Radiology Coding Alert

Proper +37222 use depends on this term tip.

Looking for a way to put your revascularization coding skills to the test without the worry of auditors second guessing your choices?

Try your hand at this case study excerpt, provided by Stacy Gregory, CCC, CPC, RCC, of Gregory Medical Consulting, at the 2011 Coding Update and Reimbursement Conference (www.codingconferences.com). Then see if the CPT® codes and modifiers you choose match the expert's.

Size Up This Case and Choose Your Codes

DESCRIPTION OF PROCEDURE:

... After induction of general anesthesia the patient's groins were prepped and draped in the usual sterile fashion. Using a micropuncture set, access to both common femoral arteries was obtained in a retrograde manner. Both sites were secured with 0.035 J wires and 6-French Introducer sheaths were set in place. In the right lower extremity, the 6-French introducer sheath was then exchanged by a 9-French introducer sheath using a Glidewire. The Glidewire was advanced to the iliac artery bifurcation. The patient had aneurysmal disease and a complete occlusion of this iliac artery.

A crosser device was then brought into the field. It was gently advanced to the common iliac artery right at the level of the complete occlusion. Using the crosser device we were able to obtain access to the infrarenal aorta. A 0.014 hydrophilic J-wire was then passed into the aorta. A glide catheter was passed over the wire and infrarenal aorta access was verified. A 6 x 40 angioplasty balloon was then used to angioplasty the area of stenosis in the common iliac artery. An 8x 59-mm atrium covered stent was then deployed from the takeoff of the infrarenal aorta into the lilac bifurcation. Using a 10 x 40 Conquest balloon the stent was then post balloon obtaining a complete resolution of the area of the stenosis along with complete coverage of the aneurysm and resolution of the problem. There is very rapid flow into the ipsilateral external iliac and common femoral systems.

Using an SOS Omni flush catheter several attempts to pass the complete occlusion of the left common iliac artery were made from both sides, the left common femoral access and the contralateral iliac access. A Glidewire was advanced. A 6 x 40 angioplasty balloon was then used to angioplasty both areas to 8 atmospheres. There was good flow from the iliac system.

There was a question whether the patient had significant areas of calcification over the common iliac artery extending into the external iliac artery and therefore, I opted not to place a stent in this area as the hypogastric can crack and rupture.

The wires and catheters were removed from the patient's body and Mynx devices were deployed into both the common femoral arteries for hemostasis. The patient tolerated the procedure well and was transferred to the recovery room in stable condition.

Take on Right Iliac Angioplasty and Stent

In this case, the physician accessed both the right and left femoral arteries. He advanced the Glidewire to the iliac bifurcation, recording aneurysmal disease and complete occlusion in the right common iliac. He angioplastied the right common iliac area of stenosis and deployed a stent.

For this collection of procedures, you should report 37221 (Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement[s], includes angioplasty within the same vessel, when performed), says Gregory.

The definition spells out that this code includes both stent deployment and angioplasty, so you should not report a separate code for the angioplasty.

Helpful: CPT® guidelines state the balloon angioplasty and stent may be of a variety of types. Angioplasty possibilities include low-profile, cutting balloon, or cryoplasty, while the stent may be balloon-expandable, self-expanding, bare metal, covered, or drug-eluting.

Now, Capture Left Iliac Angioplasty

After completing the right iliac intervention, the physician approached the left common iliac stenosis from both left femoral access and contralateral (opposite side) access. He angioplastied the left common iliac, but he chose not to place a stent. He then used vascular closure devices to control bleeding at both access points.

For this collection of services you should report 37220 (... with transluminal angioplasty), says Gregory.

Caution: You may be tempted to report +37222 (Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty [List separately in addition to code for primary procedure]) for this angioplasty because the code definition refers to an additional iliac vessel. But +37222 would not be correct.

Here's why: In this sample case, you're reporting a service in the right leg and an additional service in the left leg. A key word in the definition of +37222 is ipsilateral, which means "same side." So you should use +37222 only for an additional iliac vessel in the same leg as the first iliac vessel treated. (Keep in mind that "vessel" has a specific definition in the revascularization guidelines: "The iliac territory is divided into 3 vessels: common iliac, internal iliac, and external iliac.")

Mix in Your Modifiers to Show 2 Legs

CPT® guidelines for the revascularization codes tell you that "When the same territory(ies) of both legs are treated in the same session, modifiers may be required to describe the interventions. Use modifier 59 [Distinct procedural service] to denote that different legs are being treated, even if the mode of therapy is different."

You also may have payers who want you to append modifiers showing which side was treated: LT (Left side) and RT (Right side).

In our example, the same territory (iliac) was treated in both legs. So your final codes may appear as follows, notes Gregory:

• 37221-RT
• 37220-LT-59.

Heed the Rules on What's Included

As noted previously, code 37221 includes both angioplasty and stent deployment. In fact, "each code in this family (37220-37235) includes balloon angioplasty, when performed," guidelines state.

Additionally, to quote CPT® guidelines, the codes include:

• Accessing and selectively catheterizing the vessel
• Traversing the lesion
• Radiological supervision and interpretation directly related to the intervention(s) performed
• Embolic protection if used [devices designed to capture debris released by the procedure]
• Closure of the arteriotomy by any method [including the deployment of Mynx devices mentioned in the sample report excerpt]
• Imaging performed to document completion of the intervention in addition to the intervention(s) performed.