General Surgery Coding Alert

Until now, CPT did not include codes to describe endovascular repair of abdominal aortic aneurysms (AAA). Therefore, these procedures had to be billed using a single unlisted code, which limited the dollar value of the claim. CPT 2001, however, introduces 12 new codes many of which can be separately billed allowing for the possibility of significantly increased reimbursement for these procedures.

The codes describe the repair of the aneurysm and various associated procedures. In addition, the subsection of CPT in which the new codes appear includes an introduction noting two new radiology codes that may be billed with the repair under certain circumstances.

This new multiprocedural technique is performed on patients with an AAA, a life-threatening condition frequently associated with hypertension. The aneurysm is a bulge, or dilation, in the wall of the aorta resulting primarily from arteriosclerosis.

Unless a patient suffers from other conditions that make surgery too risky, surgery is indicated for patients with an AAA wider than 5-6 cm. Until recently, this meant open surgical repair using a direct transabdominal or retroperitoneal approach to the external surface of the aneurysm. Such procedures involve making a large incision to expose the aneurysm, temporarily occluding the blood flow, opening the aneurysm and inserting a tubular prosthesis within the open sac. These procedures often led to complications and involved high risk, particularly for ailing, elderly patients.

Because a large abdominal incision is not required, the endovascular approach is far less invasive. When an AAA is repaired in this way, a collapsed prosthesis is introduced through arteries in the groin (either femoral or iliac) and advanced into position under fluoroscopic guidance. After the prosthesis is positioned, a balloon inflates it to full size, and metal clips on the distal and proximal ends of the device latch onto the inside of the artery.

Note: Prior to surgery, the surgeon may determine that the patients anatomy will not permit this new technique (for example, the patients arteries may be too small to allow passage of the prosthetic device). In such cases, the open procedures (35081, direct repair of aneurysm, false aneurysm, or excision [partial or total] and graft insertion, with or without patch graft; for aneurysm, false aneurysm, and associated occlusive disease, abdominal aorta; and 35102, direct repair of aneurysm, false aneurysm, or excision [partial or total] and graft insertion, with or without patch graft; for aneurysm, false aneurysm, and associated occlusive disease, abdominal aorta involving iliac vessels) would be performed.

Using the New Endovascular Repair Codes

The first three codes in the endovascular AAA repair subsection describe variants of the same procedure. Code 34800 (endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using aorto-aortic tube prosthesis) describes placement of an endovascular tube graft in the aorta from a single side (although the need for accurate positioning usually requires that guidewires and catheters be passed from both sides). Because the anatomy of most patients is not suitable for this type of graft, it is not placed frequently.

More often, the patients aneurysm will extend to the very distal aorta or into the proximal common iliac arteries. Because no adequate normal distal portion of aorta is available to accept a tube prosthesis, the surgeon will instead place a bifurcated graft. Two codes describe such grafts, which resemble an upside-down Y extending from the distal aorta to the left and right proximal iliac arteries. Code 34802 (endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using modular bifurcated prosthesis [one docking limb]) uses a modular design in which the main aortic prosthesis is attached to two short docking limbs in both iliac arteries.

The other bifurcated graft, 34804 (endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using unibody bifurcated prosthesis), describes the placement of a one-piece (unibody) prosthesis specifically designed to the dimensions of the patient. Code 34804 includes passage of a special contralateral iliac limb guidewire into the aorta and subsequent capture of the wire by a snare advanced through the arteries from the opposite groin. The contralateral graft limb is then pulled downward from the aorta into the opposite iliac artery.

The surgeon selects either the modular or unibody prosthesis depending on the configuration of the vessels with aneurysms. The unibody prosthesis is more difficult to install, although this is not reflected in the number of relative value units (RVUs) HCFA has assigned to each procedure (34800, 31.96 RVUs; 34802 and 34804, 35.27 RVUs).

Note: A new code being reviewed for inclusion in CPT 2002 describes placement of a device with two modular limbs.

Coding Associated Procedures

In addition to the endovascular repair, the surgeon may perform one or more other procedures to complete the treatment successfully. For instance, an occlusion device may be placed to block a stenosed or otherwise diseased iliac artery and prevent retrograde blood flow into the aorta (34808, endovascular placement of iliac artery occlusion device [list separately in addition to code for primary procedure]). This procedure, in turn, requires the surgeon to place a femoral-femoral prosthetic bypass graft to maintain the patients blood flow to the affected leg (34813, placement of femoral-femoral prosthetic graft during endovascular aortic aneurysm repair [list separately in addition to code for primary procedure]).

Note: 34808 and 34813 are add-on codes and, as such, may not be billed alone.

Additionally, depending on the patients anatomy and the severity of occlusion (from plaque, for example), direct vascular access may be required to initiate the endovascular repair. In such cases, either the femoral or iliac artery is exposed to facilitate the introduction of the sheath required for endovascular AAA repair. If the femoral artery is entered, 34812 (open femoral artery exposure for delivery of aortic endovascular prosthesis, by groin incision, unilateral) is used. If the surgeon exposes the iliac artery, 34820 (open iliac artery exposure for delivery of endovascular prosthesis or iliac occlusion during endovascular therapy, by abdominal or retroperitoneal incision, unilateral) should be coded.

Neither of these procedures, however, affects the billing of the endovascular repair. For example, if a modular bifurcated endovascular graft is inserted via an open iliac exposure, both 34802 and 34820 are separately payable.

Note: The descriptors for both 34812 and 34820 specify that these codes are unilateral. Often, however, both femoral or iliac vessels are accessed to better position the endovascular prosthesis. In those cases, modifier -50 (bilateral procedure) or modifiers -LT (left side) and -RT (right side) should be appended to the appropriate code. Code 34812 should also be billed with modifier -50 attached if a femoral-femoral bypass graft prosthesis (34813) is performed, because both femoral arteries are dissected during this procedure.

Placing Extensions

Sometimes the prosthesis may not be long enough at either the proximal or distal end of the repaired artery, and an angiogram performed after the prosthesis is installed indicates a leak thus requiring an extension of the original prosthesis. Typically, such an extension is placed during the same session as the original AAA repair, but occasionally the leak is not discovered until the procedure has been completed. In such cases, code 34825 (placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic aneurysm; initial vessel) should be used for placing the extension. If more than one vessel requires an extension, code 34826 (placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic aneurysm; each additional vessel [list separately in addition to code for primary procedure]) should be used.

Note: If more than one extension is placed in the same vessel during the same operative session, only one code may be reported.

If a leak is discovered during the postoperative period of the original procedure (34800, 34802 or 34804, all of which have 90-day global periods), and the endovascular extension is subsequently placed, the AMA recommends using modifier -78 (return to the operating room for a related procedure during the postoperative period). If the procedure is staged, however, modifier -58 (staged or related procedure or service by the same physician during the postoperative period) should be used instead, according to the CPT manual.

Open-procedure Conversions

If, during the course of performing an endovascular repair, the surgeon is forced to abandon the procedure and repair the aneurysm via an open procedure, open procedure codes 35081 and 35102 should not be used. Instead, CPT has included three new codes to describe the conversion to an open procedure, all of which reflect higher difficulty than 35081 and 35102 (because of the prior attempt to perform the endovascular repair).

If the prosthesis is anastomosed at both ends to healthy sections of the aorta, code 34830 (open repair of infrarenal aortic aneurysm or dissection, plus repair of associated arterial trauma, following unsuccessful endovascular repair; tube prosthesis) should be used. If the proximal end of the prosthesis is anastomosed to aorta but the distal ends are anastomosed to the iliac arteries, the procedure should be coded 34831 (open repair of infrarenal aortic aneurysm or dissection, plus repair of associated arterial trauma, following unsuccessful endovascular repair; aorto-bi-iliac prosthesis). And, if the common iliac arteries or external iliacs are involved with the aneurysm or have been damaged during the endovascular procedure requiring that the prosthetic limbs be tunneled through the pelvis so that anastomoses are performed at the femoral artery level code 34832 (open repair of infrarenal aortic aneurysm or dissection, plus repair of associated arterial trauma, following unsuccessful endovascular repair; aorto-bifemoral prosthesis) should be billed.

Related Services May Be Billed Separately

All of the endovascular AAA procedures described above are initiated with the introduction of guidewire catheters and an aortogram or other angiography. Typically, the guidewire is maneuvered from the femoral artery through the external and common iliac arteries into the aorta. It is then advanced through the aneurysm itself to a position above where the renal arteries branch off from the aorta. The surgeon uses the guidewire to advance the endovascular prosthesis into position.

The placement of the catheter for this purpose is separately payable, as is the aortography or other angiography performed to map out the patients anatomy so the prosthesis can be correctly implanted. If the catheter is placed nonselectively (that is, into the aorta only), 36200 (introduction of catheter, aorta) should be billed. Sometimes, however, the procedure may require a closer look at the renal arteries to ensure that the placement of the prosthesis does not obstruct the renal arteries. If such a selective catheter placement is performed, 36245 (selective catheter placement, arterial system; each first order abdominal, pelvic or lower extremity artery branch, within a vascular family) is billed in place of 36200.

Note: The renal arteries are considered a first-order branch of the aorta.

Although the introduction to the endovascular AAA subsection states that codes 34800-34826 include vascular access and all catheter manipulations, this does not mean that 36200 or 36245 is bundled to the endovascular repair, says Elaine Elliott, CPC, an independent general surgery coding specialist in Jensen Beach, Fla.

CPT has indicated that vascular access and mapping prior to the procedure which is performed to identify the patients anatomy is separately payable. Included in the endovascular repair codes are any angiograms or x-rays taken during the procedure to aid in the inflation of the prosthesis after it is placed at the site of the aneurysm, Elliot advises. In other words, any pictures taken before the procedure begins to determine the configuration of the blood vessels, such as the renal arteries, are payable.

Elliott worries that payers may not agree with CPTs interpretation of its own guidelines and bundle any vascular access or catheter placement procedure with the endovascular repair. She recommends checking with your local carrier regarding this issue.

Note: Version 7.0 of the national Correct Coding Initiative, which became effective Jan. 1, does not bundle 36200, 36245, or 75952 and 75953 (discussed below) to any of the new endovascular AAA repair codes.

CPT 2001 also includes two new radiology codes for interpretation of the angiography performed in association with the endovascular repair. These may be billed if the surgeon performs the supervision and interpretation (S&I) of the angiogram. Code 75952 (endovascular repair of intrarenal abdominal aortic aneurysm or dissection, radiological supervision and interpretation) should be used if the angiogram is done in connection with the placement of the endovascular AAA prosthesis, whereas 75953 (placement of proximal or distal extension prosthesis for endovascular repair of intrarenal abdominal aortic aneurysm, radiological supervision and interpretation) should be billed in association with the placement of a prosthesis extension.

Note: Surgeons may bill radiology S&I codes, including 75952 and 75953, only if no radiologist is present and the surgeon files a separate radiology report.

Bilateral Procedures Billed Using Modifier -50

For many endovascular AAA repairs, catheter access is required from both of the femoral or iliac arteries. Although 36200 and 36245 are unilateral codes, if catheters are placed on both sides, modifier -50 (bilateral procedure) or modifiers -LT and -RT should not be appended. The catheter on the second side is included in the endovascular repair because it is performed not to examine the patients anatomy before the endovascular prosthesis is placed but rather to aid in its placement.

If direct vascular access is required either to the iliac or femoral arteries on both sides, however, 34812 or 34820 should be appended with modifier -50 or modifiers -LT and -RT. Because of the additional work, Medicare carriers customarily pay such claims at 150 percent of the unilateral rate, says Kathleen Mueller, RN, CPC, CCS-P, an independent general surgery coding and reimbursement specialist in Lenzburg, Ill.

For HCFA claims, the procedure should be billed on one line, as follows:

34812-50

However, some private carriers may require a two-line entry, as illustrated below:

34812
34812-50

Alternatively, claims may be filed using modifiers -LT and -RT, as follows:

34812-LT
34812-RT

Consult your carriers to find out which method they prefer for bilateral procedure claims.

New Codes Boost Reimbursement

CPT 2001s introduction of new codes could mean significant payment increases for endovascular AAA repairs.

Elliot cites the example of a 65-year-old man diagnosed with an AAA. The surgeon determines that the patient is a candidate for endovascular repair using a modular bifurcated prosthesis (34802). While attempting to cannulate the femoral artery, the surgeon is unable to pass the prosthetic sheath due to severe stenotic disease in the patient. Therefore both femoral arteries are opened to place the catheters and deliver the prosthesis (34812). After the prosthesis is in place, angiography shows leakage at the site of one of the devices docking limbs, and an extension is required.

Until the introduction of the new codes, this operative session would have been coded as follows, Elliott says:

37799 (unlisted procedure, vascular surgery)
36200
75630-26 (aortography, abdominal, by serialography, radiological supervision and interpretation; professional component)

The 37799 paid around $1,200-$1,500 in Elliotts home state of Florida.

Now, however, this session would be billed as follows:

34802
34812-50 (or 34812-LT and 34812-RT)
34825
36200
75952-26

According to HCFAs 2001 fee schedule, 34802 is valued at 35.27 RVUs and 34812 is worth 9.94. Code 34825 has been assigned 19.09 RVUs. Because 34812 was performed bilaterally, an additional 4.97 RVUs (50 percent of 9.94) can be added to the RVU total. If HCFAs national conversion rate is applied, this adds up to more than $2,600 for the three procedures.

Bundled and Billable Procedures

The balloon angioplasty performed to inflate the aortic prosthesis is a component of the main endovascular repair code (34800, 34802, 34804). Therefore, an open aortic transluminal angioplasty (35452) or percutaneous aortic transluminal angioplasty (35472) should not be billed in addition to any of these AAA repair codes. Any angioplasty performed during the same session but not related to the repair should be considered a separate and distinct service that may be claimed separately, however.

Also, extensive repair or replacement of an artery, which is not uncommon following 34812 or 34820 both of which involve opening the femoral or iliac arteries to allow passage of the (large) prosthesis may be separately coded. For example, codes 35226 (repair blood vessel, direct; lower extremity) or 35286 (repair blood vessel with graft other than vein; lower extremity) may be billed if a femoral or iliac artery is damaged and requires repair following the arteriotomy to place the prosthesis.

Furthermore, any other interventional procedure performed at the same time as the AAA repair (e.g., renal transluminal angioplasty, arterial embolization, intravascular ultrasound or even balloon angioplasty of native artery or arteries outside the graft whether aortic, femoral or iliac before the deployment of the endoprosthesis) may also be separately billed.