General Surgery Coding Alert

Coding by access site is key.

If your general surgeon performs vascular procedures, such as endovenous ablation therapy (EVAT or EVA), you can use the following scenario to shine a light on coding pitfalls that could cost you big pay.

The case: Your surgeon uses ultrasound to map the veins of the patient’s right leg and guide percutaneous insertion of a laser catheter into an incompetent vein. The surgeon positions the catheter and applies laser energy at the site and during the catheter removal to ablate the “problem vein” and divert blood to healthier veins. The surgeon then uses a single separate access site to perform the endovenous laser ablation for two additional veins in the same leg.

Read on to learn how to code the case — and what it will cost you if you code it wrong.

Distinguish Codes by Surgical Method

CPT^® provides four codes for incompetent-vein ablation therapy, as follows:

• 36475 — Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated

• +36476 — … second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)

• 36478 — Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated

• +36479 — …second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure).

You can see that there are two code families, distinguished by whether the surgeon performs the ablation using laser or radiofrequency ablation.

Payment impact: Medicare’s 2015 national nonfacility rate for 36475 ($1,569) is roughly $340 more than the rate for 36478 ($1228) (conversion factor 35.9335) — which is what you stand to lose if you use the wrong code.

Capture Additional Access Pay

Notice that the two EVAT code families have a parent code plus an indented add-on code. For each EVAT code family, you should use the parent code for the first vein treated in a single extremity using that method, and then also report the indented code for each additional access site for a second or subsequent vein using that method. The add-on code applies to services performed at the same session using the same method as the primary procedure.

Documentation tip: Ask providers to document the second insertion for +36476 or +36479 in both the summary and body of the surgical report so auditors don’t overlook the services, says Terry Fletcher, BS,CPC, CCC CEMS, CCS-P, CCS, CMSCS, CMC, ACS-CA, SCP-CA, of Terry Fletcher consulting in her “Peripheral Cardiology 2015 Updates” presentation for Audioeducator, an affiliate of The Coding Institute.

Doubling the documentation will simplify your job of identifying services to code, says Fletcher. And that’s a good thing, because each add-on code pays about $300 in the nonfacility setting.

Code the Case

Based on the code definitions and the preceding discussion, you can see that the proper coding for the case study is 36478 and +36479. Although the case involves the surgeon performing laser EVAT on two additional veins, the documentation states that he uses “a single separate access site,” so you should not bill two units of +36479.

Don’t unbundle services: The case note mentions ultrasound guidance, but you shouldn’t report a separate code for that service.

In fact, you need to get a handle on all the “Do not report with …” notes that CPT^® provides for the EVAT codes, advises Catherine Brink, BS, CMM, CPC, CMSCS, CPOM, president of Healthcare Resource Management Inc. in Spring Lake, NJ.

The notes for 36475/+35476 are almost identical to the notes for 36478/+36479, instructing you not to report the EVAT codes with the following codes when the surgeon performs them in the same surgical field:

•  Compression system codes 29581-29582

• Injection and intravenous codes 36000, 36002, 36005, 36410, 36425

• Radiology codes 75894, 76000, 76001, 76937, 76942, 76998, 77022

• Duplex scan codes 93970-93971

• Venous embolization or occlusion, such as 37241.

The notes also instruct you not to report 36475 and +36476 with 36478 and +36479.