Radiology Coding Alert

Raise reimbursement by coding variceal embolization separately

Coding for TIPS is about as easy as saying transvenous intrahepatic portosystemic shunt three times fast. We found interventional radiology coding specialists to teach you how to successfully determine which ICD-9 Codes prove medical necessity and which components you may report separately.

Report the Underlying Disease First

ICD-9 Coding mistakes lead to many TIPS denials. TIPS is most commonly performed when the patient has bleeding esophageal varices, usually caused by portal hypertension and/or cirrhosis of the liver, says Jackie Miller, RHIA, CPC, senior consultant and radiology coding specialist with Coding Strategies Inc. in Powder Springs, Ga.

When the record indicates that the patient's bleeding esophageal varices are related to cirrhosis or portal hypertension, report the varices with 456.20 (Esophageal varices in diseases classified elsewhere, with bleeding). This code appears in italics in the ICD-9 manual to notify you that it is a manifestation code - meaning it's a manifestation of an underlying disease, Miller says.

Tip: You can't report manifestation codes as the patient's principal diagnosis, says Stacy Gregory, RCC, CPC, charge capture and reconciliation specialist for Franciscan Health System in Tacoma, Wash. Instead, report the causal condition first, she says.

Example: You would report a TIPS procedure for bleeding esophageal varices due to cirrhosis of the liver with 571.x for cirrhosis (underlying disease), followed by 456.20 for the bleeding esophageal varices (manifestation), Gregory says.

If you don't know the cause of the patient's cirrhosis, assign 571.5. If the patient has documented alcoholic cirrhosis, report 571.2.
 
Or, if the varices are documented as due to portal hypertension, use 572.3 (Portal hypertension) as the principal diagnosis code.

If the patient has bleeding esophageal varices without mention of cirrhosis or portal hypertension, assign 456.0 (Esophageal varices with bleeding).

Distinguish Insertion From Revision

Insertion: Code 37182 (Insertion of transvenous intrahepatic portosystemic shunt[s] [TIPS] [includes venous access, hepatic and portal vein catheterization, portography with hemodynamic evaluation, intrahepatic tract formation/dilatation, stent placement and all associated imaging guidance and documentation]) "describes all of the work involved with creation of a TIPS," Gregory says.

Typical 37182 scenario: Via the jugular vein, the physician advances a catheter through the vena cava into the hepatic vein. He then advances a needle through the wall of the vein and passes the needle through the liver tissue until it reaches a branch of the portal vein. He uses a balloon catheter to dilate the new passage created by the needle, and places a stent to keep the passage open, allowing blood to flow from the portal system into the systemic system. Tip: If the provider obtains pre and post pressures, he should document these along with calculated gradients. The radiologist should also describe accompanying diagnostic and guiding venography.

Revision: If you need to report the work involved during the revision process, you should use 37183 (Revision of transvenous intrahepatic portosystemic shunt[s] [TIPS] [includes venous access, hepatic and portal vein catheterization, portography with hemodynamic evaluation, intrahepatic tract recanulization/dilatation, stent placement and all associated imaging guidance and documentation]), Gregory says. Revision may include treating an occluded shunt or migrated stent, she adds.

Typical 37183 scenario: Via jugular access, the physician advances a catheter through the vena cava into the hepatic vein, then into the nonfunctioning TIPS. She then performs balloon angioplasty to re-establish flow through the shunt, and may also place an additional stent. You should see documentation of all measured pressures, calculated gradients, and pre- and post-revision venography.

Don't miss: "When the initial venography and/or portography (including imaging and access) confirms the need for TIPS, and TIPS is performed, code 37182 is inclusive of these services," according to the AMA publication CPT Changes 2003: An Insider's Guide. The same is true for 37183.

Code Variceal Embolization Separately

The only service you'll typically report separately is variceal embolization, Miller says. TIPS treats the root cause of the patient's bleeding esophageal varices, but it may also be necessary to embolize the varices to eliminate the bleeding.

When the physician embolizes esophageal varices at the time of TIPS or TIPS revision, you may separately code for variceal embolization. What to look for: The physician advances the catheter through the TIPS into the varix, and then uses embolic agents such as coils or ethanol to obliterate the lumen of the vessel.

Report the catheter placement with 36012 (Selective catheter placement, venous system; second-order, or more selective, branch [e.g., left adrenal vein, petrosal sinus]), Gregory says.

Report the embolization with codes 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) and 75894 (Transcatheter therapy, embolization, any method, radiological supervision and interpretation), she adds. You should report the embolization procedure once per operative field, no matter how many varices the physician treats by embolotherapy.