Radiology Coding Alert

Hint:  Match the new RS&I and surgery codes

Don't be fooled by the new codes for endovascular repair of the descending thoracic aorta. The procedures may be similar to AAA repair, but you have a new set of rules to master, such as knowing whether you can code for distal extensions.

CPT Codes 2006 replaced category III codes 0033T-0037T with endovascular repair codes 33880-33889. CPT also swapped category III codes 0038T-0040T for radiology supervision and interpretation (RS&I) codes 75956-75959.
 
A change from category III codes is always welcome, says Marylin Brinkman, CPC, radiology coding specialist for Clarian Health in Indiana. Dedicated CPT I codes tend to make coding and receiving reimbursement easier.

CPT 2006 also added code 33891 to cover specific surgical bypass procedures performed in conjunction with endovascular repair of the descending thoracic aorta.

Decipher Code Changes to Avoid Denials

Apply the new codes when your physician repairs the descending thoracic aorta using an endovascular graft and/or supplies radiological supervision and interpretation.
 
These procedures are similar to the ones doctors have been performing for years to treat abdominal aortic aneurysm (AAA). "The key difference is that the anatomic area being treated is in the thoracic aorta--the portion of aorta between the abdominal aorta and the aortic arch," says Jim Collins, ACS-CA, CHCC, CPC, a coding consultant in Matthews, N.C.  

These codes differ from the existing AAA extension graft codes (34825-34826). For the new codes, you should separately code each graft your physician deploys rather than "each vessel" as you do with the AAA codes, Collins says.

Distal extensions: Unlike the traditional AAA repair codes, these endovascular thoracic repair codes include any distal extensions deployed at the time of the procedure to the celiac artery level.
 
Example: A patient undergoes endovascular repair of a descending thoracic aortic aneurysm with coverage of the left subclavian origin. The physician places two distal extensions.
 
What to do: Report one unit of 33880 (Endovascular repair of descending thoracic aorta [e.g., aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption]; involving coverage of left subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension[s], if required, to level of celiac artery origin), says Jackie Miller, RHIA, CPC, senior consultant for Coding Strategies Inc. in Powder Springs, Ga. Don't report codes for the placement of the distal extensions, because that is included in 33880, she adds.  Remember: You should watch for other separately reportable procedures, Miller says.

Proximal extensions: If your physician uses proximal extensions at the time of the initial graft deployment, you should report them separately with these new codes:

• 33883--Placement of proximal extension prosthesis for endovascular repair of  descending thoracic aorta (e.g., aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); initial extension

• +33884--...each additional proximal extension (list separately in addition to code for primary procedure).

Documentation should include justification for the physician's use of any additional proximal extensions.

Distal extensions at a later date: You may separately report distal extension prostheses deployed at a later date. For this, use 33886 (Placement of distal extension prosthesis[s] delayed after endovascular repair of descending thoracic aorta).

The new endovascular repair section also includes codes for surgical transposition of the subclavian to the carotid artery with endovascular repair of the descending thoracic (33889, Open subclavian to carotid artery transposition performed in conjunction with endovascular repair of descending thoracic aorta, by neck incision, unilateral) and a carotid-carotid bypass graft with an endovascular repair of the descending thoracic (33891, Bypass graft, with other than vein, transcervical retro-pharyngeal carotid-carotid, performed in conjunction with endovascular repair of descending thoracic aorta, by neck incision).

RS&I: Don't be afraid to code fluoroscopic guidance separately using codes 75956-75959. As with the AAA repair codes, you can report both the procedure and the RS&I necessary to place the graft and confirm its successful deployment. Codes 75956-75959 include diagnostic imaging angiography before primary endovascular device deployment, fluoroscopic guidance in the delivery of the endovascular component, and intraprocedural arterial angiography. If your radiologist only provides RS&I, then only report the RS&I code.

Cross Out These Codes

The new "Endovascular Repair of Descending Thoracic Aorta" section in your CPT manual has specific guidelines for reporting these new codes. It's really useful to have so much guidance about which procedures are bundled with thoracic aorta repair, says Kristin Simpson, a consultant in Yorba Linda, Calif.

Services not separately reportable: You should avoid reporting the following services with 33880-33891, according to the CPT guidelines:

• any additional codes for work your physician does to introduce, position, or manipulate the device

• balloon angioplasty or stent deployment either before or after endograft deployment in the targeted treatment area, Collins says.

Example: A patient presents with a type I endoleak 11  months after endovascular repair of a descending thoracic aortic aneurysm. The physician deploys a proximal endovascular extension. As part of the procedure, the physician guides a balloon through the pelvis, abdominal, and descending thoracic aorta and into the new component. The physician inflates the balloon to seat the component and check for leaks.

What to do: Report 33883 for the proximal extension, but don't report a separate code for the balloon. The balloon angioplasty is included in the work for 33883.

Avoid Reporting These Codes Together

For a distal extension prosthesis, you can use 33886 (Placement of distal extension prosthesis[es] delayed after endovascular repair of descending thoracic aorta), but only for procedures performed after the initial operation. A note with code 33886 tells you not to report it with 33880 or 33881 (Endovascular repair of descending thoracic aorta [e.g., aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption]; not involving coverage of left subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension[s], if required, to level of celiac artery origin).

Also, CPT says that you can't report 33889 (Open subclavian to carotid artery transposition performed in conjunction with endovascular repair of descending thoracic aorta, by neck incision, unilateral) with 35694 (Transposition and/or reimplantation; subclavian to carotid artery). Code 35694 stands on its own, while you'll find that 33889 is similar to an add-on code because the definitions says you can only report this code together with another specific procedure, Collins says.

You can't report 33891 (Bypass graft, with other than vein, transcervical retropharyngeal carotid-carotid, performed in conjunction with endovascular repair of descending thoracic aorta, by neck incision) with 35509 (Bypass graft, with vein; carotid-carotid) or 35601 (Bypass graft, with other than vein; carotid), according to a note with code 33891.