Radiology Coding Alert

The number of components comprising a TIPS procedure (transjugular intrahepatic portosystemic shunt) often means coders have a difficult time assigning the correct codes for this operation. In many cases, some of the steps that comprise the overall procedure arent being billed because each discreet activity isnt clearly documented in the radiologists written report.

Surgically speaking, these are very time-consuming and technical procedures, explains Stacey Hall, ART, CPC, CCSP, director of corporate coding and documentation for Medical Management Professionals Inc., headquartered in Chattanooga, TN. The complexity makes coding a genuine challenge. If coders have a clearer understanding of everything that takes place during a TIPS procedure, they will be able to increase their level of reimbursement.

Typically, a TIPS procedure comprises five discreet steps (as outlined below), each with medical and supervision and interpretation (S&I) coding options. If coders understand each component, can confirm appropriate documentation, and assign appropriate codes, increased payment becomes possible.

TIPS is a Difficult and Time-consuming Procedure

TIPS describes a procedure typically performed on patients suffering from cirrhosis. In a healthy liver, blood enters the liver through the hepatic artery and exits through a portal vein. These two vessels are not directly connected, but the blood nonetheless flows through the organ smoothly, through myriad small vessels.

However, this flow is obstructed by scar tissue in a liver damaged by cirrhosis. The obstruction causes portal hypertension (ICD-9-CM diagnosis code 572.3), and the increased blood pressure is transmitted backward through the portal system. To compensate, the body develops collateral blood vessels in the lower esophagus, stomach, rectum and abdominal wall to decrease the pressure by carrying the blood from the portal system into the systemic venous system. This may cause esophageal varices that often rupture and hemorrhage (varices/esophagus without mention of bleeding, 456.1; bleeding, 456.0; in cirrhosis of liver, 571.5).

To reduce portal hypertension and the risk of variceal hemorrhage, a TIPS procedure may be performed. During the operation the physician surgically creates a shunt that forms a tunnel through the liver, allowing blood to once again flow freely.

Five-step Procedure has Five Codes

Typically five stepseach with specific codes assignedmust be followed to successfully place the stent:

1. Ultrasound guidance. The complex nature of correctly coding the procedure becomes apparent right from the start. In virtually all cases, ultrasound is used to guide the internal jugular vein puncture. However, there is controversy surrounding the appropriate radiologic code to assign for this step. According to the July 1999 issue of CPT Assistant , published by the American Medical Association (AMA), there is no specific S&I code in CPT that describes ultrasound-guided percutaneous central venous catheter insertion.

Therefore, the AMA recommends that the following codes be assigned:

36488*: placement of central venous catheter, percutaneous, age 2 years or younger;

36489*: placement of central venous catheter, percutaneous, age 2 years or older;

36490*: cutdown, age 2 years or younger; or

36491*: cutdown, age 2 years or older.

Also, they recommend that coders assign S&I code 76499 (unlisted diagnostic radiologic procedure) for the ultrasound guidance.

In many instances, however, using 76499 for an unlisted diagnostic radiologic procedure during TIPS is not reimbursed. As an alternative, the Society for Cardiovascular and Interventional Radiology in its SCVIR Coding Guideline recommends that coders use 76942, generally assigned for needle biopsies. It reports more success in getting reimbursed using this code.

Because of these questionsand the possibility that use of an unacceptable code will result in denialswe recommend that you check with your local carriers and state Medicare officials to find out their recommendations.

2. Hepatic vein selection/hepatic venogram. Procedure code 36011 or 36012 is used to describe the selection of the right hepatic vein or branch with the catheter. Code 36011 would be used for a first-order venous catheter placement, while 36012 would be used for second-order venous catheter placement. In addition, S&I code 75889 would be added for the hepatic venogram with pressure measurement, while 75891 would be used for a hepatic venogram without pressure measurement.

3. Portal vein catheterization and transhepatic portography. During the procedure, the needle is then advanced from the hepatic vein to the portal vein, and the wire and catheter are positioned. This portal vein catheterization is coded 36481. Transhepatic portography with pressure reading is coded 75885. Code 75887 is used for transhepatic portography without pressure reading.

4. Venous tract dilation. The surgical code used for dilating the venous tract to create the shunt is 35476, and 75978 is the accompanying S&I code.

5. Stent placement. Finally, the vascular stent is positioned. Surgical code for this procedure is 37205, with S&I code 75960 used for intravascular stent placement.

If variceal embolization is required during the procedure, the following codes may be used for the
selection and occlusion of the coronary vein:

37204: transcatheter occlusion or embolization;

75894: transcatheter therapy, embolization, any method, radiological supervision and interpretation;

36011: selective catheter placement, venous system; first-order branch.

Coding Alert: The SCVIR has warned coding professionals that there is no national policy on TIPS coding, although the aforementioned codes are recognized as a reasonable way to describe the procedure. To maximize reimbursement, the SCVIR recommends that coders check with local carriers to determine if they prefer alternative codes. In some cases, the carriers may not understand the procedure, and it is in the coders best interest to educate them about it and which conditions warrant its usage.