Radiology Coding Alert
Meet 3 Criteria to Bill Stent Placement With PTA Codes
Don't write off your physician's work if angioplasty of same lesion fails Suppose your interventional radiologist intends to perform angioplasty or atherectomy, but the intervention fails and he places a stent. Should you report the stent code only, or should you bill the angioplasty or atherectomy code as well? 3 Tips Lead to Coding Success If your physician's note clearly documents the following three criteria, you can report your angioplasty or atherectomy with your stent codes, says Toni O'Neill, coder at Imaging Associates, a three-radiologist practice in Chicago: Renal Lesions May Not Warrant Separate Codes To bill multiple interventions of the same vessel, your physician's record must clearly establish angioplasty (or atherectomy) as his primary intention. But you probably won't be able to meet this criterion if the physician addresses lesions located at the origin of the renal arteries. Physician Intent Determines Code Note the physician's intent: Because the interventional radiologist knows from the start that he will stent the patient to treat orificial lesions, "You should report stenting of the renal artery with CPT 37205 (Transcatheter placement of an intravascular stent[s], [non-coronary vessel], percutaneous; initial vessel) and CPT 75960 (Transcatheter introduction of intravascular stent[s], [non-coronary vessel], percutaneous and/or open, radiological supervision and interpretation, each vessel)," Miller says. Your physician's medical record must establish that the primary angioplasty was unsuccessful based on your carrier's definition of a "failed" procedure. Many carriers, including Empire Medicare of New Jersey, dictate that you should report both the angioplasty and stent procedure when your interventional radiologist places stents to treat suboptimal or failed angioplasty. If the radiologist finds a calcified blockage, he may use a rotational atherectomy catheter, which has a burr on the end, to grind away the blockage. Although guidance for billing failed interventions in addition to subsequent stent deployment appears specific only to failed PTAs, the same concept holds true for failed atherectomies. Coding Example and Solution Therefore, if the medical record reflects that (1) the physician performs an angioplasty of the superficial femoral artery as the primary intention and this provides suboptimal results, (2) the physician then proceeds with an atherectomy of the lesion and this also provides suboptimal results, and (3) the physician places a stent to treat the lesion, you can code each intervention and the accompanying radiological supervision and interpretation, as follows: Because the National Correct Coding Initiative (NCCI) does not bundle these codes together, you can report them without appending modifier -59 (Distinct procedural service).
If you meet three simple criteria, you should be able to collect for each procedure.
Normally, if radiologists perform angioplasty prior to placing a stent, insurers consider the angioplasty "pre-dilation" and will not separately reimburse for it. Similarly, if the physician performs atherectomy before placing the stent, the insurer will deny the atherectomy charge and consider it "debulking of the lesion."
Because payers bundle these services into stent placement payment, most radiology practices never bill angioplasty (35470-35476 with 75962-75968 or 75978 for radiological supervision and interpretation [RS&I]) or atherectomy (35490-35495 with 75992-75996 for RS&I) with stent placement (37205-37206 with 75960 for RS&I).
1. The radiologist's intention to perform angioplasty as a primary intervention
2. Failed/suboptimal results from the angioplasty
3. Subsequent stent deployment.
Most interventional radiology experts agree that physicians should only perform primary stenting if they treat orificial lesions (the most common lesions involving the renal arteries). If, before the physician even performs the procedure, he plans to stent the patient to treat orificial lesions, you should report only the stent codes, not percutaneous transluminal angioplasty (PTA).
"If a renal artery lesion (particularly one involving the renal artery ostium) is treated by angioplasty alone, re-stenosis is likely to occur," says Jackie Miller, RHIA, CPC, senior consultant for Coding Strategies Inc. in Powder Springs, Ga. "Stenting significantly reduces the likelihood of reoccurrence." Therefore, your interventional radiologist may perform primary stenting.
When your physician performs interventions in other peripheral vessels (such as the superficial femoral artery or popliteal artery, or for non-ostial lesions of visceral arteries such as the renal or mesenteric arteries), he may intend to perform angioplasty as the primary intervention. Remember that if your radiologist plans to perform angioplasty, you should only report the stent code and the angioplasty code if the angioplasty fails.
Document 'Failed' PTA
CIGNA Medicare (a Part B carrier in Tennessee) defines a suboptimal or failed PTA as "a dilation judged by the physician to be suboptimal or failed due to the presence of unfavorable lesion morphology."
Scan the operative report: If your interventional radiologist does not specifically note that the PTA failed, you may have to dig deeper. Check the operative report for the following terminology, which signals a failed PTA:
Insurers Don't Include Atherectomy Value in PTA
In peripheral cases, you should bill for all methods of intervention that your interventional radiologist performs, O'Neill says. So if the physician performed an atherectomy, angioplasty and stent, you can bill all three.
PTA: Codes 35474 (Transluminal balloon angioplasty, percutaneous; femoral-popliteal) and 75966 (Transluminal balloon angioplasty, renal or other visceral artery, radiological supervision and interpretation).
Atherectomy: 35493 (Transluminal peripheral atherectomy, percutaneous; femoral-popliteal) and 75992 (Transluminal atherectomy, peripheral artery, radiological supervision and interpretation).
Stent: 37205 and 75960.
Don't forget: You should also report the appropriate selective catheter placement, which for peripheral lower- extremity catheterizations would typically be a first-order cath placement (36245, Selective catheter placement, arterial system; each first-order abdominal, pelvic, or lower-extremity artery branch, within a vascular family) with an ipsilateral puncture, or a third-order (36247, ... initial third-order or more selective abdominal, pelvic, or lower-extremity artery branch, within a vascular family) with a contralateral puncture site (although a second-order code may be appropriate for contralateral iliac lesions).
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