Radiology Coding Alert
Tips for TIPS Master Intricate Component Coding To Yield Benefits
The cause for this great discrepancy is the lack of a national billing policy for TIPS. As a result, some carriers, including AdminaStar Federal in Indiana, United Healthcare in Virginia and Trailblazer in Texas, require CPT 37799 (unlisted procedure, vascular surgery) be assigned when Medicare beneficiaries undergo the procedure. Most of these local medical review policies (LMRPs) have explicit language noting that 37799 encompasses all procedures and services involved in TIPS. Some even present a specific list of the component codes that are considered included and cannot be reported separately.
Infrequently, payers may require a different solitary code for TIPS, according to Lisa Riccio, assistant office manager for New Britain Radiological Associates in New Britain, Conn. "Sometimes, they will ask for 37140 (venous anastomosis; portocaval) to report the entire procedure. This requirement is unique to only a few carriers. Coders should check with the carrier or payer in question to find exactly what codes each wants."
In other areas, Medicare carriers have adopted a local code. For instance, Nationwide Medicare, which provides coverage in Ohio and West Virginia, requires that TIPS be reported with its own unique code, W0002 (percutaneous transjugular intrahepatic portosystemic shunt).
Most payers, however, have adopted the Society for Cardiovascular and Interventional Radiology's (SCVIR) recommendation for component coding that reflects the discrete services conducted during TIPS. This approach requires coders to understand clearly the intricacies of the operative report as well as the finer points of interventional radiology coding. Coders who master TIPS coding provide their practices with the opportunity to increase their reimbursement legitimately.
Diagnosis Code Is Vital to Reimbursement
According to Riccio, TIPS is performed in patients suffering from advanced liver diseases that result in portal hypertension, where the normal flow of blood through the liver is slowed or blocked by scarring or other damage. Patients with cirrhosis with or without concomitant hepatitis are prime candidates for TIPS, often considered a precursor to liver transplant.
Although each insurer may recognize different ICD-9 Codes supporting medical necessity, those most commonly reported include:
Coding experts note that the liver is supplied by two independent sources of blood. Oxygenated blood from the heart flows through the liver via the hepatic artery. Blood containing nutrients, wastes and toxins enters the liver through the portal vein. The liver processes this blood, which then exits through the hepatic vein. Liver function depends on blood flowing freely from the portal vein, through the substance of the organ (called the parenchyma), into the exiting hepatic vein. Any occlusion or increased intrahepatic pressure impedes this process, causing portal hypertension and significant complications, Riccio says. The most life-threatening of these are esophageal varices, which may rupture and bleed profusely. To correct portal hypertension, interventional radiologists thread a catheter through the venous system, create a tunnel through the dense tissue of the liver between the portal vein (inflow) and the hepatic vein (outflow), and place a shunt to allow the blood to flow freely once again.
Each Step Is Coded Independently
The access point for the procedure is typically the right internal jugular, says Donna Gullikson, CPC, division director for Medical Computer Business Systems, a national coding and billing company based in Augusta, Ga., that serves 31 radiologists. The radiologist may use ultrasound guidance to locate the internal jugular for the percutaneous approach, which is reported with 76942 (ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation). However, some payers will not reimburse for ultrasound guidance.
Once access is gained, a catheter is placed through a vascular sheath and advanced through the superior vena cava, right atrium, inferior vena cava and into a hepatic vein (36011, selective catheter placement, venous system; first order branch). In some instances, Gullikson says, the radiologist may need to once again advance the catheter further into one of the branches off the hepatic vein. "If this occurs, 36012 [... second order] would be reported instead," she says. Both codes may not be assigned because 36012 includes advancing the device through the first-order branch to attain the second-order branch. This would be overbilling. Conversely, coders who don't recognize and report second-order catheterizations when they occur may be undercoding. The practice would have lower reimbursement because payment for 36012 is higher than 36011 to reflect the additional time, effort and expertise required to advance the catheter further into the venous system. The transitioned facility total relative value units (RVUs) for 36011 are 4.70, while RVUs for 36012 are 5.38.
Although not typical, the radiologist at this point may take pressure measurements during venography, Riccio says. If performed with pressure measurements, use 75889 (hepatic venography, wedged or free, with hemodynamic evaluation, radiological supervision and interpretation). If not, use 75891 (... without hemodynamic evaluation) instead.
Whether 75889 or 75891 is performed, modifier -26 (professional component) should be appended, Gullikson says. "These procedures are usually done in a hospital setting, and you would use the modifier to indicate that the hospital is charging the technical component."
Coding Tract Dilation
The next step in the TIPS procedure is to advance a long needle into the hepatic vein, where the interventionalist punctures the wall of the vein. The needle is then pressed through the parenchyma and into a portal vein. In most cases, imaging guidance will be used. "Venography will be used to identify the structures and to assess the flow of blood through the liver," Riccio says. At this stage, the radiologist exchanges the needle for a catheter, which is placed in the portal vein.
The access into the portal system from the hepatic vein is reported with code 36481 (percutaneous portal vein catheterization by any method). Riccio says a preliminary portal venogram may be performed when access is accomplished. Most often in these instances, pressures would be taken and 75885 (percutaneous transhepatic portography with hemodynamic evaluation, radiological supervision and interpretation) would be reported. If no pressures were taken, 75887 (... without hemodynamic evaluation) would be assigned. Again, modifier -26 would be reported with the radiological supervision and interpretation (RS&I) code.
The interventionalist then creates a tract with balloon dilation in the liver, she says. Coders would assign 35476 (transluminal balloon angioplasty, percutaneous; venous), along with RS&I code 75978 (transluminal balloon angioplasty, venous [e.g., subclavian stenosis], radiological supervision and interpretation), appended with the -26 modifier.
"Once the tract is dilated, the physician then deploys a shunt or stent between the hepatic and portal veins to keep it open and allow the blood to flow freely," Riccio explains. This is reported with 37205 (transcatheter placement of an intravascular stent[s], [noncoronary vessel], percutaneous; initial vessel) and RS&I code 75960 (transcatheter introduction of intravascular stent[s], [noncoronary vessel]). Again, modifier -26 would be added to 75960.
After the placement of the stent, she adds, a follow-up portogram is conducted and pressure measurements are taken to confirm that the shunt is patent and positioned correctly. "This would not be coded and billed separately, and is considered included in 75960," she says.
If the initial TIPS procedure does not return the portal pressure to normal ranges, a second TIPS may be necessary and would be separately coded in a manner similar to the first. Furthermore, portal pressures will be successfully normalized in some cases, but the patient will nonetheless experience clinically significant flow in esophageal varices. If this occurs, the varices themselves will be treated by embolotherapy, which would be separately coded with 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).
Note: TIPS procedures are frequently performed under conscious sedation, which will be noted in the radiologist's report. If the interventional radiologist -- rather than an anesthesiologist or nurse anesthetist -- provided sedation, it may be reported with 99141 (sedation with or without analgesia [conscious sedation]; intravenous, intramuscular or inhalation) or 99142 (... oral, rectal and/or intranasal). Although these codes are available, coders should be aware that Medicare and many other payers bundle conscious sedation into procedure codes. If they are reportable, the radiology must follow the guidelines established for conscious sedation. These include the presence of an independent trained observer (e.g., a registered nurse) to assist the interventionalist in monitoring the patient's physiological status and level of consciousness.
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