Radiology Coding Alert

New codes added in CPT Codes 2001 to describe endovascular repair of abdominal aortic aneurysms (AAA) are generating great enthusiasm among interventional radiologists. The new codes allow reimbursement for this revolutionary treatment option, which uses minimally invasive techniques. Previously, AAA repair was achieved surgically, through large abdominal incisions, interruption of normal blood flow and extensive vascular suturing.

With the excitement, of course, comes the challenge of learning a new set of codes as well as deciphering how to report them correctly for optimum reimbursement. The new endovascular codes are intended to be used as component codes and have been designed to allow for maximum coding flexibility. Most of the procedures will require the efforts of two physicians usually a vascular surgeon and an interventional radiologist and each new code appropriately describes a distinct portion of the procedure. This allows each physician to report only the portions of the procedure he or she performs.

Nonetheless, the new codes bring with them one particular idiosyncrasy, says Donna Younes, BS, CPC, clinical practice manager in radiology for the University of Washington Medical Center and Harborview Medical Center in Seattle. Despite the fact that two physicians will most likely be involved in the procedure, she points out, none of the codes currently may be used with the co-surgeon modifier (-62, two surgeons).

Component Codes Reflect Stages

Endovascular repair procedures involve several stages, and radiology coders will choose component codes for services provided at each stage:

1. Vascular access
2. Catheterization
3. Placement of endovascular device

In addition, coders must consider radiology supervision and interpretation (RS&I) services, as well as placement of additional extensions or cuffs if the main device isnt long enough to compensate for leaks at either end of the repair.

Stage 1: Vascular Access

Endovascular repair procedures begin with open exposure of an artery to allow introduction of the repair device into the arterial system. Generally, this incision is made in the femoral artery in the groin area, explains Chris Sari, CPC, quality assurance manager for Advanced Radiology, which provides support to about 80 physicians, 24 freestanding facilities and eight hospitals in the Baltimore area. Alternately, if the femoral artery is diseased or very small, this incision will be made in the iliac artery. Codes describing vascular access are:

CPT 34812 open femoral artery exposure for delivery of aortic endovascular prosthesis, by groin incision, unilateral; and

CPT 34820 open iliac artery exposure for delivery of endovascular prosthesis or iliac occlusion during endovascular therapy, by abdominal or retroperitoneal incision, unilateral.

If both femoral arteries or both iliac arteries are exposed, coders would append modifier -50 to indicate that the procedure was bilateral, Sari says.

Stage 2: Catheterization

No new codes were introduced in 2001 to describe the catheterization procedures used to advance the synthetic graft from the femoral artery to the site of the aneurysm. Instead, CPT says these manipulations should be reported using the regular coding conventions that apply to catheterizations. Coders would report these in addition to the other codes assigned to the procedure. The catheterization codes may include 36140 to describe non-selective catheter in iliac artery, 36200 to describe catheter placement into aorta, 36245 to describe first-order selective catheter placement, 36246 to describe second-order selective catheter placement, 36247 to describe third-order selective catheter placement, and 36248 for each additional second- and third-order catheter placement, per vascular family (add-on code).

The catheter will most often be placed in the aorta, and 36200 will be assigned. During AAA repair, two catheters may be placed one from each femoral or iliac artery. This scenario would be coded with 36200 and 36200-59 (distinct procedural service). But, some payers may require alternative modifiers, like -51 (multiple procedures), or simply ask that 36200 be reported once with two units indicated. Coders should check with the payer in question.

Although used less often, coders must also understand how to use other catheterization codes for AAA repair, according to Lisa Grimes, RT (R), radiology special procedures technologist and reimbursement specialist for the University of Texas/Houston Health Science Center. Coders typically stumble over how to code catheterizations correctly which is vitally important because reimbursement levels are directly tied to identifying the correct vascular branch.

Many professionals undercode these types of catheterizations, Grimes says. If the physician has advanced the catheter into a third-order branch, payment is much higher than for first-order access. It makes sense: There is more time, effort and expertise involved in advancing farther into the vascular system. If coders assign 36245 when the interventionalist actually selected a second- or third-order branch, they will not receive the full reimbursement they are allowed.

Conversely, a second area of confusion regarding first-, second- and third-order access may put an interventional radiology practice at risk for fraud and abuse investigations. Coding professionals must remember that they cant assign multiple first-, second- and third-order codes for catheterizations in the same vascular family from the same access point, Grimes points out. Code 36246 (second-order) includes advancing the catheter through the first-order branch to reach the second-order branch. By the same token, 36247 includes both the first and second order.

Stage 3: Placement of Endovascular Device

CPT introduced three new codes in 2001 (34800, 34802 and 34804) to describe the primary AAA repair services. Sari points out that the repair code is selected depending on the type of device used.

The simplest device is an aortic tube prosthesis a straight cylinder that is placed into the aorta and anchored to healthy portions of the proximal and distal aorta. Use of this type of device is reported with 34800 (endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using aorto-aortic tube prosthesis).

A second device is more complex, she says, with multiple components that include a main tubular graft with a long and short leg. The longer leg is positioned in one of the two iliac arteries and attaches to a healthy vessel wall. The shorter leg terminates at the point where the two iliac arteries join the aorta (commonly called the bifurcation). The shorter leg allows additional components to be threaded through the contralateral vessel, and attached or docked to the main module. Placement of this device is reported with 34802 (endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using modular bifurcated prosthesis [one docking limb]).

Code 34802 includes insertion and docking of both components of the device (the main tubular graft and a single docking limb), Sari notes. No additional codes would be reported. However, it is likely that placement of this device would require access to both iliac arteries and therefore bilateral arterial access would be reported (i.e., 34812-50). Additional catheterization codes would also be used to describe advancement of the device through various vessels.

The third device comes in a single piece (unibody), and is shaped like an inverted Y with a tubular aortic endograft and two legs that extend from the aorta into both iliac vessels. Placement of this apparatus is coded with 34804 (endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using unibody bifurcated prosthesis). It may be placed with open surgical access to only one vessel or to bilateral vessels. If only one surgical exposure is used, the contralateral vessel is accessed percutaneously. Devices of this type require bilateral guidewire catheter placement and therefore multiple catheterization codes should be reported.

CPT also added two codes that should be assigned if extensions or cuffs need to be positioned in addition to the primary graft, Younes says. On occasion, the device is not long enough to repair the entire AAA. In other cases, leaks may be identified at either end of the endograft. In addition, these cuffs, extensions, or isolated limb prostheses may be placed as stand-alone procedures to treat late endoleaks or to treat isolated iliac aneurysms, AV fistulas, or ruptures.

When this occurs, an extension or cuff is advanced through the vessels and placed at the appropriate site. Code 34825 (placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic aneurysm; initial vessel) is assigned for extension(s) in the first vessel needing the additional repair, and 34826 ( each additional vessel [list separately in addition to code for primary procedure]) would be reported for further placements needed in separate vessels. Coders should note that the add-on code is not assigned for subsequent extensions placed, but only when cuffs are positioned in more than one vessel. Multiple cuffs in a single vessel will be reported only once.

New Codes Define Primary and Extension Services

New radiology codes have been added to CPT 2001 to describe diagnostic imaging and guidance services that are an integral component of endovascular procedures. Code 75952 (endovascular repair of infrarenal abdominal aortic aneurysm or dissection, radiological supervision and interpretation) identifies the fluoroscopic guidance for the catheter placement of the device as well as radiologic services performed during the repair.

The AMA notes that this code includes angiography of the aorta and its branches for diagnostic imaging before the deployment of the endograft, guidance in the delivery of all components, guidance for all angioplasty or stenting done within the target treatment zone for the endograft, and arterial angiography performed during the procedure to confirm positioning of the device, detect leaks in the placement and to evaluate run-off.

Code 75953 (placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic aneurysm, radiological supervision and interpretation) describes similar services performed when extensions or cuffs are placed in addition to the primary endograft. Coders should note that this code may be assigned only for each vessel, not for each cuff placed, Sari points out. Code 75953 may be reported in cases when cuffs or extensions are placed without placement of the aortic endograft.

Coding for Additional Services

Besides the primary AAA repair and placement of extensions there are occasions when additional procedures are performed. CPT has added new codes to describe these circumstances, as well.

Some repairs, for instance, may also require that one of the iliac arteries be closed off. To accomplish this, the physician would place an occlusion device at the appropriate site and assign 34808 (endovascular placement of iliac artery occlusion devise [list separately in addition to code for primary procedure]). This new code is identified as an add-on code and would be reported with the primary repair code (34800-34804).

At the same time, a femoral-femoral bypass will most likely be performed to reroute the blood flow affected by the now-occluded iliac artery. This would be reported with 34813 (placement of femoral-femoral prosthetic graft during endovascular aortic aneurysm repair [list separately in addition to code for primary procedure]), an add-on code that would usually be reported with 34812-50.

CPT has also added three codes (34830, open repair of infrarenal aortic aneurysm or dissection, plus repair of associated arterial trauma, following unsuccessful endovascular repair; tube prostheses; 34831, aorto-bi-iliac prosthesis; 34832, aorto-bifemoral prosthesis) that would be assigned if attempts to perform endovascular repairs are unsuccessful and the procedure is converted to an open surgical AAA repair. These codes would also be used for late conversions to open repair for failed endovascular grafts.

Coding Services by Each Physician

Although questions arise whenever new procedures and new codes are implemented, Younes predicts the new endovascular codes will produce a unique set of concerns. Although radiologists are familiar with component coding, this is new territory for a lot of vascular surgeons, she says. They will need to get up to speed in this area.

The learning curve will be further complicated by the fact that modifier -62 cannot be appended to the new codes. (Note: CPT is discussing this issue further, and its policy may change soon.) Since both surgeons and interventionalists will be involved in the procedures, they will need to coordinate their coding and billing efforts as well, Younes points out.

Some coding experts are recommending that modifier -52 (reduced services) be reported in place of modifier -62 for AAA repair (see example #1 on next page). However, using this modifier will change the claim to paper, as opposed to electronic, and thereby introduce delay and increased expense for both payer and provider. Modifier -52 may also reduce the combined payment amount below 100 percent at the payers discretion when reported twice.

Younes says there are other reasons not to use modifier -52. It seems to me that use of -52 is an attempt to circumvent the co-surgeon issue and may not be appropriate coding. Instead, she recommends checking with specific payers for guidance. She also suggests that coding be done on a per case basis and that the offices of each physician coordinate their reporting (see example #2). Coders should review the documentation carefully, and determine which physician performed each portion of the procedure. Then, each office should code and bill only for the services performed by that particular physician. If specific efforts are shared, the surgeon and radiologist should negotiate the proper division of labor and reimbursement in advance.

She adds that this approach will require explicit documentation on the part of the physicians, and close communication between offices. Until this issue about the co-surgeon modifier is resolved, this seems to be the best approach.

Example #1: Patient is a 59-year-old female. The vascular surgeon performs a bilateral femoral cutdown, and the interventionalist inserts the catheters into the aorta bilaterally. Both physicians work to place a unibody bifurcated prosthesis at the point of the AAA, with the radiologist performing the angiography, guidance and RS&I. The surgeon closes the incisions at the cutdowns.

Surgeon reports
34812-50 bilateral femoral arterial access
34804-52 placement of unibody bifurcated endograft, reduced services

Radiologist reports
36200 catheter placed in aorta, from left femoral artery
36200-59 catheter in aorta, from right femoral artery, distinct procedural service
34804-52 placement of unibody bifurcated endograft, reduced services
75952-26 RS&I, professional component

Example #2: Patient is a 45-year-old male. The vascular surgeon makes incisions to allow bilateral arterial access, and the radiologist places the catheter in the aorta (bilaterally) under fluoroscopic guidance. Radiologist performs preplacement angiography. The surgeon continues the procedure by positioning a modular bifurcated prosthesis, and then places an extension on the distal end to correct leakage that was identified by the radiologist. After withdrawing the catheter and guidewires, the surgeon closes the femoral cutdowns.

Surgeon reports
34812-50 bilateral femoral arterial access
34802 placement of modular bifurcated device
34825 cuff placement

Radiologist reports
36200 catheter placed in aorta, from left femoral artery
36200-59 catheter in aorta, from right femoral artery, distinct procedural service
75952-26 RS&I for primary AAA repair, professional component
75953-26 RS&I for cuff placement, professional component