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General Surgery Coding Alert

CCI, Medicare and CPT Weigh In on Abdominal Endograft

Published on Fri Feb 01, 2002

The road to coding endografts for treatment of abdominal aortic aneurysms (AAA) has been full of twists and turns ever since CPT introduced a "family of component procedures" that includes 12 different codes for AAA repair and associated procedures, with the type of prosthesis used, the route taken and the method used to position the prosthesis in the aorta distinguishing one code from another.
 
The struggle that physicians and payers have been engaged in over coding, payment and coverage of AAA endograft billing procedures may be behind some of the new edits appearing in Correct Coding Initiative version 8.0 (CCI 8.0), the introduction of Category III CPT codes for associated procedures, and the recent Medicare physician fee schedule update covering co-surgery.
 
Other factors that may have led to these changes include unanticipated problems with the prostheses, as well as the introduction of new devices associated with AAA endovascular repair since the codes were unveiled in 2001.

CCI Edits

CCI 8.0 includes 169 edits related to AAA endovascular repair codes valid Jan. 1-March 31, 2002.
 
Most of these edits bundle these repairs with other procedures, such as open aortic aneurysm and blood vessel repair, open and percutaneous angioplasty, and a variety of catheterizations or needle introductions.
 
"These new edits are a response to the coding confusion brought about by the introduction of the codes last year," says Diane Elvidge, CPC, a coding specialist with Princeton Reimbursement Group in Minneapolis. "Many of the edits are obvious, like those involving endovascular and open repair. But misuse of the codes also stems from poor understanding of the procedure or vague descriptions in the operative report by surgeons."
 
Another reason for the number of new edits, Elvidge speculates, may be the number of mechanical and operational difficulties with the devices. "There were many problems with these devices in 2001, including some that required recall," Elvidge says. "As a result, it is likely that many more conversions to open procedures were performed than anticipated."
 
A surgeon performing an endovascular procedure may be forced to convert to open because, for example, the device breaks or becomes twisted. Elvidge says the edits have been introduced to ensure that the correct code is billed in this case, 34830 (open repair of infrarenal aortic aneurysm or dissection, plus repair of associated arterial trauma, following unsuccessful endovascular repair; tube prosthesis), 34831 ( aorto-bi-iliac prosthesis) or 34832 ( aorto-bifemoral prosthesis) rather than an open aneurysm repair code.
 
Meanwhile, 34812 (open femoral artery exposure for delivery of aortic endovascular prosthesis, by groin incision, unilateral) and 34820 (open iliac artery exposure for delivery of endovascular prosthesis or iliac occlusion during endovascular therapy, by abdominal or retroperitoneal incision, unilateral) now bundle 36245-36247 (selective catheter placement, arterial system; first-, second-, and third-order abdominal, pelvic, or lower extremity artery branch, within a vascular family). Codes 34812 and 34820 describe the open exposure of the appropriate artery for placement of the prosthesis, commonly referred to as the "cutdown" method.
 
It is inappropriate to use 36245-36247 in association with 34812 or 34820, Elvidge says. She notes, however, that 36200 (introduction of catheter, aorta) may be reported separately if the catheter was moved into the aorta itself. If the catheters are introduced from both sides, 36200 may be reported with modifier -50 (bilateral procedure), she says.
 
Similarly, when an extension prosthesis is placed and reported with 34825 (placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic aneurysm; initial vessel), neither open aneurysm repair codes nor catheterization or needle introduction codes should be billed separately.

Medicare Approves Co-Surgery

Medicare Memorandum AB-01-08, dated Aug. 3, 2001, announced that the final update of the 2001 Medicare physician fee schedule database included a change to the co-surgery status of the AAA endovascular codes.
 
Previously, these codes had a status of "0," i.e., co-surgery was not covered. This did not accurately reflect the extensive and delicate nature of AAA procedures, during which one surgeon may place the prosthesis percutaneously via one artery while a second surgeon places a docking limb via the femoral artery on the right side.
 
If a cardiologist performs the endograft, a surgeon may need to be on standby in case it fails and an open procedure is required. In such cases, both the surgeon and the cardiologist are considered to have performed an endograft-to-open procedure, 34830-34832.
 
As a result of such concerns, Medicare changed the status of these codes to "2," i.e., co-surgery may be reported by appending modifier -62 (two surgeons) to the appropriate procedure code.
 
However, as with all claims involving modifier -62, each surgeon should dictate a separate operative report using the same procedure code with modifier -62 attached.
 
Medicare should pay 125 percent of the fee schedule rate for the procedure performed, split evenly between the two surgeons.

Category III CPT Codes

CPT 2002 presents "Category III Codes" for tracking emerging medical technologies, including AAA procedures 0001T (endovascular repair of infrarenal abdominal aortic aneurysm or dissection; modular bifurcated prosthesis [two docking limbs)]) and 0002T ( aorto-uni-iliac or aorto-unifemoral prosthesis).
 
Note: Category III codes replace the S codes in the HCPCS manual. Blue Cross Blue Shield and some commercial carriers recognize these codes.
 
Category III codes should be used for tracking purposes and must be used when the patient is covered by Medicare, says Jan Rasmussen, CPC, a general surgery coding and reimbursement specialist in Eau Claire, Wis., adding that the carrier may cover the service in some cases. "Surgeons should check their carrier fee schedule or other guidelines to see if their carrier covers the procedure," she says, adding that Part B carriers that cover these procedures determine their own fees.
 
Note: The fee schedule appearing in the Federal Register confirms that 0001T and 0002T are both carrier-priced with a C status.

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