Radiology Coding Alert

Interventional radiologists across the country are embracing a highly effective treatment for women suffering from uterine fibroids called uterine artery embolization (UAE). Although there have been some reimbursement difficulties because the procedure is relatively new, many coding professionals are reporting satisfactory payment ratesprovided they follow a straightforward coding strategy.

According to Scott Goodwin, MD, chief of vascular and interventional radiology at the University of California/Los Angeles Medical Center, the key to maximizing reimbursement begins with proper assignment of the diagnostic code. It is imperative that the radiologist provide an accurate ICD-9 code, he says. Embolization, in general, has been used to stop hemorrhages for a long timethree decades or moreand third-party payers are familiar with it under these circumstances. Nonetheless, many insurers are not acquainted with the use of embolization to treat uterine fibroid disease. Weve been using it as a method of treatment for only a few years, since the early 1990s.

Goodwin adds that he expects UAE use to grow because, in his experience, about 85 percent of the women who have undergone the procedure achieve substantial or complete resolution of their symptoms.

Diagnostic Codes for Abnormal Bleeding Produce Fewest Denials

Clearly, if the primary clinical reason for the UAE is to control hemorrhage, either on an acute or chronic basis, the ICD-9 code should reflect this fact. If the primary clinical concern is other than hemorrhage, however, the appropriate code for the clinical indication should be used. Under no circumstances should an ICD-9 code be chosen merely to improve reimbursement.

In most cases, Goodwin notes, an ICD-9 code from the 626-series is most successful (disorders of menstruation and other abnormal bleeding from female genital tract). According to Jackie Marrero, interventional billing specialist for the UCLA Radiology Medical Group, their practice generally assigns 626.2 (excessive or frequent menstruation [heavy periods, menorrhagia, menometrorrhagia, plymenorrhea]).

We have had the most success when we were able to use this diagnostic code, says Goodwin, who pioneered the use of UAE in the United States and estimates he has performed 250 of the procedures. In some instances, however, women dont experience abnormal bleeding with fibroid disease. They may be enduring a great deal of pain without bleeding, secondary to their uterine fibroids.

Under these circumstances ICD-9 625.9 (unspecified symptom associate with female genital organs) or 218.9 (leiomyoma of uterus, unspecified) may be assigned. We have had more denials when we have had to assign codes reflecting fibroids and pain without the abnormal bleeding, Goodwin notes.

Members of the Society of Cardiovascular and Interventional Radiology (SCVIR) concurs with Goodwins assessment of the diagnostic coding issue. SCVIR reports that there seems to be no consensus among insurers yet about which ICD-9 Codes to assign for UAE. Some accept bleeding codes, while others require a more specific fibroid code. Currently, anecdotal evidence indicates that bleeding codes seem to work better in terms of payment, but SCVIR experts speculate that the fibroid code may prevail because it specifically describes whats being treated.

Correct ICD-9 coding does allow for the description of both the most proximate coinical reason as well as
the underlying cause. As stated earlier, however, the correct coding for the service should be guided by actual clinical circumstances.

UAE Typically Comprises Three Procedure and Three S&I Codes

After an initial consultation, candidates for UAE may undergo an ultrasound examination (76856 [echography, pelvic (nonobstetric), B-scan and/or real time with image documentation; complete]) to determine the location and size of the fibroids. At the same time, a baseline measure of blood flow to the region is established. If this procedure has been performed previously and is of appropriate quality, it need not be repeated.

The procedure is performed in an angiography suite and conducted under conscious sedation. The patient commonly is held overnight and released for a five- to seven-day recovery period.

Typically, interventional radiologists will employ a unilateral groin approach. Using local anesthesia, the physician accesses the common femoral artery and inserts a catheter, which is guided through the iliac and internal iliac arteries to the uterine artery.

After the catheter is positioned where the uterine artery divides into multiple vessels supplying blood to the fibroids, an arteriogram is performed to pinpoint the precise location of the growths. The interventional radiologist then injects minute plastic (polyvinyl alcohol or PVA) and/or gelatin sponge particles into the vessels. The particlesas small as grains of sandflow to the fibroids, wedge in the vessels and slowly block the blood flow to the fibroids. The obstruction starves the fibroids, and they begin to shrink.

According to Goodwin, six basic codes typically are assigned to the procedure. Practices generally use a single embolization and two catheterization codes to describe UAEs, he says, in addition to three supervision and interpretation codes. He adds, however, that the precise catheterization codes may differ from patient to patient, depending on how the procedure progresses.

Embolization code: Code 37204 is assigned for the embolization (transcatheter occlusion or embolization [e.g., for tumor destruction, to achieve hemostasis, to occlude a vascular malformation], percutaneous, any method, non-central nervous system, non-head or neck).

Catheterization codes: Code 36246 (initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family) is assigned for ipsilateral (same side as initial access) catheter placement if the uterine artery rises from the internal iliac trunk. CPT code 36247 (initial third order or more selective abdominal, pelvic or lower extremity artery branch, within a vascular family) would be assigned if the uterine artery rises from the anterior/posterior division of the internal iliac.

In addition, CPT code 36248 (additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch within a vascular family [list in addition to code for initial second or third order vessel as appropriate]) may be assigned for additional placements in the internal iliac artery, if any are necessary.

CPT code 36247 also may be assigned for contralateral placement (opposite side from inital access). The precise number of surgical codes should be guided by the actual performance of the procedure. Therefore, an accurate and complete written or dictated operative note by the performing interventionist is mandatory to guide and support the coding of these procedures.

Goodwin notes that it is far more typical for a radiologist to use an approach resulting in CPT codes 36247 and 36248, than 36246 and 36248. In fact, we virtually never bill a 36246 with a UAE, he says.

The radiological supervision and interpretation codes that accompany these procedures include:

75894transcatheter therapy, embolization, any method, radiological supervision and interpretation(accompanies 37204)

75736angiography, pelvic, selective or supraselective, radiological supervision and interpretation (accompanies 36246 or 36247)

75774angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation (list separately in addition to code for primary procedure) (accompanies 36248)

An interventional radiologist sometimes will choose a bilateral approach and, in these instances, the above catheterization codes may be assigned twice. SCVIR recommends, however, that the embolization code be assigned only once, noting that interventional radiology coding conventions, as provided for by the SCVIR coding
guide, indicate that embolization is based on an operative field. Therefore, only one embolization code should be reported, even though both uterine arteries are embolized.

There is no additional coding for the embolic material used in the professional coding schema. Coding for institutional costs include revenue codes for room time, disposable supplies, pharmacy supplies, implantables and radiology technical components.

(Editors Note: Michael Mabry, SCVIR, and Gary Dorfman, MD, FACR, FSCVIR, past president of SCVIR and current president of Health Care Value Systems in Rhode Island, contributed to this article.)