Radiology Coding Alert

Prevent refund requests by understanding proper coding for TP trunk services.

If you've got a handle on the new iliac and femoral/popliteal revascularization codes, you're on your way to mastering the tibial/peroneal codes, as well. But this last group has rules all its own. Here's what you need to know.

Reminder: This article will focus on the tibial/peroneal codes 37228-+37235. "37220 to +37223 Create an All New Iliac Intervention Coding World" in Radiology Coding Alert, vol. 13, no. A, discussed the iliac codes, and "37224-37227 Revolutionize Your Femoral/Popliteal Coding Options" in vol. 13, no. 3, explained the femoral/popliteal codes.

Initial/Additional Designation Is Key to Accuracy

The new tibial/peroneal service codes are below. Note that all of the codes include angioplasty in the same vessel when that service is performed.

Initial vessel: The first four codes apply to the initial tibial or peroneal vessel treated in a single leg:

• Angioplasty: 37228 -- Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, initial vessel; with transluminal angioplasty
• Atherectomy (and angioplasty): 37229 -- ... with atherectomy, includes angioplasty within the same vessel, when performed
• Stent (and angioplasty): 37230 -- ... with transluminal stent placement(s), includes angioplasty within the same vessel, when performed
• Stent and atherectomy (and angioplasty): 37231 -- ... with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed.

Additional vessel: The final four codes are add-on codes that you use to report services on each additional ipsilateral (same side) vessel treated in the tibial/peroneal territory. Heed the "use with" notes following each descriptor:

• Angioplasty: +37232 -- Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal angioplasty (List separately in addition to code for primary procedure) (use with 37228-37231)
• Atherectomy (and angioplasty): +37233 -- ... with atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure) (use with 37229-37231)
• Stent (and angioplasty): +37234 -- ... with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure) (use with 37230-37231)
• Stent and atherectomy (and angioplasty): +37235 -- ... with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure) (use with 37231).

Remember: The general rule for the revascularization codes is that you should report the one code that represents the most intensive service performed in a single lower extremity vessel. All lesser services in that vessel are included in that one code.

Consider These Services Included in the New Codes

As explained in previous issues of Radiology Coding Alert, CPT guidelines state that -- in addition to the intervention performed -- the codes include:

• Accessing the vessel
• Selectively catheterizing the vessel
• Crossing the lesion
• Radiological supervision and interpretation for the intervention performed
• Any embolic protection used
• Closure of arteriotomy (incision in the artery)
• Imaging performed to document the intervention was completed.

But remember: If the physician performs mechanical thrombectomy (such as 37184-+37185, primary, or +37186, secondary), thrombolysis (such as 37201, 75896), or both, to help restore blood flow to the occluded area, CPT states you may report those services separately.

Count Vessels Carefully -- Especially TP Trunk

The new revascularization codes (37220-+37235) apply to different "territories," which each have distinct guidelines. Codes 37228-+37235 fall under the tibial/peroneal vascular territory.

Sean P. Roddy, MD, FACS, AMA CPT advisory committee member, and Gary R. Seabrook, MD, AMA/specialty society relative value scale update committee member, prepared a presentation on the new codes for the AMA's CPT and RBRVS 2011 Annual Symposium in Chicago. They noted that the tibial/ peroneal arteries include:

As you can see, this list equates to three vessels in each leg for the tibial/peroneal territory. Because you may report one code per vessel, you may use one initial code and up to two add-on codes per leg (for a total of three vessels). The three-vessel approach is similar to the iliac territory, but it differs from the femoral/popliteal territory, which counts as a single vessel for coding.

Keep in mind that -- because the codes apply per vessel -- you should not report add-on codes for additional lesions treated in a single vessel. CPT is very clear that "when more than one stent is placed in the same vessel, the code should be reported only once." In addition, in some cases, a lesion may extend from one artery into another. If the radiologist can treat that lesion with a single intervention, then you should choose a single code to report that service.

Mark this: Work performed on the tibioperoneal (TP) trunk is bundled into the code you choose for peroneal or posterior tibial work, Roddy and Seabrook's presentation noted. As the CPT guidelines explain it, "The common tibial-peroneal trunk is considered part of the tibial/peroneal territory, but is not considered a separate, fourth segment of vessel in the tibio-peroneal family for CPT reporting of endovascular lower extremity interventions." The guidelines go on to indicate that if the physician treats lesions in the TP trunk as well as in the PT artery, you should choose a single code.

Master Coding for 2 Legs or 2 Territories

The new revascularization codes are unilateral, which means they apply to a service on a single side of the body. CPT indicates that if the physician treats the identical territory (such as tibial/peroneal) in both legs at the same session, you should use modifier 59 (Distinct procedural service) to show both legs are involved.

But watch out for payers' modifier preferences. Some may prefer you to use modifier 50 (Bilateral procedure), modifiers RT (Right side) and LT (Left side), or some combination of modifiers for procedures on both legs.

On the other hand: If the radiologist treats more than oneterritory in the same leg, then you should report multiple codes, according to CPT. For example, if the radiologist places a stent in the peroneal and performs angioplasty in the internal iliac, you should report both 37230 for the peroneal service and 37220 (Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty) for the iliac service. These are both "initial" codes because each service is the "initial" service in a distinct territory.

Apply the Tibial/Peroneal Lessons to This Example

The Roddy and Seabrook presentation included a sample case in which a patient has a three-vessel tibial artery occlusion proven by angiography. The physician uses antegrade femoral access and selectively catheterizes the AT, PT, and peroneal arteries. He performs atherectomy in the TP trunk and the AT, PT, and peroneal arteries. He then performs percutaneous transluminal angioplasty (PTA) in the same vessels.

Solution: The codes you should report are:

• AT atherectomy: 37229
• PT atherectomy: +37233
• Peroneal atherectomy: +37233-59.

Note the use of modifier 59 on the second atherectomy code to make it clear that it is a distinct service in a separate vessel.

Remember that you will not report every service performed using a separate code. You should bundle the TP trunk atherectomy into the peroneal or PT intervention. You also should not code selective catheterization or angioplasty separately.