General Surgery Coding Alert

Report prosthesis insertion by site of introduction

When picking your way through an endovascular abdominal aortic aneurysm (AAA) repair op note, you-ll want to look closely for several separately reportable services, including radiologic supervision and interpretation (S&I), artery exposure for prosthesis placement, and others. Make sure you have the information you need to identify and report all components of an AAA repair and garner the full payment you deserve.

Include Angioplasty Within Treatment Zone

You should not separately report balloon angioplasty or stent deployment within the target treatment zone along with primary AAA endovascular repair codes 34800-34805, according to CPT guidelines. The surgeon uses angioplasty to inflate, and a stent to help maneuver, the prosthesis after placing it. The AMA has designed 34800-34805 to include these services.

But CPT guidelines confirm that when the surgeon must perform angioplasty or deploy a stent in a separate area, you may report the angioplasty and/or stent as separate from the AAA repair. You will have to append modifier 59 (Distinct procedural service) to the angioplasty or stent code to show the payer that the procedure is not a part of the primary service, and the surgeon's documentation will have to substantiate that the angioplasty and/or stent occurred at an area distinct and separate from the AAA repair.

Have all the information at your fingertips: For complete information on how to report primary AAA repair/prosthesis, as well as endovascular to open conversion repairs and placement of extension cuffs, look to -Technology Review Allows You to Report Endovascular AAA Repairs With Ease,- General Surgery Coding Alert, No. 9, Vol. 9, pp. 61-64.

Get the Prosthesis Into the Vein

In some cases, the surgeon must expose either the femoral or iliac artery to facilitate introducing the sheath required for the endovascular AAA repair, says Gary W. Barone, MD, associate professor of surgery at the University of Arkansas for Medical Sciences in Little Rock. The primary repair codes do not include this service, and therefore you should report it separately.

For femoral artery exposure, report 34812 (Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral). For insertion into an iliac artery, call instead on 34820 (Open iliac artery exposure for delivery of endovascular prosthesis or iliac occlusion during endovascular therapy, by abdominal or retroperitoneal incision, unilateral).

Bilateral procedure calls for bilateral modifier: Codes 34812 and 34820 are unilateral, as specified by AMA/CPT and CMS/Correct Coding Initiative (CCI) guidelines. Therefore, if the surgeon must access arteries bilaterally (that is, one in each leg), be sure to append modifier 50 (Bilateral procedure) to the appropriate exposure code. Because of the additional work, Medicare carriers customarily pay such claims at 150 percent of the unilateral rate.

Example: If the surgeon uses a modular bifurcated endovascular graft inserted via an open iliac exposure, you may report both 34802 (Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using modular bifurcated prosthesis [one docking limb]) and 34820.

Repair is also separate: The surgeon might have to perform extensive artery repair or replacement following open arterial exposure (34812 or 34820). You should report these repairs separately using 35226 (Repair blood vessel, direct; lower extremity) or 35286 (Repair blood vessel with graft other than vein; lower extremity), as appropriate, for either a femoral or iliac artery repair.

Catheterization Calls for Compensation

If the physician introduces a catheter(s) into the aorta, you may report the placement separately using 36200 (Introduction of catheter, aorta). -Introduction of guidewires and catheters should be reported separately- with 36200, 36245-36248, 36140, CPT specifies.

Watch for more selective placement: The surgeon may place the catheters selectively into the renal or femoral arteries (which are first-order aortic branches) rather than the aorta. When this occurs, you-ll want to report 36245 (Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family) rather than 36200, says Jim Collins, CPC, ACS-CA, CHCC, CEO of the Cardiology Coalition in Matthews, N.C.

In addition, surgeons will often require catheter access from both the right and left femoral or iliac arteries. If the physician documents this, you may once again call on modifier 50 to indicate that first order selective placement (36245) occurred bilaterally.

Report S&I if Surgeon Reads Angiogram

CPT allows you to report radiographic studies related to prosthesis selection and sizing separately, says Roseanne R. Wholey, president of Roseanne R. Wholey and Associates in Oakmont, Pa.

You should select 75952 (Endovascular repair of infrarenal abdominal aortic aneurysm or dissection, radiological supervision and interpretation) for an angiogram for endovascular AAA prosthesis placement (34800-34805).

For placement radiographic studies for extension cuff placement (34825-34826, as discussed in General Surgery Coding Alert, No. 9, Vol. 9), report 75953 (Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal aortic or iliac artery aneurysm, pseudoaneurysm, or dissection, radiological supervision and interpretation).

A word of warning: You may report S&I codes for the surgeon only if no radiologist is present and the surgeon dictates a radiology report.

Pay Attention to Occlusion

Less frequently, the surgeon may place an occlusion device to block a stenosed or otherwise diseased iliac artery and prevent retrograde blood flow into the aorta. You should report this using +34808 (Endovascular placement of iliac artery occlusion device [list separately in addition to code for primary procedure]).

When the surgeon uses an occlusion device, in turn, he must place a femoral-femoral prosthetic bypass graft to maintain the patient's blood flow to the affected leg. This is again an independent procedure, which you would code with +34813 (Placement of femoral-femoral prosthetic graft during endovascular aortic aneurysm repair [list separately in addition to code for primary procedure]).

Both 34808 and 34813 are add-on codes, which you should not report alone. CPT lists the acceptable codes with which you may claim 34808 and 34813.

Unrelated Procedures Are Fair Game

Finally, you can separately report all unrelated interventional procedures that occur at the same time as the AAA repair. Per CPT guidelines, these include:

- Renal transluminal angioplasty

- Arterial embolization

- Intravascular ultrasound

- Balloon angioplasty or stenting of native artery(s) outside the endoprosthesis target zone (discussed above).