Advanced Search

Radiology Coding Alert

UAE Involves Three Components Plus Modifiers

Published on Tue Jan 01, 2002

Interventional radiology practices consistently receive payment from Medicare and most private insurers for uterine artery embolization (UAE), a relatively new and highly effective treatment for uterine fibroid tumors. As recently as two or three years ago, however, some radiology billing departments reported reimbursement problems because of the novel nature of the procedure.
 
For instance, Jeff Fulkerson, BA, CPC, coding specialist at the Emory Clinic in Atlanta notes that radiologists in the Emory practice perform up to five UAEs each month. "We've had no denials that I can recall, and we do enough of these procedures to know successful reimbursement depends, in part, upon a coder's understanding of the three primary components of the procedure angiography, catheterization and embolization which of these can be billed more than once if performed multiple times, and how to use the most appropriate modifiers to meet various payer requirements," he says.

Multiple Imaging and Catheterization Codes Assigned

During UAE, Fulkerson explains, the interventionalist advances a catheter through the arterial system to the uterine artery. Once the catheter is in position, the radiologist implants particles, coils or other embolization devices to block the blood flow to the fibroid tumors. Deprived of blood, the tumors shrink. UAE is generally performed in both uterine arteries to ensure that all access to blood flow is interrupted. In some cases, collateral arteries are also treated to complete the therapy.
 
Access to the patient's vascular system is achieved at the common femoral artery. According to Stacey Hall, RHIT, CPC, CCS-P, director of corporate coding for Medical Management Professionals Inc., a national billing and management firm for hospital-based practices in Chattanooga, Tenn., the radiologist typically begins with a contralateral approach initially treating the arteries on the opposite side of the body from the side punctured in the single femoral access point. In some cases, the interventionalist may first place the catheter in the aorta in order to assess the multiple potential arteries to the uterus. If this is done, the radiological supervision and interpretation (RS&I) code for nonselective abdominal and proximal runoff arteriography is CPT 75630 (aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision and interpretation). The code for nonselective catheter placement, 36200 (introduction of catheter, aorta), is not charged because the work will be included in any subsequent selective or superselective vascular catheterizations from the same puncture site.
 
"Next the guidewire and catheter are advanced into the contralateral internal iliac artery," she explains. The interventional radiologist may obtain images of the internal iliac artery circulation. Subsequently, the catheter is further advanced into the uterine artery branch of the internal iliac artery. Images of the uterine artery that is feeding the uterus and the fibroids to be treated are obtained. Hall notes that, even though both arteries are imaged, the primary pelvic angiography code may be reported only once per vascular family. Therefore, coders would assign 75736 (angiography, pelvic, selective or supraselective, radiological supervision and interpretation) for images of the internal iliac, and +75774 (angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation [list separately in addition to code for primary procedure]) for images of the uterine artery.  
 
However, if the interventionalist catheterizes only one of the two vessels (typically the uterine artery) and films from only one vantage point, only 75736 is used. Coders would also report the catheterization. For the contralateral placement, 36247 (selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family) would be assigned. Only the most selective catheterization (e.g., third order) is reported because the less selective catheterizations in the same vascular family (e.g., first order and second order) are included in the more selective procedure.

Reporting Embolization

At this point of the procedure, Fulkerson explains, the interventional radiologist delivers the embolization materials (e.g., minute coils and spheres, or glue) to block blood flow. Code 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) is reported. In addition, Hall says, 75894 (transcatheter therapy, embolization, any method, radiological supervision and interpretation) would also be used.
 
After embolization, she adds, the radiologist will often obtain follow-up images to assess the procedure. This will be billed with 75898 (angiography through existing catheter for follow-up study for transcatheter therapy, embolization or infusion).

Procedure Usually Repeated on Ipsilateral Side

With one side completed, Fulkerson says, the radiologist will usually retract the catheter and repeat the procedure on the ipsilateral side (the same side of the body as the common femoral puncture). During this second stage, images of the internal iliac and the uterine artery may be obtained and once again reported with 75736 and 75774. Coders should recall, however, that if only one of the arteries is studied, only 75736 is used.
 
Modifiers will be appended to the repeated RS&I codes to prevent payers from erroneously thinking they are duplicate codes. In some cases, modifier -50 (bilateral procedure) will be added to the second use of a code, while other insurers may prefer the -RT/-LT designation on both codes. Still others require -51 (multiple procedures) each time a particular code is used, while additional payers expect radiology practices to report modifier -76 (repeat procedure by same physician). Coders should learn the particular requirements of each payer.
 
Coding for catheterization on the ipsilateral side may differ somewhat from the contralateral positioning, Hall warns, because of anatomic variations from patient to patient. In some women, the internal iliac artery has anterior and posterior divisions before it branches into the uterine artery. In this case, the uterine artery typically arises from the anterior branch of the internal iliac and is considered a third-order catheterization (36247). In other women, the uterine artery branches directly off of the trunk of the internal iliac, which makes it a second-order catheterization. This would be reflected with 36246 (selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity branch, within a vascular family).
 
"Because of this possible variation, it's important that coders follow the interventional radiologist's documentation carefully," says Hall. "This will give them information they need to assign the correct catheterization code which will affect the level of reimbursement." In fact, she advises coders to mention this to their radiologists, so they understand the importance of noting anatomical variations and all the vessels accessed during each procedure.
 
Note: This variation doesn't affect contralateral placement because the uterine artery is always at least a third-order catheterization, whether or not an anatomical variation occurs. According to the American College of Radiology (ACR) Bulletin in April 2000, if the uterine artery branches directly off the internal iliac artery, it is a third-order catheterization (the common iliac would be the first order and the internal iliac the second). If it arises from an anterior/posterior division, the uterine artery is then a fourth-order vessel, which would also be coded with 36247.
 
If the catheterization is reported with the same code on both contralateral and ipsilateral sides, -RT/-LT designations would be used, or the -50 modifier would be appended to the second use of the code.
 
Embolization is repeated during the ipsilateral approach. However, 37204 and 75894 may be reported only once during the UAE since the embolization procedure and accompanying RS&I are allowed to be reported only once per operative field. Follow-up angiography may also be done on the ipsilateral side. Some coding experts say it is appropriate to report these services a second time with the appropriate modifier (e.g., 75898-RT). Others, however, recommend that follow-up angiography be reported only once per operative field. Radiology coders should ask individual payers for their coding policy.
 
If the follow-up angiogram shows continuing blood flow to the fibroids (e.g., because of collateral feeding vessels), these vessels may also need to be catheterized, studied and embolized. The rules described above would be used to determine the degree of selectivity of any subsequent catheterizations and the corresponding RS&I code (likely 75736). No additional embolization procedural or RS&I codes would be used.

Diagnosis Coding Is Vital

The most common ICD-9 code accompanying UAE is 218.9 (leiomyoma of uterus, unspecified), says Fulkerson. Other coders, however, report success with codes from the 626 series (disorders of menstruation and other abnormal bleeding from female genital tract), especially when one of these codes accompanies the fibroid code. Because local Medicare carriers and private insurers may have differing policies on which diagnoses support medical necessity for UAE, coders should ask the payer for its coding policy.

Other Articles in this issue of

Radiology Coding Alert

View All