Radiology Coding Alert

Question: The radiologist used jugular vein access and advanced the catheter through the vena cava into the hepatic vein. She advanced a needle through the vein wall and into the liver tissue to reach a portal vein branch. With a balloon catheter, she dilated the passage the needle created and placed a stent to keep the passage open and allow the blood to flow from the portal system. Documentation shows pre- and post-pressures and calculated gradients, as well as hepatic venography. The diagnosis is bleeding esophageal varices caused by alcoholic cirrhosis. Which CPT and ICD-9 codes apply to this case?

Washington Subscriber

Answer: 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]) is the only CPT code you need to describe inserting the shunt under imaging guidance. Pay close attention to the part of the code definition that begins with "includes," and you'll see that CPT intended this to be an all-inclusive code for TIPS procedures, including imaging guidance.

For the diagnosis, you should first report 571.2 (Alcoholic cirrhosis of liver) as the first-listed diagnosis. Then add 456.20 (Esophageal varices in diseases classified elsewhere; with bleeding) for the bleeding esophageal varices.

Reason: ICD-9 identifies 456.20 as a manifestation code, meaning the varices (abnormal blood vessels) are a manifestation of an underlying disease (in this case, alcoholic cirrhosis). ICD-9 conventions state that you may not sequence such manifestations as the first diagnosis. Instead, you should report the causal condition first (571.2 for alcoholic cirrhosis) and then report the manifestation (456.20 for varices related to another disease).