Part B Insider (Multispecialty) Coding Alert

Coding peripheral vascular services in addition to cardiac catheterizations is one of the trickiest areas of an already tricky specialty.

Case in point: If you don't know when to use a HCPCS code -- rather than a CPT® code -- for renal angiography, you're setting your practice up for serious scrutiny and unpleasant payback requests.

To keep your claims in the clear, master these essential pointers for G0275 (Renal angiography, non-selective, one or both kidneys, performed at the same time as cardiac catheterization and/or coronary angiography, includes positioning or placement of any catheter in the abdominal aorta at or near the origins [ostia] of the renal arteries, injection of dye, flush aortogram, production of permanent images, and radiologic supervision and interpretation [List separately in addition to primary procedure]).

Jump 3 Hurdles Before Reporting G0275

Before submitting a claim for G0275, be sure you consider these three requirements:

1. Medicare patient: Code G0275 was created for use on Medicare claims, says Jessica Chandler, CPC CPC-H, CPC-P, CCC, certified coder with WV Heart & Vascular Institute in South Charleston. Coders often make the mistake of reporting the code to non-Medicare payers who don't accept the code.

Payers that follow Medicare guidelines may choose to accept the code, but you should check with the individual payer before submitting G0275, says Christina Neighbors, MA, CPC, CCC, ACS-CA, charge capture reconciliation specialist and coder at St. Joseph Heart & Vascular Center in Tacoma, Wash.

2. Cardiac cath, too: The code definition states "performed at the same time as cardiac catheterization and/or coronary angiography." If the patient doesn't have a cardiac cath or coronary angiography at the same session, you should not report G0275.

3. Non-selective: Before you report G0275, check the documentation to be sure the service was non-selective, says Chandler. Only then does the code apply. Coders often make the mistake of using the code for selective renal angiograms, Chandler warns. But different codes apply if the physician performs selective renal angiography, as described below.

Dive Deeper Into When G0275 Does and Doesn't Apply

The G0275 service essentially describes a service where, after the physician performs a cardiac or coronary cath, he pulls the catheter back through the aorta and pauses above the renal arteries. The physician "shoots the dye and allows it to run into the renal arteries," says Chandler.

The service may sound straightforward, but payers still have specific requirements for medical necessity, like any other diagnostic study. The documentation needs to show the renal angiography was medically reasonable and necessary. The G0275 service is usually done in patients with certain types of "hypertension, CKD [chronic kidney disease], previous renal artery stenosis, or renal failure," says Chandler.

For instance, First Coast Service Options, Part B MAC for Florida, lists very specific requirements for the service in LCD L29941:

1. Suspicion for atherosclerotic renal artery stenosis (RAS) must be high, as defined by additional criteria in the policy, such as malignant hypertension or unexplained renal failure, AND

2. "There are reasonable anticipated therapeutic implications for which the results of this angiogram will be used," AND

3. "The results of noninvasive imaging studies cannot be obtained or are inconclusive."

Providers reporting to Trailblazer have a similar set of defined indications (LCD L31450). An important reminder in the Trailblazer policy is that the coverage requirements for renal angiography with cardiac cath are just as strict as for renal angiography performed as a separate service. In either case, coverage is considered if noninvasive imaging isn't available, conclusive, or appropriate for a patient with:

• Abdominal trauma
• Primary vascular abnormalities, including aneurysms, vascular malformations, and vasculitis
• Renal tumors (diagnosis and staging)
• Preoperative and postoperative evaluation for renal transplantation
• Renal Artery Stenosis (RAS) when additional coverage indications are met (such as renovascular hypertension and unexplained recurrent pulmonary edema).

Bottom line: A G0275 service isn't something that should be performed on every cardiac cath patient. Before you report this code, be sure the documentation clearly meets medical necessity requirements defined by the payer.

Avoid G0275 for Selective Services

If the physician decides a patient requires selective renal catheterization, you should not report G0275. This is true even when the physician performs both non-selective and selective renal angiography. You should bundle the non-selective service into the selective.

In other words, "if the physician states that the catheter was placed in the renal artery, that completely wipes out" G0275, says Chandler.

Remember that there are four new codes for selective renal angiography in 2012. Key elements distinguishing the codes include whether the service is first order or higher and whether the service is unilateral or bilateral:

• 36251, Selective catheter placement (first-order), main renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; unilateral
• 36252, ... bilateral
• 36253, Superselective catheter placement (one or more second order or higher renal artery branches) renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture, catheterization, fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; unilateral
• 36254, ... bilateral.

Reminder: "Renal arteries that originate from the aorta are first order and each bifurcating branch within the renal is a second or higher order (example: superior and/or inferior branches)," says Neighbors.

Watch for the Uncommon Aortogram

In rare cases, the physician may decide a patient requires abdominal aortic angiography based on medical necessity. In particular, the physician may suspect abdominal aortic aneurysm (AAA) based on what he sees on the cardiac cath, leading him to perform a diagnostic aortogram before removing the catheter from the patient. ›› ›››› ››

In these rare cases, you should report an aortography code, such as 75625 (Aortography, abdominal, by serialography, radiological supervision and interpretation). Code G0275 would not apply because the purpose of the imaging is to look at the aorta rather than the renals. Similarly, +93567 (Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for supravalvular aortography [List separately in addition to code for primary procedure]) would be incorrect, says Neighbors.

Smart move: On your claim, remember to append modifier 59 (Distinct procedural service) to 75625 to indicate the separate nature of the service, Neighbors says. The physician's documentation should clearly state the reason for the imaging, the location of the catheter when the injection and imaging is performed, the precise anatomic areas studied, and the findings. Because of common misuse of 75625 with cardiac caths, payers may initially deny the aortography code or may require supporting documentation.

Beware: If you report 75625 when documentation instead supports G0275, expect a payback request. Medicare's national rate for 75625-26 (Professional component) is around $56 compared to less than $13 for G0275 on the physician fee schedule.

Try a Renal Angiography Example

Suppose the cardiologist performs left heart catheterization with LV-gram in addition to right and left coronary angiography, documenting findings. Then, due to a history of uncontrolled hypertension, the physician withdraws the catheter in the aorta, stops above the renal arteries, and performs contrast injection to view the renals, finding 70 percent stenosis on the right.

You should report:

• The LHC and coronary angiography using 93458 (Catheter placement in coronary artery[s] for coronary angiography, including intraprocedural injection[s] for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection[s] for left ventriculography, when performed)
• The non-selective renal angiography using G0275.