Lower Extremity Arterial Endovascular Revasculariza<on Codes

Transcription

1 Peripheral Interven.ons: Part 1 Angioplasty, Atherectomy, and Stent Placement 2012 Presented by: David Zielske, MD CIRCC, CPC- H, CCC, CCS, RCC Lower Extremity Arterial Endovascular Revasculariza<on Codes Lower Extremity Arterial Anatomy Right Transfemoral Approach Non- selec.ve First order Second order Third order Antegrade Right 3 Retrograde Right 1

2 Guidelines for Lower Extremity Arterial Endovascular Revasculariza.on Procedures The following guidelines apply to codes , and refer to interven<ons described by angioplasty, atherectomy and stent placement for treatment of occlusive vascular disease. Angioplasty u<lizes a balloon to dilate a hemodynamically significant vessel stenosis. The balloon may be a compliant or non- compliant balloon, a cryoplasty balloon, a cukng balloon, etc. Atherectomy is performed u<lizing photoabla<on (laser), rota<onal (Rotoblater, Diamondback Orbital) or direc<onal cukng (Silver Hawk) devices Stent placement u<lizes a bare metal, drug- elu<ng, balloon- expandable, self- expanding or covered stent to effec<vely treat the lesion(s) Codes all include an angioplasty if performed Guidelines for Lower Extremity Arterial Endovascular Revasculariza.on Procedures These codes are specific for 3 dis<nct lower extremity vascular territories: the iliac, femoral/popliteal, and <bial/peroneal. There are 3 separately billable arteries in the iliac territory: the common, external and internal iliac arteries. There is only 1 separately billable code submiued for interven<on within the femoral/popliteal system, regardless of the types and numbers of separate and dis<nct vascular interven<ons (angioplasty, atherectomy and/or stent placements) that are performed in the CFA, SFA, PFA and popliteal arteries. There are 3 separately billable arteries below the knee: the peroneal, anterior <bial and the posterior <bial. The <bial/peroneal trunk is considered part of any distal interven<on (in the posterior <bial or peroneal. The anterior <bial is considered a separate vessel for interven<on when <bial/peroneal trunk interven<on is also performed. 5 Guidelines for Lower Extremity Arterial Endovascular Revasculariza.on Procedures Codes are applicable to both open or percutaneous approach and include closure of the open or percutaneous access site with s<tches, pressure, or device placement (do not bill G0269 for MD. Hospitals may report for tracking purposes for Medicare per AHA, AMA) These codes include conscious seda<on, vascular access, catheter placement, work involved with crossing the lesion (including use of specialty guidewires, subin<mal recanaliza<on, ultrasound vibra<on, etc.), imaging related to the en<re procedure, use of an embolic protec<on device, angioplasty (if done), and closure device angiography Atherectomy bundling for codes only applies to infra- inguinal arteries. Use Category III code 0238T for supra- inguinal iliac atherectomy Thrombolysis (37201, 75896), thrombectomy procedures (37184, and 37186), emboliza<on (37204, 75894), and extensive repair or replacement of the artery (35226, 35286) can be addi<onally reported. 6 2

3 Guidelines for Lower Extremity Arterial Endovascular Revasculariza.on Procedures Codes describe either angioplasty alone, atherectomy +/- angioplasty, stent placement +/- angioplasty and stent placement with atherectomy +/- angioplasty Stent with atherectomy > atherectomy > stent placement > angioplasty (even thought codes not listed in this order in CPT) This actually only affects coding for the <bial/peroneal arteries The femoral/popliteal and <bial/peroneal territory codes incorporate atherectomy procedures. The iliac territory does not as the iliac territory codes only describe angioplasty and stent placement (+- angioplasty). Iliac atherectomy is addi<onally coded with 0238T if performed and is coded per iliac vessel treated (up to three <mes) 7 Guidelines for Lower Extremity Arterial Endovascular Revasculariza.on Procedures A maximum of 1 ini<al and 2 addi<onal interven<ons can be performed in a unilateral iliac system, 1 ini<al in the femoral/popliteal system and 1 ini<al and 2 addi<onal in the <bial/peroneal system. Code each territory separately. All interven<ons within a single vessel are always coded as a single interven<on (except iliac atherectomy) Code bridging lesions as one vessel interven<on, even if bridging into another arterial territory. There are 4 iliac, 4 femoral/popliteal and 8 <bial/peroneal artery revasculariza<on codes. These codes ONLY apply to arterial stenoses, NOT venous. 8 Guidelines for Lower Extremity Arterial Endovascular Revasculariza.on Procedures Code may be billed for each separate access made with ultrasound guidance for LE revasculariza<on procedures. Must be documented per CPT guidelines. 3

4 Guidelines for Lower Extremity Arterial Endovascular Revasculariza.on Procedures Diagnos<c angiography IS NOT separately coded at the <me of these interven<ons if: The angiography is included in the interven<onal procedural code descrip<on Performed for vessel measurement and sizing, lesion localiza<on, roadmapping, and consists of contrast injec<ons and imaging rela<ng to guidance necessary to perform the interven<on Follow- up ager angioplasty, atherectomy, stent placement, thrombectomy, etc. Diagnos<c angiography IS separately coded at the <me of these interven<ons if: There has not been a prior catheter based angiogram and a complete study is performed and the decision for interven<on is based on this angiographic study There is a prior study, but There is change in clinical status since prior study The prior study was inadequate for visualiza<on of the area of concern There is change in the clinical status during the interven<on that requires imaging outside the area treated 10 Lower Extremity Arterial Endovascular Revasculariza.on Procedures: Iliac Revasculariza<on, endovascular, open or percutaneous, iliac artery, unilateral, ini<al vessel, with angioplasty Revasculariza<on, endovascular, open or percutaneous, iliac artery, unilateral, ini<al vessel, with stent placement, includes angioplasty within the same vessel Revasculariza<on, endovascular, open or percutaneous, iliac artery, unilateral, each addi<onal vessel, with angioplasty Revasculariza<on, endovascular, open or percutaneous, iliac artery, unilateral, each addi<onal vessel, with stent placement, includes angioplasty within the same vessel Lower Extremity Arterial Endovascular Revasculariza.on Procedures: Femoral/Popliteal Revasculariza<on, endovascular, open or percutaneous, femoral/popliteal artery, unilateral, with angioplasty Revasculariza<on, endovascular, open or percutaneous, femoral/popliteal artery, unilateral, with atherectomy, includes angioplasty within the same vessel when performed Revasculariza<on, endovascular, open or percutaneous, femoral/popliteal artery, unilateral, with stent placement, includes angioplasty within the same vessel when performed Revasculariza<on, endovascular, open or percutaneous, femoral/popliteal artery, unilateral, with stent placement and atherectomy, includes angioplasty within the same vessel when performed 4

5 Lower Extremity Arterial Endovascular Revasculariza.on Procedures: Tibial/Peroneal Revasculariza<on, endovascular, open or percutaneous, <bial/ peroneal artery, unilateral, ini<al vessel, with angioplasty if done Revasculariza<on, endovascular, open or percutaneous, <bial/ peroneal artery, unilateral, with atherectomy, ini<al vessel, includes angioplasty within the same vessel when performed Revasculariza<on, endovascular, open or percutaneous, <bial/ peroneal artery, unilateral, ini<al vessel with stent placement, includes angioplasty within the same vessel when performed Revasculariza<on, endovascular, open or percutaneous, <bial/ peroneal artery, unilateral, ini<al vessel with stent placement and atherectomy, includes angioplasty within the same vessel when performed Lower Extremity Arterial Endovascular Revasculariza.on Procedures: Tibial/Peroneal Revasculariza<on, endovascular, open or percutaneous, <bial/ peroneal artery, unilateral, each addi<onal vessel, with angioplasty Revasculariza<on, endovascular, open or percutaneous, <bial/ peroneal artery, unilateral, each addi<onal vessel, with atherectomy, includes angioplasty within the same vessel when performed Revasculariza<on, endovascular, open or percutaneous, <bial/ peroneal artery, unilateral, each addi<onal vessel, with stent placement, includes angioplasty within the same vessel when performed Revasculariza<on, endovascular, open or percutaneous, <bial/ peroneal artery, unilateral, each addi<onal vessel, with stent placement and atherectomy, includes angioplasty within the same vessel when performed Lower Extremity Arterial Endovascular Revasculariza.on Procedures: Simplified - Iliac Iliac angioplasty, ini<al vessel Iliac stent, ini<al vessel Iliac angioplasty, addi<onal vessel Iliac stent, addi<onal vessel 0238T Iliac atherectomy, each vessel, (bill separately) Use 1 ini<al vessel and up to 2 addi<onal vessel interven<ons if done. Use - 59 modifier for interven<ons in the contralateral iliac 5

6 Lower Extremity Arterial Endovascular Revasculariza.on Procedures: Simplified Femoral/Popliteal Fem/pop system angioplasty Fem/pop system atherectomy Fem/pop system stent placement Fem/pop system stent placement with atherectomy Only submit 1 of the above codes per extremity. Use - 59 modifier for an interven<on in the contralateral femoral/popliteal artery Lower Extremity Arterial Endovascular Revasculariza.on Procedures: Simplified Tibial/Peroneal <bial/peroneal angioplasty, ini<al vessel <bial/peroneal atherectomy, ini<al vessel <bial/peroneal stent placement, ini<al vessel <bial/peroneal stent placement with atherectomy Only submit 1 of the above codes per extremity. Use - 59 modifier for an interven<on in the contralateral <bial/peroneal artery Lower Extremity Arterial Endovascular Revasculariza.on Procedures: Simplified Tibial/Peroneal <bial/peroneal angioplasty, each addi<onal vessel <bial/peroneal atherectomy, each addi<onal vessel <bial/peroneal stent placement, each addi<onal vessel <bial/peroneal stent placement with atherectomy, each addi<onal vessel List up to 2 addi<onal codes separately in addi<on to the ini<al vessel code. Use - 59 modifier for an interven<on in the contralateral <bial/peroneal arteries 6

7 Guidelines for Lower Extremity Arterial Endovascular Revasculariza.on Procedures Catheter placement in leg for thrombolysis and diagnos<c day 1 with stent placement at a separate session on the same day is separately billable. Catheter placement in leg for thrombolysis and diagnos<c day 1 with stent placement on a subsequent day is separately billable. Catheter placement in 2 <bial vessels for secondary thrombectomy ager an iliac stent placement is bundled (if via the same access and in the same vascular family as the iliac stent placement). Guiding IVUS for recanaliza<on is bundled as used to cross the lesion. Diagnos<c IVUS to determine if a stent is appropriately deployed or to determine if there is a complica<on of the procedure is separately billable. Stent- grag placement for popliteal aneurysm, use LE Endovascular Revasculariza.on Case 1: Pa<ent with leg leg pain. Via right femoral approach, aortogram from high cath posi<on, followed by selec<ve (1 st order) bilateral renal angiography. The catheter is pulled down for complete bilateral lower extremity run- off from leg common iliac artery and right femoral sheath injec<ons. Catheter advanced to contralateral SFA and addi<onal images obtained to evaluate haziness in the popliteal. 90% stenoses of leg external iliac with 70-80% diffuse disease throughout the en<re SFA and popliteal. The <bial/peroneal trunk and distal vessels are unremarkable. Angioplasty is performed in the external iliac, SFA and popliteal arteries with stent required in the popliteal for dissec<on. 20 Lower Extremity Arterial Anatomy Right Transfemoral Approach Non- selec.ve Antegrade Right Retrograde Right First order Second order Third order 21 7

8 LE Endovascular Revasculariza.on Case 1: Bilateral selec1ve renal angiography Bilateral lower extremity angiography Add l selec1ve angiography, le> popliteal External iliac angioplasty Femoral/popliteal stent placement, includes angioplasty (in the SFA and popliteal arterial distribu1on) 22 LE Endovascular Revasculariza.on Case 2: Via right femoral approach, diagnos<c aortogram, cath reposi<on to bifurca<on, bilateral run- off, addi<onal selec<ve catheter placement with images in contralateral SFA. New leg antegrade CFA puncture with leg SFA recanaliza<on of occlusion mid- SFA to Hunter s canal. Angioplasty and covered stent placement in SFA. Laser is performed in the mid popliteal, throughout the <bial/peroneal- trunk, in the mid posterior <bial, mid and distal anterior <bial, and dorsalis pedis arteries. Adjunc<ve angioplasty is performed in all these <bial/ peroneal vessels ager the atherectomy. Stent placement is necessary in the <bial/peroneal trunk for flow- limi<ng dissec<on. 23 Lower Extremity Arterial Anatomy Right Transfemoral Approach Non- selec.ve Antegrade Right Retrograde Right First order Second order Third order 24 8

9 LE Endovascular Revasculariza.on Case 2 Codes: Abdominal aortography Bilateral lower extremity angiography Add l selec1ve angiography, le> SFA rd order selec1ve catheter placement via separate access Femoral/popliteal stent placement with atherectomy Tibial/peroneal trunk stent with atherectomy including posterior 1bial atherectomy and adjunc1ve angioplasty Anterior 1bial/dorsalis pedis atherectomy, including adjunc1ve angioplasty 25 LE Endovascular Revasculariza.on Case 3: Pa<ent with known 4cm SFA occlusion. Previous antegrade approach failed. The pa<ent is placed in the prone posi<on, the popliteal fossa prepped, and using ultrasound guidance (vessel is patent, needle access confirmed and permanent recorded image placed in the chart) access and 5FR sheath placed. Heparin is given (4000units). The SFA occlusion is traversed, angioplasty performed (4mm with subop<mal result) followed by 5mm covered stentgrag across previous occlusion. Emboliza<on into the peroneal is noted on rou<ne follow- up. This is treated with suc<on thrombectomy ager new CFA access is obtained. Follow- up angiography looks good. Closure device is placed in the CFA. 26 Lower Extremity Arterial Anatomy Right Transfemoral Approach Non- selec.ve Antegrade Right Retrograde Right First order Second order Third order 27 9

10 28 LE Endovascular Revasculariza.on Case 3: Superficial femoral artery covered stent placement (includes preliminary angioplasty) Ultrasound guidance for vascular access rd order selec1ve catheter placement into the peroneal artery via separate CFA access Secondary arterial thrombectomy in the peroneal artery 29 LE Endovascular Revasculariza.on Case 4: Pa<ent with prior CTA showing renal, iliac and fem/pop stenoses. Here for interven<on. Via right common femoral access, right renal angioplasty (3mm predila<on) followed by 6mm stent placement is performed. The catheter is pulled back and used to cross separate and dis<nct 90% stenoses of the proximal leg common iliac artery, mid leg external iliac artery, distal leg CFA/SFA artery (bridging lesion), and 90% PFA stenosis 1cm distal to origin. These are all treated with angioplasty and stent placements. Treatment of the proximal SFA and PFA stenoses required kissing stent deployment and two catheter placements. Occlusion of the distal SFA required ini<al treatment with laser atherectomy followed by adjunc<ve angioplasty here and in the popliteal artery

11 Lower Extremity Arterial Anatomy Right Transfemoral Approach Antegrade Right Retrograde Right Non- selec.ve First order Second order Third order 31 LE Endovascular Revasculariza.on Case 4: st order selec1ve catheter placement into the renal artery for stent placement Renal stent placement Renal stent placement, S&I Proximal SFA, CFA, PFA stent placements, distal SFA atherectomy (includes angioplasty) Common iliac stent placement External iliac stent placement (addi1onal iliac artery stent placement) 32 LE Endovascular Revasculariza.on Case 5: Via brachial approach, 90% leg external iliac calcific stenosis is treated with Diamondback atherectomy device. This results in 40% residual stenosis, treated effec<vely with subsequent high pressure 7mm x 4cm balloon angioplasty. Exchange is made for a 5mm balloon which is used for angioplasty of a 95% origin stenosis of the internal iliac artery and a 2mm balloon is used for angioplasty of a 70% internal pudendal artery stenosis

12 Lower Extremity Arterial Anatomy Right Transfemoral Approach Antegrade Right Retrograde Right Non- selec.ve First order Second order Third order 34 LE Endovascular Revasculariza.on Case 5: 0238T External iliac artery atherectomy External iliac artery angioplasty (ini1al) Internal iliac artery angioplasty (addi1onal iliac angioplasty, includes both the internal iliac artery origin and the distal internal pudendal artery angioplas1es in the same iliac vascular distribu1on) 35 LE Endovascular Revasculariza.on Case 6: Via contralateral approach, bridging lesion from the proximal leg external iliac extending into the proximal leg CFA treated ini<ally with 8mm angioplasty requiring 8mm x 6cm stent for proximal dissec<on. A catheter is then advanced across a short segmental occlusion of the popliteal artery and a stent is placed with excellent results

13 Lower Extremity Arterial Anatomy Right Transfemoral Approach Antegrade Right Retrograde Right Non- selec.ve First order Second order Third order 37 LE Endovascular Revasculariza.on Case 6: External iliac artery stent placement (ini1al) Popliteal artery stent placement (Had the proximal lesion been primarily a common femoral lesion, only one femoral/popliteal stent would be coded as all lesions would have been in one femoral/popliteal territory. In the above example, the bridging lesion is documented as primarily external iliac in nature so it is separately coded in addi1on to the popliteal treatment) 38 Complex Therapeu<c Radiology Coding Angioplasty 13

14 Angioplasty U<lizes a balloon to dilate a narrowed vessel (this includes cryo, cukng, compliant, non- compliant, etc. types of balloons) May be percutaneous or open technique Peripheral Artery (for Brachiocephalic arteries only) Ini<al vessel Each addi<onal vessel (even if there are two separate punctures, there is s1ll only one ini1al brachiocephalic angioplasty S&I per human body) Renal or Visceral Artery (including Aor<c Angioplasty) Ini<al vessel Each addi<onal vessel Venous (including peripheral, central, portal, pulmonary veins) Ini<al and each addi<onal vessel Angioplasty Surgical codes specific to approach and specific artery: Percutaneous (involves an 11 blade to access through the thick skin, but no mul<layered closure) Renal or visceral artery Aorta Brachiocephalic trunk or branches Open (documenta<on of surgical incision and mul<layered closure of the access site) Renal or visceral artery (C) Aorta (C) Brachiocephalic trunk or branches *(C) Is inpa<ent only procedure for Medicare pa<ents Venous Angioplasty (Venoplasty) Surgical codes based on approach Venous Use for venous stenosis in extremity veins, central veins and portal veins Percutaneous Open 42 14

15 Guidelines for Lower Extremity Revasculariza.on - Angioplasty Only Open or Percutaneous, includes catheter placement, access across lesion, angioplasty, image guidance, follow- up, & closure device Iliac artery, ini1al vessel Iliac artery, each addi1onal vessel (up to 2 1mes) Femoral- popliteal artery (includes CFA, PFA, SFA and POP) Tibial/peroneal artery, ini1al vessel Tibial/peroneal artery, each addi1onal vessel (up to 2 1mes) Angioplasty Angioplasty is coded per vessel treated (except the femoral popliteal system), not per stenosis. The <bial/peroneal system is now limited to three vessels. Do not need to be successful to charge for angioplasty CAN code for angioplasty and separate stent in the same site/vessel in the brachiocephalic arteries, visceral, and renal arteries and veins (use new bundled codes for lower extremity revasculariza<on) If intent is to perform a successful angioplasty with an adequately sized balloon, however there is a vessel rupture, 20-30% residual stenosis (recoil, residual), 5mm residual sytolic gradient, flow- limi<ng dissec<on or acute occlusion, then both may be coded as these are indica<ons for coding both PTA and stent placement. This does NOT apply to lower extremi<es. Angioplasty Bill separately for Catheter placement (however NOT for lower extremi<es) Diagnos<c angiography (will require - 59 modifier to let CMS know this was a true diagnos<c study) Do not bill separately for angiography related to Guiding shots Road mapping/trace subtrac<on/ Posi<oning Sizing Localiza<on Comple<on 15

16 Do not code pre- dila<on angioplasty prior to stent placement. Do not code post- stent deployment angioplasty to fully dilate or deploy the stent or for residual stenosis in the self- deploying stent. Do not code angioplasty when the intent was to stent the vessel from the start. Do not code angioplasty, when the angioplasty gives a great result, but we stented the vessel anyways. Do not code angioplasty when the original balloon is too small to give a good result to start with and stent is then required. Do not code mul<ple angioplas<es in a single vessel. Do not code two angioplas<es when trea<ng a short bridging lesion across two adjacent vessels. Do not code angioplasty when macera<ng clot, this is part of a thrombectomy procedure. Do not code angioplasty when done with atherectomy or stent placement in the lower extremi<es. Brachiocephalic Angioplasty Caro<d and Vertebral artery angioplasty without stent placement are non- covered services for Medicare pa<ents. (CMS states the caro<d artery is not a peripheral artery so do not use 75962, implies not to use 35475). Discuss this with your payer. We recommend with GZ modifier to alert payer this is non- covered. Brachiocephalic refers to the vessels arising from the cervicocerebral arch, including the upper extremi<es. The code applies to the right brachiocephalic artery, the right and leg subclavian, axillary, brachial, radial and ulnar arteries of the upper extremi<es and can be used with arterial anastomo<c stenoses of upper extremity AV fistula/grag interven<on. 47 Intracranial Angioplasty, Atherosclero.c Since intracranial angioplasty and intracranial stent placement have been non- covered services by CMS. In 2006, new CPT codes were created for treatment of atherosclerosis and vasospasm. *Effec<ve 11/2006 CMS recommends for intracranial angioplasty and stent placement for atherosclero<c stenoses but the physician and hospital must be part of Class B IDE study and the treatment is limited to atherosclero<c stenoses 50%. This was reconfirmed in No changes since, except recent study (SAMPRAS study, Sept. 2011) suggests intracranial angioplasty/stent may have higher morbidity/mortality compared to maximal medical therapy alone. If not part of study, this procedure remains non- covered. Consider GZ modifier. Check with payer Intracranial angioplasty for atherosclerosis Intracranial stent for atherosclerosis (includes preliminary angioplasty) (These codes include ipsilateral catheter placement, ini<al and follow- up imaging, along with the interven<on. If the diagnos<c study shows that the interven<on is not indicated, bill the diagnos<c studies and catheter placements only.) *Medicare Claims Processing Manual, Chapter 32 Billing Requirements for Special Services, 161C Intracranial PTA with Sten<ng, 1/5/

17 Intracranial Angioplasty Intracranial balloon angioplasty for vasospasm, ini1al vessel Intracranial balloon angioplasty for vasospasm, each addi1onal vessel in the same vascular family Intracranial balloon angioplasty for vasospasm, each addi1onal vessel in a different vascular family These codes include catheter placement, intra- procedural imaging, roadmapping, vessel measurements, and guidance, along with the interven<on and follow- up imaging. If a diagnos<c study is needed the day of the interven<on, it is separately billable even if performed on the same date of service. Due to the rapidly changing clinical status in these pa<ents it is common to have to perform repeat diagnos<c studies. These codes remain non- covered by Medicare at this <me. GZ modifier may be considered for Medicare pa<ents. 49 Lower Extremity Angiography, Angioplasty, and Stent Gra\ Case 7: Via a right femoral approach, abdominal aortography high catheter placement, complete lower extremity run- offs ager catheter reposi<oning to the low abdominal aorta, followed by imaging ager selec<ve catheter placement into the leg main renal artery and an accessory leg renal artery (the right renal artery is occluded). Bilateral common iliac artery stenoses of 80% were present. A leg sheath was placed and kissing angioplasty of the iliac arteries was performed with 8mm balloons with excellent results. 50 Lower Extremity Arterial Anatomy Right Transfemoral Approach Non- selec.ve Antegrade Right Retrograde Right First order Second order Third order 51 17

18 Lower Extremity Angiography, Angioplasty, and Stent Gra\ Case 7 Codes: Unilateral selec<ve renal angiography Bilateral lower extremity angiography, S&I Right iliac artery angioplasty, ini<al vessel (right) Leg iliac artery angioplasty, ini<al vessel (leg) 53 Lower Extremity Diagnos.c Angio, Angioplasty, and Stent Case 8: Pa<ent with right ax- fem, fem- fem x- over and leg fem- pop bypass grags. Via direct puncture of the ax- fem grag, a catheter was advanced through the subclavian artery and into the abdominal aorta. Aortogram showed occlusion below the renals. The catheter was pulled back for subclavian inflow angiography which showed anastomo<c 80% stenosis. Angioplasty was performed. The catheter was reversed in the ax- fem grag and imaging down the ax- fem grag and both lower extremi<es was performed. The catheter was advanced through the fem- fem x- over into the leg fem- pop grag where a stent was placed across a distal anastomo<c stenosis

19 55 Lower Extremity Arterial Anatomy Right Transfemoral Approach Antegrade Right Retrograde Right Non- selec.ve First order Second order Third order 56 Lower Extremity Diagnos.c Angio, Angioplasty, and Stent Case 8 Codes: Catheter placement into the aorta Abdominal aortography, S&I Le> subclavian angiography, S&I Le> subclavian artery/gra> anastomo1c angioplasty Lt subclavian artery/gra> anastomo1c angioplasty, S&I Le> fem- pop distal anastomo1c stent placement Bilateral lower extremity angiography S&I (to evaluate the ax- fem and fem- fem gra>s and runoff down the legs) 57 19

20 Angioplasty Case 9: Pa<ent with abnormal renal Doppler study and bilateral claudica<on, leg worse than right. A right groin puncture is performed. A catheter is advanced into the aorta, and an aortogram is performed. The catheter is pulled down to the bifurca<on. Contrast is injected and complete bilateral lower extremity angiography is performed. Ager catheter exchange, both renal arteries were selected and imaged. 80% right and 90% leg renal stenoses are seen. Angioplasty was then performed with 6mm balloons in each renal artery. Follow up angiography showed excellent results, except that the right renal artery required a 6mm stent placement for treatment of a flow limi<ng dissec<on. The catheter was then advanced into the leg common iliac artery. Contrast injec<on confirms 70-90% stenoses of the proximal external iliac, the profunda femoral and the distal popliteal arteries. Angioplasty is performed at these three lower extremity separate and dis<nct sites with 7mm, 4mm, and 5mm balloon respec<vely. Lower Extremity Arterial Anatomy Right Transfemoral Approach Non- selec.ve First order Second order Third order Antegrade Right 59 Retrograde Right Angioplasty Case 9 Codes: Bilateral extremity angiogram, bilateral, S&I Bilateral renal angiogram (includes catheter placement and S&I) Bilateral renal artery angioplasty Visceral angioplasty, ini1al vessel, S&I Visceral angioplasty, addi1onal vessel, S&I Stent placement (right renal artery) Stent placement, right renal artery, S&I Iliac angioplasty, perc, ini1al, (external iliac) Femoral/popliteal angioplasty, (includes both the profunda femoral and popliteal artery angioplas1es) 60 20

21 Complex Therapeu<c Radiology Coding Atherectomy Atherectomy U<lizes rota<onal burrs, direc<onal cukng devices or photo abla<on (laser) to clean out arterial structures and remove atheroma from the vessel Excimer Laser, Fox Hollow EV3 Silver Hawk, Orbital Atherectomy Device, Rotablator, Simpson device, Jetstream G2, G3, Crosser catheter, etc. Atherectomy Surgical codes specific to approach and specific artery Percutaneous or Open, including S&I for procedure Supra- Inguinal 0234T Renal artery 0235T Visceral artery 0236T Aorta 0237T Brachiocephalic trunk or branches 0238T Iliac artery Venous Infra- Inguinal femoral/popliteal, includes angioplasty bioperoneal, ini1al vessel, includes angioplasty bioperoneal, addi1onal vessel, includes angioplasty 21

22 Supra- Inguinal Atherectomy Rules Bill separately in addi<on to T atherectomy codes: - Catheter placement - Diagnos<c angiography - Angioplasty and/or Stent placement to treat the same or different lesion in the same or in different vessels - Closure device placement Atherectomy is per vessel treated, not per stenosis. Same rules as angioplasty and stent placement. If mul<ple stenoses in mul<ple NON- fem/pop/<bial/peroneal (supra- inguinal) vessels are treated with atherectomy, use the same atherectomy T- codes mul<ple <mes as needed for the addi<onal vessels treated (e.g., use 0238T up to 3 <mes in unilateral iliac territory, use 0236T once for the aorta) Infra- Inguinal Atherectomy Rules The following are bundled with atherectomy below inguinal ligament: - Vascular access, catheter placement, work to cross the lesion & angioplasty same vessel. - Imaging related to the procedure along with follow- up imaging. Use of EPD. - Other interven<ons to treat the same or other vessels may require different codes (stent placement bundles atherectomy, atherectomy bundles angioplasty in same vessel). - Vessel closure with sutures, device placement or pressure. Atherectomy is per vessel treated, not per stenosis. (Does not apply to fem- pop vessels as all 4 vessels are consider 1). There are 3 <bial/peroneal vessels now. Tibio- peroneal trunk is part of any distal interven<on (posterior <bial and peroneal.) The dorsalis pedis and medial malleolar branches are part of the anterior <bial and posterior <bial arteries respec<vely.) If mul<ple stenoses in mul<ple femoral/popliteal or <bial/peroneal vessels are treated with atherectomy, use codes 37225, 37227, 37229, 37231, 37233, and as appropriate. Atherectomy Case 10: 65 year old with known occlusion of the proximal leg popliteal artery along with high grade stenoses of the proximal anterior <bial, peroneal, <bial/peroneal trunk and mid posterior <bial arteries. There is also a severe stenosis of the dorsalis pedis artery. Pa<ent is here for interven<on. Via an antegrade common femoral artery approach, a 6 Fr sheath was placed and a catheter advanced to the SFA and imaging performed, confirming lesions. Wire recanaliza<on, followed by 2mm angioplasty of the popliteal lesion followed by 5mm atherectomy resul<ng in 20% residual stenosis. 2.5mm atherectomy was then performed in all <bial/peroneal arteries above. Angioplasty of the dorsalis pedis artery with a 1.5mm balloon is then performed

23 Lower Extremity Arterial Anatomy Right Transfemoral Approach Antegrade Right Retrograde Right Non- selec.ve First order Second order Third order 67 Atherectomy Case 10 Codes: atherectomy proximal popliteal artery atherectomy in posterior <bial artery addi<onal vessel atherectomy in anterior <bial artery (includes angioplasty in dorsalis pedis artery) addi<onal vessel atherectomy in peroneal artery 68 Complex Therapeu<c Radiology Coding Stent Placement 23

24 Non- Coronary/Caro.d/Vertebral/Lower Extremity Stent Placement Rules There is one S&I code Transcatheter introduc1on of stent percutaneous or open, not coronary, vertebral, caro1d, cerebral or lower extremity artery, S&I The procedure codes are more specific Percutaneous stent placement ini1al vessel (not coronary, vertebral, caro1d, cerebral or lower extremity artery) stent placement each addi1onal vessel (not coronary, vertebral, caro1d, cerebral or lower extremity artery) Non- Coronary/Caro.d/Vertebral/Lower Extremity Stent Placement Rules Procedure codes Open stent placement ini1al vessel stent placement each addi1onal vessel Codes are for placement in the vascular system only Use these codes when procedures are done by cut- down technique Non- Coronary/Caro.d/Vertebral/Lower Extremity Stent Placement Rules Bill per vessel treated (not per lesion). Use mul<ple <mes on mul<ple vessel stent procedures. Bill separately for catheter placement diagnos<c angiography (must meet medical necessity) Do not bill separately for a guiding or follow- up angiogram. 24

25 Non- Coronary/Caro.d/Vertebral/Lower Extremity Stent Placement Rules Angioplasty is not billed separately when Performed as pre- dila<on of a lesion to assist in placement of the stent Performed as part of the stent deployment Performed to model, completely expand or increase the size of the stent Non- Caro.d/Vertebral/Lower Extremity Stent Placement Rules Angioplasty is billable when: Performed ini<ally as a primary angioplasty, but with a sub- op<mal result (i.e., elas<c recoil with 20-30% residual stenosis, flow- limi<ng dissec<on, 5mm residual systolic pullback gradient or acute occlusion) Performed to treat an area of the vessel not treated with the stent Performed to treat a dissec<on or stent- induced stenosis (i.e., plaque movement) Only applies to renal, visceral and brachiocephalic arteries and venous structures 74 Infra- Inguinal Lower Extremity Stent Placement Rules Vascular access, catheter placement, work to cross the lesion is bundled. Atherectomy and angioplasty in the same vessel is included in the stent placement codes. Other interven<ons to treat the same or other vessels may require different codes (stent placement bundles atherectomy and angioplasty, atherectomy bundles angioplasty in same vessel). S&I related to the procedure along with follow- up imaging is included. Use of embolic protec<on device is included. Closure device placement is bundled. 25

26 Lower Extremity Stent Placement Codes Iliac stent, ini<al vessel Iliac stent, each addi<onal vessel Femoral/popliteal stent Femoral/popliteal stent, with atherectomy Tibial/peroneal stent, ini<al vessel Tibial/peroneal stent, with atherectomy, ini<al vessel Tibial/peroneal stent, each addi<onal vessel Tibial/peroneal stent, with atherectomy, each addi<onal vessel Caro.d Angioplasty (Concurrent with Caro.d Stent Placement) Must be performed in facili<es that have been determined to be competent in performing: the evalua<on the procedure the follow- up necessary to ensure op<mal pa<ent outcomes 77 Caro.d Angioplasty (Concurrent with Caro.d Stent Placement) The facility must have: Advanced physiologic monitoring Readily available emergency management equipment and systems A clearly delineated program for gran<ng CAS privileges and for monitoring the quality of the individual interven<onists and the program as a whole A data collec<on system maintained by the facility or its contractor on all CAS procedures done 78 26

27 Caro.d Stent Placement Caro<d cervical stent placement with embolic protec<on Caro<d cervical stent placement without embolic protec<on & include: Ipsilateral selec<ve catheteriza<on Ipsilateral caro<d cervical and cerebral artery S&I All other related S&I during stent placement procedure All road- mapping, guiding shots and follow- up images All angioplas<es within the region of stent deployment remains an inpa<ent C- status indicator procedure (1/2012) - Code not appropriate as the caro<d artery is not a peripheral artery Common Caro.d and Vertebral Stent Placement 0075T Percutaneous placement extracranial vertebral or intrathoracic common caro1d stent, ini1al vessel Includes radiological S&I, imaging and catheter placement 0076T Percutaneous placement of vertebral or intrathoracic common caro1d stent, each addi1onal vessel Includes radiological S&I, imaging and catheter placement This is an add- on code to 0075T Codes 0075T and 0076T expire January Stent Placement Case 11: Pa<ent with Doppler stenoses of the leg caro<d and leg vertebral arteries. Possible vertebral steal. Via femoral approach, arch exam followed by selec<ve catheter placements with injec<on of contrast, imaging and findings via the right and leg common caro<d arteries and right and leg vertebral arteries with imaging of the head and neck is performed. Arch, right proximal subclavian, right vertebral, right cervical and cerebral arteries and basilar arteries are normal. The proximal leg internal caro<d, proximal leg subclavian and separate leg vertebral artery origin are 90% stenosed. Using embolic protec<on, stents were placed in all three vessels. Follow- up imaging is normal. 27

28 Non- selec.ve First order Second order Third order Normal Arch Arterial Anatomy - Detailed Transfemoral Approach Stent Placement Case 11 Codes: Le> cervical caro1d stent placement 0075T Le> extracranial vertebral stent placement Le> subclavian stent placement Le> subclavian stent placement S&I Right vertebral catheter placement Right common caro1d cath placement Cervicocerebral arch S&I Right cervical caro1d S&I Right cerebral caro1d S&I Right vertebral S&I *This is an inpa<ent only procedure 28

29 David Zielske, MD, CIRCC, CPC- H, CCC, CCS, RCC Copyright 2012 ZHealth Publishing CPT 2011 American Medical Associa.on 29