Radiology Coding Alert

Whether the radiologist works on the left or right side can change your coding.

ICD-9 offers you only one option for pelvic congestion syndrome (PCS), but picking the proper CPT codes for the treatment isn't as simple. Here's how to pair the appropriate ovarian vein embolization codes with the case you're reporting.

ICD-9: Pick 625.5 for PCS Claim Success

When the documentation states a patient has pelvic congestion syndrome (PCS), the appropriate code is 625.5 (Pelvic congestion syndrome). The syndrome essentially describes varicose veins in the pelvis, which can cause pain and affect anatomical structures, such as the uterus, ovaries, and vulva, says Melanie Witt, RN, CPC, COBGC, MA, an ob-gyn coding expert based in Guadalupita, N.M.

The ICD-9 manual indicates that this diagnosis code is appropriate for female patients only and that 625.5 is also appropriate for "congestion-fibrosis syndrome" and "Taylor's syndrome." Other terms you may see for PCS include chronic pelvic pain (CPP) syndrome or pelvic venous incompetence.

Look ahead: The current expectation is that U.S. payers will require ICD-10 codes, rather than ICD-9, beginning Oct. 1, 2013, and many practices are preparing for the transition already. If you search the 2010 ICD-10-CM index for "syndrome, pelvic congestion-fibrosis, female," the indicated code is N94.89 (Other specified conditions associated with female genital organs and menstrual cycle). Find additional ICD-10 information at www.cms.gov/icd10/.

Seek Out Relevant CPT Options

The correct CPT codes for an individual case will depend on the precise services the radiologist performs and documents. Services to watch for include the following areas.

Look at Left vs. Right for Proper Cath Code

For ovarian vein embolization, the radiologist often inserts the catheter into the femoral vein and then guides the catheter through the venous system to the ovarian vein. The codes you're most likely to choose between for the catheter placement are 36011 (Selective catheter placement, venous system; first order branch [e.g., renal vein, jugular vein) and 36012 (... second order, or more selective, branch [e.g., left adrenal vein, petrosal sinus]).

How to decide: If the radiologist moves the catheter into the inferior vena cava (IVC) and then directly to the ovarian vein, you should report first order catheterization code 36011. Typically, the right ovarian vein connects to the IVC directly (see image), so you'll often report 36011 for catheter placement in procedures in the right ovarian vein.

If the radiologist instead moves the catheter from the IVC into another vein or veins (such as the renal) and then into the ovarian vein, you should report a second order or higher catheterization (36012). The left ovarian vein generally joins the left renal vein, which connects to the IVC, so typically you'll report 36012 for procedures in the left ovarian vein.

Don't assume: Verify the radiologist's route to the ovarian vein so you can choose the most appropriate code.

End Embolization Code Search at 37204

Once the radiologist reaches the ovarian vein, she performs the embolization to close the vein. The goal is to block the vessels, by methods such as inserting coils with a sclerosing agent, so the veins no longer become engorged with blood. You should report the embolization using 37204 (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).

You should report 37204 only once for each operative field addressed, according to CPT Assistant (October 1998). So one unit of 37204 is appropriate whether the radiologist treats one vessel or multiple vessels in the same field.

Check CPT Guidelines for Imaging Accuracy

To report the imaging required to perform the catheter insertion and embolization, you should use 75894 (Transcatheter therapy, embolization, any method, radiological supervision and interpretation).

For a follow-up venogram performed at the same encounter, report 75898 (Angiography through existing catheter for follow-up study for transcatheter therapy, embolization or infusion). Physicians often perform multiple injections following placement of the coils or Gelfoam pledgets, says Kim French, CIRCC, director of interventional coding and reimbursement at Crouse Radiology Associates in Syracuse, N.Y. "Angiography following embolization (75898) may only be reported once per session, per operative field regardless of how many injections are required to complete the procedure."

Caution: Sometimes, the radiologist will perform a diagnostic venography at the same encounter as the embolization. For a unilateral venogram, 75831 (Venography, renal, unilateral, selective, radiological supervision and interpretation) is the correct code, says French. For a bilateral venogram, report 75833 (Venography, renal, bilateral, selective, radiological supervision and interpretation), she says. But before you code a diagnostic venography, be sure all requirements are documented, including medical necessity and findings, French says.

CPT guidelines state that "diagnostic venography performed at the time of an interventional procedure is separately reportable if" you meet one of two requirements:

You should not report 75831 or 75833 for nondiagnostic imaging such as roadmapping or vessel measurement.

Coverage note: Some payers consider ovarian vein embolization for PCS to be investigational and will not cover it. Other payers may require a definitive diagnostic exam and documentation of failed pharmacological  therapy.