Radiology Coding Alert

Don't confuse the rules for these codes with those for 37220-+37235.

You may have mastered the 2011 Category I updates for revascularization coding, but if you ignore Category III codes, your claims aren't fully compliant. You also could be cheating yourself of future Category I codes.

Codes 0234T-0238T are the key to coding supra-inguinal atherectomy correctly. Here's a breakdown of these codes, what they include, what you may code separately, and when you'll use these codes. The codes in focus are below:

Get a Grip on New Codes With Terminology Primer

The glut of new atherectomy-related codes is partially due to atherectomy being flagged by a RUC (Relative-Value Update Committee) screen for excessive growth, noted the presentation by AMA CPT^® Advisory Committee member, Sean P. Roddy, MD, FACS, and AMA Specialty Society Relative Value Scale Update Committee member Gary R. Seabrook, MD, at the AMA's CPT^® and RBRVS 2011 Annual Symposium.

Category I codes were created for "PTA, stent, and atherectomy interventions from the aortic bifurcation distally," the presentation noted. So those codes essentially relate to the lower extremities. (See 37220-+37235.)

Supra-inguinal: The AMA created Category III codes for atherectomy in the supra-inguinal vessels, the presentation explained. Supra-inguinal means above (supra-) the inguinal ligaments (which essentially run from the lower, central part of the pelvis to the outer, top of each hip bone). From the code definitions, you can see that the vessels involved are the renal artery (0234T), non-renal visceral arteries (0235T), the abdominal aorta (0236T), the brachiocephalic (innominate) trunk and branches (0237T), and iliac artery (0238T). For more on coding iliac artery services -- which fall under both the new Category I and Category III codes -- see "Focus on Iliac Code 0238T" below.

Atherectomy: Each code descriptor starts with "Transluminal peripheral atherectomy." Transluminal means the physician passes a catheter along the lumen (cavity) of a blood vessel. Peripheral indicates a noncoronary artery. And atherectomy refers to excising plaque from inside the vessel. The physician may use directional, rotational, or laser methods, for example, state CPT^® guidelines preceding 0234T.

Approach: The common portion of the code descriptors also specify "open or percutaneous." That means these codes are appropriate for both approaches. The physician may make an open incision. Alternatively, the physician may access the vessel percutaneously, meaning through a small incision in the skin.

Include RS&I, Report Catheterization Separately

The common portion of the 0234T-0238T code descriptors spells out that the codes include radiological supervision and interpretation (RS&I). That means you should not report the following radiology services separately, noted Roddy and Seabrook.

Report cath separately: Although RS&I is included in 0234T-0238T, you may report catheterization separately, Roddy and Seabrook explained.

This instruction to code accessing and selectively catheterizing the vessel differs from the new Category I lower extremity atherectomy codes that include catheterization: 37225 and 37227 (Revascularization ... femoral/popliteal artery[s] ...); 37229, 37231, +37233, and +37235 (Revascularization ... tibial/peroneal artery ...).

Furthermore, unlike the Category I codes for atherectomy below the inguinal ligaments, CPT^® guidelines with 0234T-0238T tell you that those codes do not include the work of "traversing the lesion, embolic protection if used, other intervention used to treat the same or other vessels, or closure of the arteriotomy (by any method)."

So be sure you separately report appropriate codes for catheterization, any diagnostic studies, and any additional interventions performed at the same session as the supra-inguinal atherectomy.

Focus on Iliac Code 0238T

If you take a look at the new Category I revascularization codes (37220-+37235) and the new Category III atherectomy codes (0234T-0238T), you'll see one vascular territory listed in both: iliac. Here's what that overlap means for your coding when angioplasty or stent placement is also performed.

Basic rule: For most of the new codes in the 37220-+37235 range, you should report the one code that represents the most intensive service performed in a single lower extremity vessel. All lesser services are included in that code.

For example, if the physician both placed a stent and performed an atherectomy in in a popliteal artery, you would report only 37227 (Revascularization, endovascular, open or percutaneous, femoral, popliteal artery[s], unilateral; with transluminal stent placement[s] and atherectomy, includes angioplasty within the same vessel, when performed).

Iliac difference: Iliac coding is an exception to the basic rule. If the physician performs iliac atherectomy in the same vessel as angioplasty or stent placement, it is appropriate to report one code for atherectomy (0238T) and a second code for the angioplasty and/or stent placement, such as 37221 (Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement[s], includes angioplasty within the same vessel, when performed).

Requirement: Use Cat. III When It's Available

If you ever feel the slightest temptation to substitute an unlisted procedure code for a Category III code, remember this: When a Category III code is available for a service or procedure, CPT^® requires you to use that code rather than an unlisted procedure Category I code.

CPT^® creates Category III codes for emerging technologies, services, or procedures. Use of the Category III code allows tracking of their use. That information plays a role in deciding whether the Category III code will be replaced with a more permanent Category I code.

Resource: Because the AMA releases Category III codes in January and July, you may find a number of additions or deletions between published CPT^® manuals. Check the AMA website for updates and descriptions for all Category III codes: http://www.ama-assn.org/ama1/pub/upload/mm/362/CPTcat3codes.pdf.