General Surgery Coding Alert

Endovascular repair of abdominal aortic aneurysms (AAA) involves a range of separately reportable procedures, depending on circumstances. In addition, CPT contains a specific code group to describe endoscopic-to-open conversions for aneurysm repair. By reviewing all the services the surgeon may provide, you can make use of all the available codes and ensure complete reimbursement.

Independently Report Associated Procedures

Placement of a prosthesis as described by 34800-34804 accounts for only a portion of the total procedure, says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver.

Although CPT specifies that balloon angioplasty (to inflate the prosthesis after it is placed) and stent deployment within the treatment zone (that is, the area in which the physician places the prosthesis) are bundled to the primary procedure code, other services are separately reportable. As noted in the December 2000 CPT Assistant , these include extensions cuffs (discussed last month), open surgical exposure of the femoral arteries (or, less often, the iliac arteries), catheter placement, radiological supervision and interpretation (when appropriate), "conversion" surgery, and other, less common separately reportable maneuvers. "Since each situation and aneurysm will be different, the specific codes reported will depend on the actual procedure performed and the circumstances involved in the repair," CPT Assistant further notes.

Arterial Exposure Precedes Prosthesis Placement

Now, all prosthetics approved by the U.S. Food and Drug Administration for endovascular AAA repair require surgical exposure of at least one artery (for a description of the various types of prosthetics, see General Surgery Coding Alert, April 2003). The surgeon must open the artery to introduce the prosthesis, which he or she will then maneuver into place at the site of the aortic aneurysm.

The primary repair codes (34800-34804) do not include surgical exposure of arteries for device introduction. Therefore, you may report direct vascular access of the iliac or femoral arteries separately using 34812 (Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral) or 34820 (Open iliac artery exposure for delivery of endovascular prosthesis or iliac occlusion during endovascular therapy, by abdominal or retroperitoneal incision, unilateral), Hammer says, depending on which artery the physician accesses. Note that these are unilateral codes. 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, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J.

Use Modifier -50 for Catheters

If the physician introduces a catheter(s) into the aorta, you may report the placement separately using 36200 (Introduction of catheter, aorta). On occasion, however, the surgeon will place the catheters selectively into the renal arteries (a first-order branch of the aorta). In such cases, 36245 (Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family), rather than 36200, is appropriate. For many endovascular AAA repairs, catheter access is required from both of the femoral or iliac arteries. Again, because 36245 is a unilateral code, if catheters are placed on both sides, you should append modifier -50 or modifiers -LT (Left side) and -RT (Right side).

Note: Code 36200 is for the aorta and is never bilateral.

Report S&I If Surgeon Reads Angiogram

Radiographic studies related to prosthesis selection and sizing are separately billable, and CPT added two new radiology codes in 2001 for interpretation of the angiography performed with the endovascular repair. Code 75952 (Endovascular repair of infrarenal abdominal aortic aneurysm or dissection, radiological supervision and interpretation) is appropriate for an angiogram done with the placement of the endovascular AAA prosthesis (34800-34804). For placement of extension cuffs (34825-34826), 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). The surgeon may report these S&I codes only if no radiologist is present and the surgeon files a separate radiology report.

Conversions Have Specific Codes

If, during the endovascular repair, the surgeon must abandon the procedure and repair the aneurysm with an open procedure, do not report an open procedure code (35081/35102), Hammer says. Instead, CPT includes specific codes to describe the conversion. (This is unusual because, in most cases, you would report an endoscopic-to-open conversion as an open procedure.)

If, following conversion, the physician anatomoses the prosthesis at both ends to healthy sections of the aorta, you should report 34830 (Open repair of infrarenal aortic aneurysm or dissection, plus repair of associated arterial trauma, following unsuccessful endovascular repair; tube prosthesis). If the surgeon anastomoses the proximal end of the prosthesis to the aorta but anastomoses the distal ends to the iliac arteries, report the procedure using 34831 (... aorto-bi-iliac prosthesis). If the common iliac arteries or external iliacs are involved with the aneurysm or have been damaged during the endovascular procedure thereby requiring that the prosthetic limbs be tunneled through the pelvis so that anastomoses are performed at the femoral artery level report 34832 (... aorto-bifemoral prosthesis).

Don't Forget Repairs and Ancillary Procedures

Extensive repair or replacement of an artery may be required following open arterial exposure (34812/34820). Report these procedures separately using 35226 (Repair blood vessel, direct; lower extremity) or 35286 (Repair blood vessel with graft other than vein; lower extremity), as appropriate, if a femoral or iliac artery is damaged and requires repair following placement of the prosthesis.

In addition, you may separately report other ancillary procedures, such as balloon angioplasty (only if performed outsideof the endograft; if performed inside the stent it is bundled to the primary procedure) and stent placement (again, only if performed outside of the endograft).

Multiple-procedure rules apply to all of the above codes. Payers will reimburse in full for the primary procedure (34800-34804) but will apply a 50 percent reduction for all subsequent procedures during the same operative session. For those payers that require it, be sure to append modifier -51 (Multiple procedures) to any secondary/subsequent procedure codes.