General Surgery Coding Alert

The crucial difference among these procedures is the type of prosthesis employed. Consequently, coders must be especially careful of terminology to guarantee proper code selection, says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver.

Code 34800 describes placement of an endovascular tube graft in the aorta. To position the graft appropriately the surgeon may pass guidewires/catheters from both the left and right iliac arteries, however.

Code 34802 describes placement of a more complex prosthesis, which extends in the shape of an upside-down "Y" from the aorta into the right and left common iliac arteries, Barone says. The design consists of two pieces (i.e., modular), with a primary portion positioned in the aorta and extending to one iliac artery and a "docking" limb placed in the other iliac artery and extending upward to meet with the primary portion.

Note: For endovascular repair of infrarenal AAA or dissection using a modular bifurcated prosthesis with two docking limbs (a docking limb in each of the iliac arteries meeting a primary portion in the aorta), CPT directs you to Category III code 0001T (Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; modular bifurcated prosthesis [two docking limbs]).

Code 34804 also describes a bifurcated graft (that is, it extends from the aorta into both iliac arteries in the same, upside-down "Y" shape), but one comprised of a single piece (unibody) rather than a primary portion and one or two docking limbs. The prosthesis is custom-made to match the patient's anatomy. The procedure includes passing a special contralateral iliac limb guidewire into the aorta. The physician captures the wire using a snare advanced through the arteries from the opposite groin, and he or she then pulls the contralateral graft limb downward from the aorta into the opposite iliac artery.

Code Extensions Separately

On occasion, the surgeon may choose to place extension cuffs at the ends of the prosthesis, either because the extension is necessary to reach past the aneurysm or because he or she has detected an endo-leak (often, postoperatively) at the proximal or distal end(s) of the prosthesis.

Report placement of an extension or extensions (see below) in the initial vessel using 34825 (Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, or dissection; initial vessel). If more than one vessel requires an extension, use +34826 (... each additional vessel [list separately in addition to code for primary procedure]) for each additional vessel.

When the surgeon must place extensions due to a leak detected postoperatively and within the (90-day) global period of the primary procedure (34800-34804), the AMA recommends appending modifier -78 (Return to the operating room for a related procedure during the post-operative period) to the appropriate extension code(s). will alert that payer that the return to the operating room was neither planned nor included in the original procedure.

Note that CPT defines 34825/34826 as "initial" or "additional" vessel, not "initial" or "additional" cuff. From a coding standpoint, only the number of vessels matters not the number of cuffs placed and you should report multiple cuffs placed in the same vessel only once. For instance, report two cuffs placed in the right iliac artery using 34825 only (because the surgeon repaired only one vessel).

Next month: Part 2 Reporting separate, related procedures, including catheter placement, radiological supervision and interpretation, direct arterial access, endoscopic-to-open procedure conversions, as well as billing co-surgery with a general surgeon and interven-tional radiologist.