Radiology Coding Alert

Question: When the radiologist intends to perform angioplasty or atherectomy, but the intervention fails and he places a stent, should I report the stent code only, or should I include the angioplasty or atherectomy code as well?


Idaho Subscriber

Answer: If you meet three simple criteria, you may be able to collect for both.

The physician's documentation must clearly illustrate the following:

1. The doctor's intention to perform angioplasty as a primary intervention;

2. Failed/suboptimal angioplasty results (based on your carrier's definition of "failed"); and

3. Subsequent stent deployment.

If your physician does not document each of these three factors, your payer will consider the angioplasty as predilatation of the lesion and the atherectomy as lesion debulking, and it won't pay them separately.

Watch for: Your physician usually can't treat ostial lesions of the renal arteries with angioplasty alone. According to a March 28 letter from the Society of Interventional Radiology to CMS, "Approximately 80% of atherosclerotic [renal artery] stenoses are ostial, and these respond poorly to balloon angioplasty. In this population, 'primary' or 'direct' renal artery stent placement is the standard technique. Attempts at balloon angioplasty alone with provisional stenting reserved for those with suboptimal results of balloon angioplasty are not the standard of care and not justifiable" (www.sirweb.org/codeReim/CMS_RAS_Response_3-28-07.pdf).

Because the physician knows from the start that he will be stenting the renal ostial lesion, only report the stent codes, not PTA.

Individual Medicare carriers and private payers further specify types of lesions that typically require stent placement and for which you should not bill angioplasty in addition to the stent placement.

Examples: The most common are blockage areas with significant calcification, eccentric lesions, blockage areas caused by extrinsic artery compression, lesions with significant propensity for recoil, and bilateral lesions at the aorto-iliac junction (frequently treated with kissing balloons and subsequent stent placement).

Caution: Although you may be tempted to "rubber stamp" every planned stent placement as a "sub-optimal primary angioplasty requiring stent deployment," this practice promises to attract regulatory attention and substantial penalties.