General Surgery Coding Alert

Make sure you identify initial and additional vessel procedures.

With a new section for endovascular revascularization in CPT 2011, you'll need to make sure your practice is up to date when billing for tibial/peroneal revascularization services.

Context: Use this information as a companion to prior articles on the 2011 CPT changes: "37220, 37221 Overhaul Your Iliac Vascular Intervention Choices" in General Surgery Coding Alert Vol. 13, No. A, and "37224-37227: Capture Pay for Femoral/Popliteal Revascularization" in Vol. 13, No. 4.

1. Keep Initial/Additional Designation in Mind

CPT 2011 divides the new codes by initial or additional vessel -- each including angioplasty in the same vessel, when the surgeon performs it -- as follows:

Initial vessel: The first four codes apply to the initial tibial or peroneal vessel treated in a single leg:

Angioplasty: 37228 -- Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty

Atherectomy (and angioplasty): 37229 -- ... with atherectomy, includes angioplasty within the same vessel, when performed

Stent (and angioplasty): 37230 -- ... with transluminal stent placement(s), includes angioplasty within the same vessel, when performed

Stent and atherectomy (and angioplasty): 37231 -- ... with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed.

Additional vessel: Use the remaining four add-on codes to report services on each additional ipsilateral (same side) vessel treated in the tibial/peroneal territory:

Angioplasty: +37232 -- Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal angioplasty (List separately in addition to code for primary procedure) (use with 37228-37231)

Atherectomy (and angioplasty): +37233 -- ... with atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure) (use with 37229-37231)

Stent (and angioplasty): +37234 -- ... with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure) (use with 37230-37231)

Stent and atherectomy (and angioplasty): +37235 -- ... with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure) (use with 37231).

Remember revascularization general rule: "Report the one code that represents the most intensive service performed in a single lower extremity vessel. All lesser services in that vessel are included in that one code," says La Donna Brown, CPC, coding specialist with Sanford Clinic in Sioux Falls, S.D.

2. Count Vessels Carefully -- Especially TP Trunk

The new revascularization codes (37220-+37235) apply to different "territories." Each territory has its own specific set of guidelines. Codes 37228-+37235 fall under the tibial/peroneal vascular territory.

The tibial/peroneal arteries include anterior tibial (AT), posterior tibial (PT) and peroneal, according to Sean P. Roddy, MD, FACS, AMA CPT advisory committee member, and Gary R. Seabrook, MD, AMA/specialty society relative value scale update committee member, in their presentation on the new codes for the AMA's CPT and RBRVS 2011 Annual Symposium in Chicago.

That means the new codes relate to three vessels in each leg for the tibial/peroneal territory. Because you may report one code per vessel, you may use one initial code and up to two add-on codes per leg (for a total of three vessels). The three-vessel approach is similar to the iliac territory, but it differs from the femoral/popliteal territory, which counts as a single vessel for coding.

Don't miss: Because the codes apply per vessel, you should not report add-on codes for additional lesions treated in a single vessel. CPT is very clear that "when more than one stent is placed in the same vessel, the code should be reported only once." In addition, in some cases, a lesion may extend from one artery into another. If the surgeon can treat that lesion with a single intervention, then you should choose a single code to report that service.

Anatomy vs. coding: Work performed on the tibioperoneal (TP) trunk is bundled into the code you choose for peroneal or posterior tibial work, Roddy and Seabrook's presentation noted. As the CPT guidelines explain it, "The common tibial-peroneal trunk is considered part of the tibial/peroneal territory, but is not considered a separate, fourth segment of vessel in the tibio-peroneal family for CPT reporting of endovascular lower extremity interventions." The guidelines go on to indicate that if the physician treats lesions in the TP trunk as well as in the PT artery, you should choose a single code.

3. Master Coding for 2 Legs or 2 Territories

The new revascularization codes are unilateral, which means they apply to a service on a single side of the body. CPT indicates that if the physician treats the identical territory (such as tibial/peroneal) in both legs at the same session, you should use modifier 59 (Distinct procedural service) to show both legs are involved.

But watch out for payers' modifier preferences. Some may prefer you to use modifier 50 (Bilateral procedure), modifiers RT (Right side) and LT (Left side), or some combination of modifiers for procedures on both legs.

On the other hand: If the surgeon treats more than one territory in the same leg, you should report multiple codes, according to CPT. For example, if the surgeon places a stent in the peroneal and performs angioplasty in the internal iliac, you should report both 37230 for the peroneal service and 37220 (Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty) for the iliac service. These are both "initial" codes because each service is the initial service in a distinct territory.

4. Consider Included Services

Remember that CPT guidelines state that the endovascular revascularization codes include these services: accessing and catheterizing the vessel, crossing the lesion, any radiological supervision or embolic protection, arteriotomy closure, and imaging of the completed intervention.

Extras: If the physician performs mechanical thrombectomy (such as 37184-+37185, primary, or +37186, secondary), thrombolysis (such as 37201, 75896), or both, to help restore blood flow to the occluded area, CPT states you may report those services separately.