity up over the horn into the left lower extremity, that 36140 was in the approach to the selective catheter placement on the opposite leg.  The CPT book reference is something that applies to every single person and the two other quotes that I put on the bottom of page 12 and top of page 13 are really authoritative sources that are saying, 'this is really how these codes apply.'  Of course they aren't government references but that is what most payers are basing their policies on when you really get down to the nitty gritty of it. 

I would imagine if you were to bill 36140 with selective catheter placement, you would be able to get some payers to reimburse it, but that is just because they do not understand these rules.  Maybe these people are not on the conference call right now, it does not mean that these people aren't going to learn these rules in the near future and then come back and retrospectively look at what their payment data has been and ask for a refund back.  So it is really something that I think you need to look at the CPT book definitions, how the codes are intended to be applied, the fact that the leading references that are typically utilized for these areas of billing have all been on the same page and saying that 36140 should not be billed.  I personally will not ever code it myself.  It is too risky and they can easily come back and identify which claims were paid inappropriately and ask for that money back.

Comment:  Al right, thanks for the input.

The next question comes from Debby of Carolina Vascular Surgeons.  Please state your question.

Question:  My question is I just want a little bit more clarification on when do we use the 51 modifier and when do not we use it?  I know Medicaid has to have it but where should we use or not?

Answer:  I would say, are you in North Carolina?

Comment:  Yes.

Answer:  North Carolina has said not to use the 51 modifier and I have gotten that not directly from them but from some clients that are in North Carolina.  So you might double check on that but what I have heard from people is that North Carolina Cigna and Medicare does not want the 51 applied and a good chunk of the other carriers has offered the same thing.  So for Medicare, it may not be necessary and then with your private payers, what I found is that for some of those they never wanted the 51 to be applied in the first place.  So with Medicare you do not need to put it on.  You do not need to sequence claims either.  You do not need to put the highest RVU first in the sequence and then the other ones.

With your non-Medicaid patients it is going to be up to the individual payers and might be worth your time to write one form letter and send it off to your top 5 or 6 payers and say, 'here is the Medicare web page where they have told carriers not to use this 51.  Do you want us to file using this guidance or do you have a different one?' And the web page for that CMS guidance is in your handbook so you can easily access that, print it out and put together one form letter and zip it off to your top 5 or 6 payers.  See what they come back with.  That will give you the definitive answer.

Comment:  OK.  Thanks.

Answer:  You are welcome. 

The last question comes from Adrian Lee of Mount Carmel Regional Medical Center.  Please state your question.

Question:  My question goes back to, you know when you were talking about doing aortogram during cardiac catheterization.  If the physician has a very specific reason, say that the person had like an aortic fem bypass or something and is having symptoms of claudication and he does an abdominal aortogram and then actually does a run-off all the way down to the foot--do you still have to use the G code, the G0278 or can you go ahead and code like a  75630 with the 59 modifier?

Answer:  The 75630.  There is not actually a CCI edit that is going to prevent you from doing that but there is one with the 625.  I think it is going to be one of those cases in which you are going to have to deal specifically with the payer on a patient by patient basis, even with the abdominal aortic aneurysm, which is just as clear a case as could be, you are still going to have to deal with your payers.  So I think for the amount of times that you do those at the time of a heart cath, there is a lot on your side to say you need to bill in a different way so that you get more than the 14$ for each of the G0275, G0278. But you are really going a need to make your case and that is: 'we are not doing just G0275; G0275 is just non-selective renal.  We are looking at the abdominal aorta, we are looking at this bypass graft that is sewn into place on it, we are looking at the full lower extremity distribution, not just the iliac arteries.'  You should be able to have a lot of success with that but it is something that you are not going to be able to do just by putting down a 59 modifier on your claim.  I think that you going to have to submit the medical record.  It is definitely worth your time because you are going to be more than quadruple your reimbursement for those studies.

Question:  Okay, so as long as you have a documentation to support that.

Answer:  Exactly, but it is just going to be on a patient by patient basis and then, as you know if you have been dealing with payers for very long, they are not always going to be consistent but you should have a good leg to stand on.  If they do not agree with you, go to the appeals process.  I know with Medicare in nine out of ten claims, if you get to that second level of appeal they pay completely.  You know the people that are processing your claims are the first level and do not have any clinical background most of the time and when you go through the appeal process, you actually get to talk with a registered nurse or maybe a physician assistant who actually understands what you are talking about and they pay those claims 9 times out of 10.  So do not accept your denials if you have a leg to stand on--definitely fight for it.

Comment:  Okay Thank you.

You are welcome.  Let's see ... we are back on page number 19 now and we are going to shift gears and stop talking about strictly catheter placement, and start talking about using diagnostic studies, which we have talked about just a little bit up to this point.  When we talk about the diagnostic studies we are mainly talking about the radiologic supervision and interpretation.  We are looking positioning these catheters at the different points in the patient's body, injecting a contrast agent, that contrast agent is going to the flood the downstream vessel and allow us to kind of visualize it from the outside with a moving x-ray camera.  We are going to take basically a movie of that contrast agent flooding the vessels and then flowing off downstream.

Catheter Placement Rules  And S&I Rules Do Not Correlate

Imaging:  Looking at those images that are created is separately billable.  We are going to be looking at those images, we are going to be watching them run-off as the doctor interprets the images and makes a report on them.  That is what the S&I component is.  Usually when we do a peripheral imaging study we get to bill separately for it and this is totally in conflict with the catheter placement billing rules we just talked about, and that is why I am kind of presenting them to you as a separate sets of rules.  They are not the same thing.  We have got one set of rules that is specific to catheter placement and another set of rules that is specific to S&Is.  They do not correlate whatsoever--do not try to make them reconcile or else you are going to go absolutely nuts. 

The few exceptions that exist to not being able to bill for any given injection and imaging--one is the selective renal studies.  When we do a selective renal study, whether it be a unilateral or a bilateral study, those code definitions actually say that they include a flush aortogram.  And the reason why they include that is because when the doctor goes up into the patient's abdominal aorta to selectively engage the renal arteries, they do not actually know where the renal arteries are in relation to the tip of their catheter so they cannot navigate that territory without taking a road map picture.  What they will do is they will position at the tip of the catheter at a point they know is above the renal arteries, inject a small--I think of it as like a little puff of contrast, it is just a small amount of it.  That contrast mostly is going to flow downstream through the aorta.  It is going to flush out of the system, that is why they call it a  flush aortogram; but some of this going to actually show where the opening of the renal arteries are because some of the contrast is going to get carried into them.  That is going to tell the doctor exactly where the tip of his catheter is in relation to the opening of the left and the right renal arteries, and also if the patient has multiple left to right renal arteries which are called accessory arteries.  That is going to give the doctor the road map that is necessary to go in and selectively engage his arteries.  That flush aortogram, that guiding shot (which is what a lot of doctors will call it) is not going to be separately billable. 

Guiding Shots Are Included In Selective Catheterization And Artery Imaging

The same is true when we are talking about an aortic arch study.  If the doctor is going to go up and do one of these four vessels head studies like the one that we just talked about in our last case study here, they are going to be doing a lot of times, an injection--a small little contrast injection at the aortic arch just so that they can see exactly where those three vascular families branch off from the aorta and also to see if the patient has normal arch anatomy.  If the doctor is doing that shot just to localize the opening of those three vascular families, that is a guiding shot and is not going to be separately reimbursed or separately billable.  If however the doctor is doing that study for truly diagnostic purposes, the patient may have aortic arch disease or they might have stenosis in the opening of those vascular families, in those cases we can bill for it.  But if it is truly a guiding shot--like the flush aortogram would be considered a guiding shot--we do not get to bill separately for it, it is something that is included in the work of this selective catheterization and the imaging of those arteries selectively.  Other than that, we are typically going to be able to bill for the different studies we do. 

Now the first set of studies that we will talk about is the aortography studies which are at the bottom of page number 20.  The ones on this page that you are going to be using are basically everything but the first one.  The first one is something that you might want to go ahead and just cross out of your CPT book because this is one where the doctor times the camera to take a still shot of the patient's thoracic aorta so that they just get one picture of it.  Typically what doctors will do is what they call a serialography, which is taking a series of pictures, formatting them so that it looks like a moving picture--like a movie. And you can see that 75600 says aortography of the thoracic aorta without serialography.  I do not really know of any labs that actually use that technology.  Most of the time when the doctors are in there doing injection of contrast they are going to actually do moving pictures of it and that would include the serialography codes and we would use something else on that page. 

The other codes on there you could be using quite frequently include the 75605 that is thoracic aortography, 75625 is abdominal aortography, 75630 is abdominal aortography plus run-off, and then the 75650 is going to be the diagnostic arch study which if we are doing it for diagnostic purposes as opposed to a guiding shot that 75650 can be billed. 

Coders Need To Understand When To Use 75625 Versus 75630

Now the two codes that create confusion here are 75625 and 75630.  These codes--it is very important to get the distinction down between these two because they somewhat overlap each other.  It is very easy to bill these things inappropriately and in auditing literally thousands of these reports over the last four or five years, this is one of the places where I see coders making mistakes a lot.  So it is really important to understand these distinctions.

One of the places you can go to get really clear on the distinction is at www.cardiologycoalition.com.  On that web page you can actually find an article that is dedicated specifically to these different studies and how they correlate with each other and how the code should be applied.  You can also take a proficiency test on that web page which is absolutely free and it will go through and you can have each of your different coders, even your physicians, take this test and it will make sure that you understand the distinction between these two codes and the other codes that apply when the studies are performed frequently. 

When you take that proficiency test, once you get the correct answers entered on the web page it will actually generate a certificate for you that will give you three continuing education units that are AAPC pre-approved.  So it is something that is totally free, gets you three free CEU units and the big important thing is that it will help you understand without any shadow of a doubt, the difference between 75625 and 75630. 

In a nutshell though, 75625 is when we are looking at just the abdominal aorta and nothing else. This is going to include from just above the renal arteries all the way down through that bifurcation.  The bifurcation is where the aorta splits and carries blood down both of the patient's lower extremities.  Right after that split is what is called a common iliac artery.  The common iliac arteries are going to have a bifurcation shortly into them where it splits into the internal iliac and external iliac.  Then the external iliac actually converts into the femoral artery at the point it crosses the patient's femoral bone.  The code 75625 includes looking at the abdominal aorta plus the first portion of that bifurcation in the lower extremities. 

75630 Includes Lower Extremities Down To The Iliac And Femoral Arteries On Both Sides

The 75630 includes that same study but also the run-off down through at least the femoral artery.  If you look at the definition of 75630 it says 'abdominal plus bilateral iliofemoral lower extremity.'  So the iliofemoral means we are looking at the iliac arteries and we are also looking at the femoral arteries on both sides of the patient's lower extremities.  So until we actually have documentation saying that the doctor imaged the abdominal aorta plus the common iliac down through the femoral arteries, we should be billing 75625.  Once a doctor mentions the lower extremities down to the iliac and femoral arteries on both sides then we have a green light to go ahead and bill the 75630.  It is a really important distinction to make because those two codes overlap so much.  That is really a fine line that distinguishes the two of them but that is what the fine line is, that is where the line in the sand is--as soon as the doctor mentions anything in the common femoral or below on both sides that is going to give you the green light to bill the 75630 as opposed to the 75625.

On the next page on the top of page #21, we have got the carotid study codes and what you see here is that we have got three different set of codes, and within each set of codes we have unilateral and bilateral.  These are commonly referenced at the external carotid, internal carotid and common carotid. 

Do Not Use 75665, 75671 Unless Doctor Documents Looking At Cerebral Distribution

Now one of the things to make note of is that the internal carotid codes: 75665, 75671 are actually more than just the internal carotid.  When we are talking about the carotid arteries we have the common carotid that comes to a point and then splits into the internal and external carotids.  The codes 75665, 75671 are actually the internal carotids and the cerebral distribution.  You could see that definition code says 'carotid, cerebral unilateral versus bilateral.'  The cerebral distribution just means when those internal carotid arteries start branching off into the brain--that is what we consider to be the cerebral distribution.  This is the territory that the doctors are typically going to be looking at, but a lot of times they just don't document it.  The doctors might say, 'we went off and did carotid angiography, the common carotid looked absolutely fine and the bifurcation looks normal' and that is all they will say.  And based on just that, you really should only be billing for the common carotid study codes, because of two things.  One is that the internal carotid code, the 75665, 75671 codes, they really should be documenting the internal carotid arteries and also their distributions, which is going to be the cerebral area. 

Now there is no guideline that says exactly how specific they have to get about the cerebral distribution, but they might say that if there are any abnormalities or if it looks like a normal patent cerebral distribution, that is going to give you the green light to go ahead and bill for that.  The one code that should not be billed nearly as frequently as it is in my mind are the first set of codes on there, the external carotids.  The reason why is that if you look at the code definitions here, 75660, 75662, which are just unilateral versus bilateral upper external carotid arteries, they actually include the word selective in those codes definitions.  And this is one of those concepts that escapes some beginning coders in peripheral billing.  If the S&I code includes the word 'selective' in it, the catheter tip has to have been selectively engaged inside of the artery in order to bill for it.

A lot of doctors are not comfortable selectively engaging the external carotid arteries just because they are so high up in the patient's neck area that it is a relatively risky procedure.  So a lot of doctors will choose to position the catheter into the common carotid arteries, inject the contrast, watch the contrast float up the common carotid artery into the internal and external and then their distribution.  Based on that, we are able to go ahead and bill for both the internal and the common carotid studies codes--but not the external because we are not actually advancing the catheter up into the external carotid artery. 

In The CPT Book, Highlight The Word 'Selective' In S&I Code Definitions

One of the things you can do to help advance your coding specificity and accuracy is to go through your CPT book, this section of it anyway, and actually highlight those words 'selective' in the definition of those S&I codes.  That is one of things I did that really helped me get my feet firmly planted in coding & billing for these services--to really make a whole lot of notes in these sections of the CPT book because without doing that, it is easy to get lost.  These codes are not laid out in a logical format and they throw in the word 'selective' sporadically it seems like.  But it is important to understand that the external carotid arteries have to be selectively engaged before you can bill for either unilateral or bilateral external carotid angiography. 

The same holds true for your renal artery study codes, which are at bottom of page number 21: 75722 is unilateral, 75724 is bilateral renal angiography.  The word selective is there so those arteries have to be selectively engaged.  You can see the parenthetical note in each of these that says these codes include flush aortogram--that is going to be that guiding shot that the doctor does to position the catheter above the renal arteries, inject a small little puff of contrast which is going to show them exactly where they are in relation to the renal arteries and will now allow them to selectively engage.  That little puff of contrast is included in 75722, 75724 code. 

The extremity study codes 75710, which is unilateral; 75716, which is bilateral - these codes are really catch-all codes in the fact that they do not say selective, so these codes can be applied whether for selective imaging or non-selective imaging.  And they also do not say whether it is upper extremity or lower extremity.  So we are going to use the same code to essentially bill for upper extremity studies and lower extremity studies whether we are selectively inside of them or not. 

When To Bill Extremity Arteries 75710 Versus 75716

This is another area that is really important to understand, which is on that web page that I mentioned--the article that really fully addresses the abdominal aortography studies.  It really clarifies the distinction between 75710, 75716 and also tests your coding staff to make sure that they understand how to apply those.

The concept behind these being applicable, whether selective or non-selective: in the case where we have the catheter positioned in the lower abdominal aorta, we inject the contrast and watch it flow down both of the lower extremities.  In that case we have got 75716 because we are not selectively imaging both of the lower extremities. 

Same patient, let's say the doctor placed the catheter into the common iliac arteries on both sides, he does two separate injections, two separate diagnostic studies, we are still going to be billing 75716 because that code says it applies whether the study is done selectively or non-selectively, and when you look back and say what did the doctor really look at?  Again he is still looking at both of the lower extremities so code 75716 will apply.  From a single injection at the lower abdominal aorta just above what they aortoiliac bifurcation; or if the catheter is actually positioned inside of the both of the lower extremities for two separate injections, 75716 applies in both cases. 

The other specific arteries are listed at the top of page 22 and again these are listed out.  We have got brachial, vertebral, visceral arteries and internal mammary arteries.  These codes are all just specific to the different arteries that are recognized.  We also want to make sure to take note of the 75736, which is going to be your pelvic angiograph.  That catheter placement has to be selective or supraselective, which just means they are more selective than regular selective, basically.  If you do not have selective catheter placement of those arteries, we cannot bill for that S&I code. 

Another code that escapes billers and physicians a lot is a 75774 code.  This is a code that is used when we do one study of an area, the complete study of let's say the lower extremity, and the doctor want to do another diagnostic study further down the patient's legs.  We might have a patient with really extensive peripheral disease in the right lower extremity and the doctor does a diagnostic study of that lower extremity from a point high up in the patient's leg.  He or she looks at it and gets all of the diagnostic images taken but wants to take another diagnostic study from a different point in that lower extremity.  When the doctor bills out the first basic study it is going to be 75710, which would be a unilateral lower extremity study basically.

When the doctor moves the catheter to another position more downstream in that patient's leg and does a follow-up study looking at a more specific location of the lower extremit--like down in the knee or calf area even, that additional study is going to be separately billable with code 75774.  In some peripheral study reports, you might actually be billing this code 2, 3, 4 times because the doctor may do a whole lot of different studies and when you look at them they are really in the same vascular family but we have already billed for the basic study and 75774 comes into play after the fact.  This code pays somewhat around 30$ right now, for each of these that we do.  So, if you have a doctor that does 2 or 3 of these in any given peripheral operative session and you do not accurately assign the 75774, you are losing close to 100$ in reimbursement and that is just for your Medicare patients.  So it is important to understand how that 75774 code applies. That is something that we will talk about in a little bit more detail here as we go through a couple of case studies. 

The 51 Modifier Does Not Apply To Any Of The S&I Codes  For PV Studies.

The modifiers that apply to these services at the top of page 23--the modifier 51 does not apply regardless of who your payer is in this case, regardless of what your specific payers are requiring.  The 51 concept just does not apply to S&I codes.  However the 26 modifier does and that just says, 'our doctor is doing this radiologic service, they are interpreting and generating a report but we are not actually providing the equipment that was utilized.  We are providing the professional component only.' 

Quickly we will go through a couple of examples at the bottom of page 23 and again if you look at page number 24 you can see a diagram that shows you where the catheter is being placed and where the diagnostic studies are being performed at. 

Diagnostic Study Case Example #1

We have a left femoral access site, which when you look at the top of page 24 you can see a kind of puncture mark there on the patient's left femoral artery.  The catheter is placed above the renal arteries.  Abdominal arteriogram is performed.  The catheter is lowered to the aortic bifurcation and bilateral lower extremity angiograms are performed.  At this point, we need to push back and think about the whole concept that I presented first off, which was two separate boxes of rules that we are dealing with. 

The first box of the rules is catheter placement.  When we make access into the patient's left femoral artery, we are actually going to be in a non-selective position.  At that point, it is 36140.  However ,we move the catheter up to the point that it actually goes into the abdominal aorta and at that point, we will lose our 36140 and become 36200 which is catheter placement in the abdominal aorta.  We move that catheter up above the renal arteries, do our diagnostic study and then we come out.  So for our first set of rules, the only code that we have to apply is 36200 because we went from any access into the aorta, any position in the aorta is going to be 36200.

The other codes that we have to apply are going to be specific to the S&I.  What we did at the point where we were above the renal arteries is we did one diagnostic injection and looked just at the abdominal aorta, that is going to be 75625; and the reason why we will use that again is because we did not document down to the iliac and femoral arteries on both sides.  After we did that one study, we moved the catheter down to the point that it was just above the aortoiliac bifurcation, did a single injection and it flowed down both of the patient's lower extremities.  That is going to be a bilateral lower extremity study, code 75716.  So we look at the code on the top page 25 the ones that apply here--we have got 36200 for cath placement, 75625 for the abdominal study, 75716 for the bilateral lower extremity study.
 
Even though we look at the abdominal aorta plus the lower extremities all the way down towards the patient's toes, we do not bill 75630 primarily because the abdominal study was separate from the lower extremity studies in that we had catheter movement after the first study was conducted and before the second one was conducted.
Diagnostic Study Case Example #2

On the bottom of page 25 we have another case study, which is going to further illustrate how these codes kind of correlate with each other.  We have left common femoral access.  The catheter gets positioned above the renal arteries, multiple images are taken of the abdominal aorta with run-off down to below the superficial femoral artery on both sides.  There is no catheter movement between the abdominal study and the lower extremity, so it is all one in one position.
 
First box of rules says that we go into the patient's lower extremity, we advance that catheter up above the renal arteries and again we are at 36200.  The study is conducted from that point and the catheter gets withdrawn.  36200 is going to be the only code we need to apply from our first box of rules. 

Second box of rules is specific to the diagnostic studies.  At the point that we were above those renal arteries, we injected the contrast.  We watched that contrast flow all the way down to below the superficial femoral arteries which is below the iliac and the femoral arteries on both sides.  That is going to be code 75630.  Even though we looked at basically the same area that we looked at in the case study we just covered, we did it all from one catheter position so we going to consider it to be all one study.  When we look and say what study did we do from this one position, what code is most applicable, it is going to be 75630.  So the codes we apply are at the top of page 27, 36200, no modifiers are necessary because we only have one catheter placement, nothing else is being billed that is impacted by CCI; and then we put a 26 modifier on the 75630 because we are providing just the professional component.

Diagnostic Study Case Example #3

One more case study we will go through quickly before we talk about the next set of rules and that is going to be the interventional rules.  But example number four on the bottom of the page number 27--catheter access in the left common femoral artery and again on page 28 you can see the diagram where we are accessing and where we are going through here.  The catheter gets positioned above the renal arteries for the first injection, which is to assess the abdominal aorta.  The catheter is then repositioned to the aortoiliac bifurcation for the second injection which helps to visualize both of the lower extremities. After the initial lower extremity imaging is completed, additional filming is performed and then the catheter selectively placed into the right external iliac--and it is important to note that this is on the contralateral side.  So we are going into the aorta and then we are leaving the aortic and going into a different vascular family than the one we came in on, the other lower extremity basically.  Imaging is completed of that leg in more detail. 

So when we look at box of rules number 1 on page number 28, you can see we have access to the patient's left lower extremity.  We first moved the catheter up above the renal arteries and did a study there.  The second we go into the aorta, we lose our 36140 which would had been our access into that patient's left lower extremity.  We cross into aorta and we become 36200, then we drop that catheter down to above the aortoiliac bifurcation.  We do another study.  We are still at 36200 at that point because at any point in the aorta, we are going to be 36200 regardless how many times we stop.  At that point however, we move the catheter from the aorta into the right lower extremity, which is on the contralateral side.  The second we leave the aorta, we lose our 36200, we become 1st order selective, which is going to be 36245.  We keep moving down that lower extremity and we are going to come to that point where there is a bifurcation and the doctor has to choose, do I want to go to the right and continue down the patient's leg or do I want to go the left into the internal iliac selectively?  What the doctor chooses to do is go the right and continue down into the patient's lower extremity.
 
At that point, we are going to change from being 1st order selective, that code ends in a 5 to becoming 2nd order selective, which is a code ends in a 6, 36246.  For our first box of rules that is all that we are going to have to apply--36246 for that catheter placement in the aorta, the access site, all that gets bundled into the second order selective catheter placement code that is on the opposite leg where the access site was.

Our second box of rules: we placed the catheter above the renal arteries and did an abdominal only study--that is going to be 75625--then we move the catheter down to that aortoiliac bifurcation and did bilateral lower extremity studies, that is going to be billed separately to 75716.  Then we moved the catheter, after we did that basic study of all four extremities, we moved the catheter to a different selective position and we did another study of the right lower extremity--that is where that 75774 code comes in to play. 

So in a nutshell, before you bill your 75774, you have to jump through a couple of hoops.  The first hoop is you have to have already done a diagnostic study of that area and billed for it with a different code, which is going to be like 75716.  After you do that, you move to a different selective position and do another diagnostic study in that same area--that is when 75774 comes into play.  So we met all those requirements and that is the total we get to bill.  We look at our claim form, again on the top of page 29, no modifier 51 is necessary.  What we end up having here is 36246 for catheter placement and then our three diagnostic studies that we illustrated.  In each of those you are going to have a 26 modifier attached because we are providing just the professional component. 

Rules For Interventional Codes, Cath Placement, Diagnostic Imaging Cannot Be Combined

The next set of rules is really the most simple set of rules out there as far as understanding how to apply the code.  So most of the worrying that you have to do today, the hard part is pretty much done.  When we talk about these peripheral studies, it is important, again just to reiterate keep the sets of rule separate--catheter placement is one set of rules, diagnostic imaging is another set of rules.  Do not try to combine the two because you are just going to lose money in the process and you are going to drive yourself crazy. 

When we look at the third set of rules, which is interventional, it is important to understand that the interventional codes are unique from the first two sets of rules.  Again do not try to correlate the two.  You can put them all in the same claim form, but they do not necessarily reconcile with each other.  When we code for interventional procedures, one thing you have to do is separate carotid and vertebral interventions from other interventions in the peripheral system. 

So the first set of rules here I am going to talk about are things that are outside of the carotid and vertebral artery.  First we have got angioplasty, PTA--percutaneous transluminal angioplasty, it is very similar to PTCA, which is percutaneous transluminal coronary angioplasty.  But it is not in the coronary arteries so they have to get rid of that C so it is just PTA. 

Don't Forget To Include The Appropriate S&I Code With The Interventional Code

Whenever we bill an intervention outside the carotid arteries or the vertebral arteries, one rule of thumb that you can follow is you are always going to have one code that says, 'this is the interventional that we did' and you are also going to have another code that  says, 'this is the imaging of that intervention'.  These codes go hand in hand, lock step.  They are always going to be married together.  If you put down an interventional code without the appropriate imaging code, the appropriate S&I code, you are losing money.  Make sure that whenever you do an intervention in the peripheral system, you always have an S&I code that goes with it.

With our angioplasty codes, our PTA codes, you can see that we have got one list of codes on the left hand side at the bottom of page 30 here and we have got basically the different arteries that are recognized to have procedures performed in.  It can be a peroneal trunk and branches, renal and visceral arteries, aortic--each of these has a different procedural code.  If we were to go in and do interventions in two of these different arteries, like let's say we do angioplasty in the right external iliac artery and we did an angioplasty in the left external iliac artery, we would actually bill that 35473 code two separate times.  So these codes are all per vessel, they are not like coronary arteries in which we have got three recognized coronary arteries, if we go off in a different branch of the coronary arteries and do multiple interventions, we still can only bill for one intervention. 

In the peripheral, if it is in a separate vessel, we get to bill separately for it and the rule that you really need to follow there is if the vessels are separated by a bifurcation that means it is going to be absolutely safe to bill separately for them.  So you just need to look at your diagrams and see where the interventions are performed.  If they are in separate vessels, you need to bill separately of each of those. 

With each of these interventions that we do, we are also going to be billing for the appropriate radiologic supervision and interpretation code.  So if we do two iliac angioplasties we are going to have 35473 listed once and then we are also going to be putting on a 75962 on the first one and a 75964 on the second one. 

As you can see these, the imaging codes that go with the angioplasties, they have a base code and an each additional vessel code, very similar to our carotid intervention code.  We have one code that says that this is the first one that we do and we have another code that says this is each additional vessel.  So if we actually do three iliac angioplasties, which might be one in the left common iliac, one in the right common iliac, one in the left common iliac, we would actually have one at the base S&I code 35962; and then two of each additional vessel codes 75964 and each of those would have to get paired up with 35473 for each of the interventions.  You can see that these codes are not that hard to apply but they are totally different than what we might bill if we were doing a coronary intervention.  That's where all the confusion comes in.  We think that because the doctor is using the same equipment, the procedures sound very similar when you listen to how the doctor documents them, it is the same disease, same cath lab, we start thinking that the codes have to be the same but they are really not.  Once you get over that hurdle, then you separate them out into the three separate boxes of rules and it really makes a small little anthill out of a mountain of peripheral vascular coding and it makes your job a lot easier and helps you to get full reimbursement. 

Renal/Visceral Codes May Create Confusion

At the top of page 31, we have the atherectomy codes--very similar to the angioplasty codes in that we have procedural codes, we have S&I codes.  Of course they start changing around the logic on us.  If you look at the S&I codes that go with angioplasty on the bottom of page 30, you will see that renal and visceral codes are lumped together as far as the imaging.  When we get to the top of page 31, you can see they break the renal and visceral out separately on the imaging but they keep them together on the intervention itself--which is just something that I think creates confusion.  There is really no logic behind it whatsoever but this is the how the codes are set up.

You also see that renal imaging code--you have got 75994--and that is going to apply to any renal atherectomy that you do.  So if you do two renal arthrectomies, you actually bill 75994 twice.  There is no base code and each additional vessel code--even though for every other peripheral vessel there is, and they stick to that concept.  So, it is really just matter of the fact that these codes have evolved over such a long period of time.  Nobody has taken the effort to make the coding for these simple and the code structure uniform in any measure so this is just one of many variations.

When you look at the next slide on the bottom of page of 31, you can see that they switch around even more when we start doing stent placement in that for the S&I code, there is only one of those.  Whether we do one S&I or three S&Is, we are still going to bill 75960 for each one of those--but they actually give us the base code and then each additional vessel code for the stent placement.  So we will have 37205 for the first stent that we placed, 37206 for each additional stent that we placed in the peripheral system.  One of the things that the government and individual payers and individual carriers are really ratcheting down on is this longstanding guidance that has been out there that says if you do a failed angioplasty and then you proceed on to place a stent, you should actually bill for the angioplasty and the stent even though you are addressing the same lesion.  That guidance is still applicable in some cases but not the majority of cases.  In order to bill that safely you really need to look and see what your individual carrier and individual payer policies are.  What I have done is that I have looked through every single Medicare carrier in the country and identified what their policies are.  Of course, some of them don't have policies, which is typical.  But the ones that do have a policy, there is a kind of smorgasbord about what their guidelines are. 

Angioplasty As A Viable Primary Intervention

First off, they say that if the angioplasty is done and you want to be billing for it, it has to be the primary intention of the doctor to do angioplasty--which means the doctor's true intention is to just go in and fix this specific lesion with a balloon and not proceed on to stent placement.  This is a huge hurdle to come over because a lot of times the doctors know that they are going in to place a stent.  So in those cases where the doctor knows he is going to go in and place a stent--which gets us into this concept what the doctor's 'intent' is and how that needs to be documented--but if the doctor's intent is to place the stent, we should not be billing for an angioplasty no matter how the report is documented out.

One of the other things that they are starting to ratchet down on at a nationwide level and also at the individual carrier level is when it is considered inappropriate for the doctor to consider angioplasty as a viable primary intervention?  In looking at all the policies that are out there, I have got a listing of what they consider to be not viable and these are going to be lesions that have significant calcification, eccentricity, extrinsic compression, propensity for significant recoil. 

One of things is they have specifically said in a lot of these policies is that if it is an ostial renal lesion, you should never bill or never consider angioplasty to be a viable primary intervention.  This is because these lesions are very elastic and when you go in to do an angioplasty of an ostial renal lesion and then pull the balloon out, in virtually all the cases, that lesion is going to automatically go back to the shape it was, thereby necessitating stent placement. 

When we have patients with fibromuscular dysplasia of the renal arteries however, in those cases a lot of times angioplasty will be a viable primary intervention can be billed separately even if it is a failed intervention that ultimately leads on to a stent placement.  But the majority of renal lesions are going to be those ostial renal lesions because that is where this low-density cholesterol gets deposited and the majority of these patients have renal angioplasty and that is where the intervention is going to be performed.  So one of the things that they are starting to say is 'even if the doctor documents his or her intent, if it is one of these types of lesion, we do not believe him/her or we are not going to consider it to be viable.'  And if the doctor goes on to do stent placement, they should only bill stent placement. 

Proving That The Stent Or The Angioplasty Was Suboptimal 

The next hurdle is to prove that the stent or the angioplasty was suboptimal.  To do that we need to show that there is a 30% or greater stenosis after the angioplasty or that there is a greater than or equal to 5 mmHg residual gradient across the lesion, which just means that after the doctor does the angioplasty, there is still a significant barrier to blood flow there that is going to necessitate stent placement.  If we jump through all these hoops, meaning the doctor's intention is truly to do a angioplasty, and it is not one of those lesions that your individual carrier or payers say angioplasty is not a viable primary intervention for, and then the doctor's documentation shows that the angioplasty was suboptimal based on these specific criteria, and then the doctor decides to go ahead and place a stent--then in those cases only, we can bill for angioplasty plus the stent to address the same exact lesion. 

Pre-Dilatation Of A Lesion Is Not Separately Billable

Now if the doctor documents that that angioplasty is really just pre-dilatation of a lesion, that is not separately billable.  Pre-dilatation just means that we are going in, trying to open up the arteries to make a nice place for the stent to be deployed in and that cannot be considered a primary intervention.
 
We will go through another example or two here to show you how these different codes kind of apply to each other and again on the top of page 33, you have got a diagram to look at.  You have got left common femoral access--the top diagram basically shows where the procedure is being done and the bottom diagram shows you the codes assigned to the different places where it is appropriate. 

Left common femoral access.  We do an abdominal aortogram.  The catheter gets repositioned in the lower abdominal aorta where bilateral extremity angiography is done.  Selective catheter placement into the right external iliac, so this is going to be in the contralateral side, and it is going to be a selective catheter placement.  Angiogram is performed there, the lesion is pre-dilated and a stent is successfully deployed in the right external iliac artery.  The fact that the report says that it was pre-dilated is going to basically throw out the concept of being able to bill separately for the angioplasty and the stent placement.

So we look at our first box of rules, catheter placement only.  This is where you really need to push yourself away from it--even though you are chomping at the bit to slap codes down.  Under the first box of rules, where did the catheter go?  When we made our access we are technically at a 36140.  The second we cross into that abdominal aorta, we become 36200, we go up above the renal arteries to do our first study and we are still 36200; we come down to above the bifurcation and we are still 36200.  At that point, we decide to go into the right lower extremity, the second the catheter leaves the aorta and goes into that right lower extremity, we become first order selective.  Then we come to the split in the road where the doctor has to say, do I want to go the right and continue down the patient's leg or do I want to go to the left into the internal iliac artery?  This doctor chooses to go to the right and the second he crosses through that bifurcation it becomes second order selective and then the catheter gets withdrawn after that point.  This is going to be 36246, which is second order selective catheter placement. 

Second box of rules is the diagnostic imaging that is conducted.  We are going to forget about the intervention--just look at the diagnostic portion of this procedure.  When we have had the catheter up above the renal arteries, we do an abdominal study only, that's our 75625 code.  The catheter gets lowered down to the aortoiliac bifurcation and a bilateral lower extremity study is done and that's 75716, which is a bilateral lower extremity study.  It does not say selective, it does not say non-selective, so it does not matter.  At that point, after we do our basic study of both lower extremities, the doctor moves the catheter selectively into the right lower extremity and does another study of that leg--that is where out 75774 code is going to come into play.  We have already done our basic study of that lower extremity, we have already billed for it, now we are going to a different selective position and doing a follow up study.  That is going to be a 75774 in nutshell. 

After that we look at our third box of rules, which is going to be our intervention, and because the angioplasty that was performed was documented as pre-dilatation as opposed to a primary intervention, we do not bill for angioplasty, all we are going to be billing for is the stent placement, which is 37205.  And we also bill our base S&I code with that for the stent, which is 75960.

Top of page #34, you can see how these codes look on your claim form, and again if you have to use the 51 modifier, the only two codes that are going to apply there are going to be your stent placement and your catheter placement.  You are going to list the 37205 first, list the 36246 second with a 51 attached to it.  The only other modifiers you need to be concerned with are the 26 modifiers that are going to go on each of your codes that begin with a 7 because you are providing the physician skill, not the equipment that is being utilized--so you will use a professional component modifier there.

When we look at Kissing Balloons, which is on the top of page #35 here, you can see that Kissing Balloons are actually when we are going in to address two separate lesions that happen to be at the point of a bifurcation.  A lot of times you will have patients with, for example, bilateral common iliac disease where it gets just completely occluded at that bifurcation.  If we were try to go on with a balloon into one of those iliac arteries and inflate the balloon to open up that artery, all it is going to do is completely occlude the other one because they are both in close proximity to each other.  At that point, it may not be possible to engage the other iliac artery.  So what the doctor will do is to actually engage both of the iliac arteries at the same time, inflate the balloons, simultaneously, and the balloons actually touch each other when they are inflated, that is why they are called the Kissing Balloons. 

Kissing Balloons Require Two Separate Catheter And Stent Placements, S&Is And Imaging

The main thing to focus on here is twofold.  One is that most of these Kissing Balloon procedures are going to immediately proceed on to stent placement.  Angioplasty is not going to be considered a viable primary intervention for these lesions, primarily because they are just severely eccentric lesions that are just going to recoil relatively soon, they are ostial and so forth.  So these are going to proceed on to stent placement.  The big thing to keep in mind is that there are two separate vessels, so we are going to have two separate stent placements, two separate S&Is and also keep in mind that these are going to require two separate access sites.  We are going to be coming in from both the patient's lower extremities to come up from two different angles to access these.  So usually these are going to be two separate catheter placements.  W are going to bill two separate catheter placements, we also are going to bill for two separate stent placements and two separate S&Is for the stent placements plus whatever diagnostic imaging we do.  

Embolic protection devices.  Right now the reimbursement for these is kind of in a holding pattern.  Embolic protection devices are basically little filters that get deployed either usually downstream from the area of the lesion.  They also have proximal protection devices in which the doctor will actually occlude the vessel above where the intervention is being performed.  The whole concept here is that they want to try to filter out or suck out any debris that breaks loose when they are crossing these lesions or performing the interventions so that it does not flow downstream and cause damage.  Right now there is no code that specifically says we are using embolic protection in the peripheral arteries other than the codes we will talk about next, which are specific to just the carotid arteries. 

Bill Embolic Protection With 22 Modifier On Intervention Code Or With Unlisted Code

So if you are going to be billing for embolic protection, make sure you do it in a way that is safe.  You can either use a 22 modifier on your intervention code or you can list out the embolic protection separately with an unlisted code, which is in this case will be 37799.  Either one of these approaches is going to require you to submit documentation of the operative report to your individual payers, explain what the procedure is, explain what the reimbursement should be and fight for it.  I have seen practices receive up to $200 dollars for embolic protection.  However, a lot of payers come back and say we consider embolic protection to be included in the interventional procedure itself. 

There is a lot of justification you can try to give to your payer.  One of which is going to be showing them what these carotid stent placement codes are, which is on the top of page 36.  You can see that Medicare and CPT are actually recognizing the use of embolic protection at a separately reimbursable service.  They do not have it as a separate code but they do have carotid stent placement with embolic protection and without embolic protection and there is a reimbursement variance there.  So the code structure and the relative value that is assigned by CMS is kind of paving the pathway for us to fight for embolic protection reimbursement in either the coronary arteries or the peripheral arteries.  It is clearly a separately recognized service, it is recognized as having more work associated with it and that is one of the legs you have to stand on, but of course some payers are not going to listen to that no matter how you present it to them.

CPT Says Carotid Stent Placement Includes Catheter Placement, Diagnostic Imaging

The carotid stent placement codes came out in 2005.  You can see we have got two different codes, one is 37215, which is transcatheter placement of intravascular stent or stents in the cervical carotid artery, percutaneous with embolic protection; and the other one is without embolic protection.  Now one of the things that you will see with these codes and you really have to look at the instructions that CPT gave us with these codes both above and below the code definitions--they mainly say that when you bill for carotid stent placement, it is going to include your catheter placement in that artery and also any diagnostic imaging that preceded it during the same operative session, which is totally different than anything we just talked about.  When we look at doing peripheral studies anywhere other these carotid vertebral arteries, if you do a diagnostic study, you are going to be able to bill for your catheter placement, you are going to be able to bill for your diagnostic study, which is box of rules #1 and box of rules #2, plus your intervention, which is going to be box of rules #3. 

If, however, we are talking about an intervention in the carotid arteries, these codes say if you did a diagnostic study during the same session and it proceeded on to carotid stent placement, these 37215 or 37216 codes include everything, they include the catheter placement, they include the diagnostic studies, they include the stent placement.  If however, the doctor does a diagnostic study on Monday then discharges the patient from the operating room and then the patient comes back in on Tuesday to have these carotid stents placed; in that case, the doctor will bill for the full diagnostic study on Monday and also bill for the 37215 or 37216 on Tuesday.  So it is really a goofy spin that they have put on these codes in that they are going to bundle them in if we proceed on to stent placement.  There is a lot of controversy around them, but I think it does show where we might be heading with these peripheral codes. 

Right now when we look at generating these claims for even relatively common peripheral studies, you are going to see claims that have 15 or 20 codes on them.  These new codes that they are putting out for carotid stents are showing that they are starting to bundle a lot of this work in together into individual codes. 

The Medicare coverage for these, you really need to just read through what the CMS Medlearn Matters publication says.  It tells you what they consider to be covered--that the patients have to be enrolled in this data collection system if you want to have it billed and much much more than we can get into this teleconference today. 

We also see new codes coming out for vertebral stenting.  They are in the back of your CPT book--0075T, 0076T, which again are very similar in concept to the carotid stent codes in that they say if you are doing a diagnostic and proceeding on to these stent placements then that work is going to include everything that is included in the procedure.

Finally on page #38, I have got the web page that I mentioned earlier for you.  If you really want to understand the abdominal and lower extremity angioplasty studies, which are in many regards the most complex issues that we talked about today, make sure you go to that web page www.cardiologycoalition.come.  Read through the publication, the sample publication that is on there.  Also, take the proficiency test that is on there.  If you get the answers wrong one time, go back and take it again.  You can really take it as many times as you want--it will not penalize you at all.  Once you get the right combination of codes on the claim form, on the answer grid, it will generate instantly a CEU certificate for you that will allow you to print it out and send it in with your APC continual education units.  You get 3CEU for free - two for attending today, plus another 3 so this is 5 of your CEUs, which is a good chunk of them. 

At this point, I will open up the lines for about 10 minutes for the questions and answers and then we will adjourn for the day. 

Again ladies and gentlemen I would like to remind to you that this portion of the teleconference is also being recorded.  If you have a question at this time, please press *1 on your touchtone telephone. 

Q & A Session:

Our first question comes from Lisa of Stanford Hospital, please state your question.

Question:  Hi, this is actually going to come from Michelle, she is an interventional biller.  We often have abdominal aortograms performed and then the physicians dictates that a pelvic arteriogram is performed but we have not gone selectively into one of the iliacs.  How do you code that?

Answer:  That is going to basically be similar to what we have already talked about when we were doing abdominal studies of the renals.  If it is not selective, you cannot bill that selective study code that goes along with the 75736.  So it is going to be basically considered a lower extremity study whether it be 75710 or
71716 based on you know, what the doctor's report looks like.

Comment:  Thank you.

Answer:  You welcome, thank you for the question.

Our next question comes from Billy Hamilton of Cardiac Disease Specialists.  Please state your question.

Question:  Hi, just a quick question. I know you didn't go into that much on the Kissing Balloons but I know with the Kissing Balloons you go into the fact that you can do two PTAs and that's fine, but as a rule, it is really difficult to tell where should you be putting the catheter placement?  Do they wind up usually in the aorta or do they stay ipsilateral?

Answer:  You know most of the times I have seen them actually going into the aorta because they want the tip of the catheter to be fully across the lesion before they dilate it and when we code for catheter placement, it is really important that you code to the tip of the catheter, which in a lot of cases is going to be different from two different things.  One is that a lot of times we are going to have the guidewire, which is something that the catheter is actually going to ride over, like the guidewires are kind of like train tracks that the doctor will lay down in the arterial system.  The catheter glides over the top of it to get into position.  A lot of times the guidewire will be in a more selective position than the actual catheter tip is and we are supposed to code to the catheter tip. 

So when we do these Kissing Balloons, if you see that the catheter tip is going into the aorta, which is going to often be the case, then you code it as two different 36200's, because that is where the tip of the catheter went to.  Now this is not going to be every single case.  You might have a stray case where the doctor comes in from the right brachial artery and goes down with two different catheters from that position into the each of the lower extremities--it could happen.  More times than not we have got two separate access sites in the lower extremities and those Kissing Balloons are going to progress up into the abdominal aorta in both cases. 

Question:  Okay, that is a kind of what I have seen a lot but sometimes they do not make it real clear that the catheter goes into the aorta.

Answer:  You know, with a lot of this stuff, and that is a relatively small dollar amount, but with a lot of these things, make sure you illustrate to the doctor the impact of the clarity of the documentation.  I would imagine that your doctors do not understand that there is difference in selectively moving the catheter into the abdominal aorta as opposed to leaving it in the lower extremities.  But just show them the dollar amount that assigned each of the code and say look, if you go into the abdominal aorta, this is the money you get.  If you stay in the iliac, this is money you get.  And without you telling us which is which, we have to go with the lesser paying all the time.  That is really what works with the doctors I have worked with.  Then they appreciate the candor, in all honesty.  Great question, thank you.

Our next question comes from Jennifer Whittaker of Lexington Clinic.  Please state your question.

Question:  Hi, I have actually got a question regarding placement of a stent and when they do the drug eluding stents or the taxis stents, our physicians are actually wanting us to apply the 22 modifier on the 92980.  Is that appropriate or not?

Answer:  No, it is not at all.  And the logic behind it is that the physician's work associated with placing any type of stent is considered to be equal, so the reimbursement system is set up to recognize the physician work is the same regardless of whether you are using a bare mental stent or a drug alluding stent, or drug coated stent, heparin coated or whatever.  There is a difference in reimbursement on the facility side in that they actually get to bill a little bit more for the increased supply expense; but on the physician side it is not going to impact billing whatsoever and they should not be putting a 22 modifier on it.  It is just going to make it so that you have to submit those records for each of those 22 modifiers and it is going to hold up the reimbursement for 3 or 4 months in all honesty--and when they do get paid, they are not going to get paid a penny more than that what they would have without using the 22 modifier.

Comment:  Okay, thanks.

Our next question comes from Dana of Cleveland Clinic, please state your question.

Question:  My question is regarding the peripheral stent placement in angioplasty.  You have definitely cleared up the whole pre-dilatation issue but I was told that post dilatation is considered therapeutic and that I should be billing angioplasty and stenting in that scenario and I am very hesitant to do that and was wondering if you could clarify for me the post dilatation issue and perhaps somewhere, any web site I can get to justify a decision.

Answer:  I do not know a web site off the top of my head but I do know that it is not separately billable.  Post dilatation is going to be included in the work of deploying the stent--and all that post dilatation means is that after we deploy the stent, we are going to go in and inflate the balloon several more times, perhaps at different points along the stent, to firmly seat it in the position and that work is all included in the placement as is any follow up radiologic imaging and interpretation that is being performed. 

I am fairly confident that the Society of Interventional Radiology's coding guide references that.  As far as a web page, I do not know if any of the CMS guidelines are going to give those specifics but I would imagine some of them might; but I do know for a fact and I have seen it in several authoritative places that it is not separately billable.  Post dilatation, anything you do after you place stent in that one lesion, whether it be imaging or post dilatation of it to more firmly seat the stent, is not going to be separately billable.

Comment:  Thank you.  That is the approach I was taking but I am being told otherwise so I just...


  I would probably recommend that you ask whoever is telling you otherwise to provide proof.  You should be able to find proof that it is not separately billable and if somebody else feels confident enough to challenge that they should be able to provide you with something authoritative.  And when I say 'authoritative' I do not mean something coming from a consultant or somebody doing a goofy teleconference, I mean from CMS, or the AMA.  The AMA is authoritative because they create the codes.  They define how they should be applied.  CMS is authoritative because they are ones that are enforcing these rules and then below that, we of course have the specialty societies, whether it be the ACC or the Society of Interventional Radiology who are not the authority on these issues as far as how Medicare applies them, but they help to develop these codes and they help illustrate how they should be applied.  So they are very authoritative in that regard, but AMA, CMS references should be something that you consider to be absolutely authoritative.

Question:  So just to clarify, even though they were saying that the post dilatation is done for therapeutic purposes I should still not be reporting it as a separate angioplasty code.

Answer:   Right, there are a lot of references out there, and I can't give them to you right off the top of my head, but I believe the Society of Interventional Radiology site has said that that and if we look through the individual coverage policies, I would imagine that you should find them relatively quickly, if you just go under the CMS coverage web page and just type in 37305 and just briefly scan through each of the policies that are in place at the individual carrier levels.  It is very common that they say that post dilatation and any follow-up angiography to confirm the success of the intervention is not separately billable.

Comment:   Okay, great.  Thank you.

You are welcome, thank you.

Our next question comes from Ira of Heart Care Associates, please state your question.

Question:  Hi, my question is involving the embolic protection devices.  I was told that through Medicare that we should get credentialed with durable medical suppliers and that it would be a C code, do you know anything about that?

Answer:  Are you billing for a hospital or for ...

Question:  No.  Our provider who is doing this wants to bill for the embolic protection device but he said that it is a C code, I think it is C1884 so I called Medicare and they said you need to be credentialed with medical durable supplies even though we are the physician.

Answer:  The only way you would be billing one of those C codes is if you are the facility that is supplying the equipment.  I do not imagine your doctor is walking in with embolic protections ...

Question:  And the hospital would get paid but. ...

Answer:  And those C codes are only specific to the supplies that are being used, which you would not able to bill for as the provider.  And I think it is interesting to illustrate to them that we are not supplying this stuff.  We are just using it, and it is a lot of extra work associated with that and we feel it is appropriate to get paid another couple 100 dollars or whatever you feel is appropriate.  But if you are not supplying the device, you should not be billing for it.

Question:  So the code 37799 is that an unlisted?

Answer:  That is an unlisted because there is no code in the book that says that you are using distal protection devices or embolic protection devices.  The carotid stent placement codes--there are two of them: with versus without embolic protection.  But, there is no standalone code that says 'in addition to doing something else we are using embolic protection.'  That very well might change in the near future but right now we have to use an unlisted code.

Comment:  Thank you.

You are welcome, thank you.

Our next question comes from Julie of Lexington Cardiology, please state your question.

Question:  My question is when you go and do an interventional stent placement, let's say an extremity, you had mentioned doing follow up angiography, do you always get to bill for that?

Answer:  No, the follow up angiography that you are able to bill for is not really a follow up angiography--it is a separate study of a different area in a vascular family that you have already assessed, which was one of our case studies where we looked at both lower extremities from the aortoiliac bifurcation.  The doctor saw extensive disease in one of the lower extremities and advanced the catheter more selectively into it to do a separate study--that is where you get to bill for a follow up, 75774.

If however we are doing an intervention, and then after the intervention, the doctor wants to look to see how the intervention worked. And what they are mainly looking for is, if I deployed a stent, is it positioned appropriately, do we have good seating of the stent, is there any dissection that is going to limit the flow of blood, did we fully address the lesion or do we have to go and put 2 or 3 more stents in there to fully address it?  That follow up imaging is not separately billed.  That is included in the code that you are using for your stent placement.  Post intervention imaging is never going to be separately billable, when we are talking about placing stents anyway.

Our next question comes from Kelly of Swedish Physicians, please state your question.

Question:  My question is on the carotid stenting codes.  If you placed a stent in the internal carotid artery would that be 37215 or the 0075T?

Answer:  They have not really clarified--the internal carotid arteries, however, are typically what they reference as the 'cerebral' and that kind of puts us into this area of, did they screw up on these code definitions?

Because they are saying in the code definition of 37215 that it applies to cervical carotid arteries, not cerebral carotid arteries.  When you look at the definitions of the imaging codes that we have talked about, we have the ones that say cerebral and cervical, which are clearly listed out separately where you have got your internal carotids 75665, 75671 that clearly state cerebral and that is what most people refer to as the internal carotid arteries.  And then the external carotid arteries, they refer to those as external.  The common carotid artery, they refer to as cervical.  So I think that it is matter of these codes were not clearly defined and it is an area that I am currently trying to clarify with the AMA  to try to see exactly how they intended for these codes to be applied.  So that is a great question but right now there is not a great answer for it. 

Question:  Okay, I have been billing a 0075T for those, do you think that is appropriate at this point in time?

Answer:  Yes, I think that is definitely safe.

Comment:  Okay.

Answer:  You know it is going to be the path of more resistance because it is one of these temporary codes as opposed to one of these new fangled codes.  But if you look at the imaging codes that are established in the book and the fact that it says cervical instead of cerebral I think that definitely is the safer route.  

Comment:  Okay, thank you.

Our next question comes from Susan of Hilton Head Heart, please state your question.

Question:  Hi, Jimmy you still sticking around--this is Dennis again.  I had a question about this picture, it looks really familiar, in these diagrams you used?

Answer:  That is a good looking guy, isn't it Dennis!

Question:  Right, but the serious question about that is that I am using diagrams that are from Medlearn and they are pretty good but the diagrams that you used today are really better for me ...quot; are those available somewhere or?

Answer:  Yes, we can make those available to callers if anybody is interested.  Those are actually diagrams that I have developed for training purposes and it is a picture of me if anybody wants to know what I look like.  Those are things that I developed in response to physician needs for an effective way to document the procedures.  What we do typically is take that image and shrink it down to sit on half of the page of paper and then put codes on the other half of the page of paper.  So that what the doctor can actually do in coding and in documenting these procedures out, is after the procedure is done is they will typically make handwritten notes and then they will go on and see another patient in consultation or do an admit or another procedure and come back later in the day and actually dictate from their handwritten report. 

What the diagram was designed to do was allow doctors to document the procedure right on the diagram itself.  So if the doctor selectively engaged the four different vessels of the head study instead of documenting that out in handwriting what they can do is put X's at the places where they positioned their catheter.  If they see a 60% stenosis on the right common carotid, they can just draw a little scribble there with a 60% next to it with an arrow and they will actually be able to come back and document much more efficiently from that than from the handwritten report.  And then they actually turn that piece of paper in to the coding staff and as you can see, looking back at what we covered today, that is going to have the majority of the work performed for you by the doctor. 

So, if anybody is interested in obtaining those forms, please feel free to e-mail me and I will give you a proposal for those.  It is not a lot of money, just  depending on if you want just the image itself or if you want an image with an encounter form kind of worked in with it and of course my e-mail is on the last page on page #38 at the bottom there.

Due to time constraints we must now conclude the question and answer period.  I would like to turn the program back to Mr. Collins for any closing comments he may have.

Okay, thank you Mandy.  Again you know the biggest closing comment I would have is to really recommend that you to go to that read that article on the web page www.cardiologycoalition.com.  It is something that is totally free but it is going to take the information that we presented today specific to the abdominal, lower extremity angiography and help clarify it to a point that you have absolutely no question about how to accurately assign these codes.  Not only that, it also gives you a way to conduct a proficiency test for yourself to make sure you understand how to apply it--it actually has a case study on there that you actually read through and then pick multiple choice, which codes are supported by the operative report and again, it gives you 3 AAPC free continuing education units.

You can have everybody in your office to do that.  You can also have your doctors go ahead and do it and it really illustrates one of the benefits to becoming a member of the Cardiology Coalition, which is an organization that is designed to evolve your levels of coding skill in cardiology.  We also have a lot of advocacy efforts which are illustrated on there--trying to get our reimbursement rate for diagnostic heart cath brought up to where they should be, getting Correct Coding Initiative edits changed, adding new codes.  Like right now there are no codes for biventricular device interrogations or the removal of left ventricular leads.  These are all things that we are aggressively working on through the Coalition.  I really recommend you to go visit that site, read the article that is on there, take the proficiency test, you will get a lot of benefit out of it.

This is the conclusion of "Peripheral Vascular Billing Boot Camp" national teleconference.  We hope you enjoyed this session.  Please complete your teleconference evaluation form and return it to the Coding Institute at the address listed on the form.  Mr. Collins, the Coding Institute, and I would like to thank you for your attendance.  To end this call, just simply hang up your phone.  Good bye.