2014 Vascular IR Coding: Transcatheter Stenting, Embolization, FEVAR & More. Presented by. Jeff Majchrzak, BA, RCC, CIRCC Zeke Silva, M.D.

Transcription

1 2014 Vascular IR Coding: Transcatheter Stenting, Embolization, FEVAR & More Presented by Jeff Majchrzak, BA, RCC, CIRCC Zeke Silva, M.D., RCC.. April 9,

2 Disclaimer MedLearn Publishing has prepared this seminar using official Centers for Medicare and Medicaid Services (CMS) documents and other pertinent regulatory and industry resources. It is designed to provide accurate and authoritative information on the subject matter. Every reasonable effort has been made to ensure its accuracy. Nevertheless, the ultimate responsibility for correct use of the coding system and the publication lies with the user. MedLearn Publishing, its employees, agents and staff make no representation, warranty or guarantee that this information is error-free or that the use of this material will prevent differences of opinion or disputes with payers. The company will bear no responsibility or liability for the results or consequences of the use of this material. The publication is provided as is without warranty of any kind, either expressed or implied, including, but not limited to, implied warranties or merchantability and fitness for a particular purpose. The information presented is based on the experience and interpretation of the publisher. Though all of the information has been carefully researched and checked for accuracy and completeness, the publisher does not accept any responsibility or liability with regard to errors, omissions, misuse or misinterpretation. Current Procedural Terminology (CPT ) is copyright 2013 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT is a trademark of the American Medical Association. Copyright 2014 by MedLearn Publishing. All rights reserved. No part of this presentation may be reproduced in any form whatsoever without written permission from the publisher Published by MedLearn Publishing, 287 East Sixth Street, Suite 400, St. Paul, MN, MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 3 Recommended Resources Procedural Coding Manuals and References 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 4 2

3 Recommended Resources American Medical Association CPT Assistant Authoritative Guidance CPT Changes 2014 Clinical Examples in Radiology 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS CPT Codes Affecting Radiology *(Current Procedural Terminology 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.) The following defines codes that are felt to be most relevant to Radiology procedures affected by CPT additions, deletions or changes in CPT This summary does not include all codes for For a complete representation of all changes, additions or deletions, refer to the 2014 AMA CPT Manual. All codes are effective January 1, There is no grace period to use old or new codes MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 6 3

4 Embolization - Clinical Catheter directed use of embolic agents or devices to decrease blood flow To treat: Bleeding Tumors [chemoembolization, Y-90 (Yttrium)] To assist other procedures (i.e. embolization before stent grafts) 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 7 Embolization - Clinical Types of embolic agents Particles Embospheres Gel foam (slurry, pledgets, torpedos) PVA Devices Coils (Regular, detachable, Gianturco) 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 8 4

5 Embolization New Codes for BODY embolization Arteries, veins, lymphatics all included Excludes: CNS / Head and Neck 61624, 61626, 61710, Ablation / sclerotherapy 36468, 36470, Pseudoaneurysm / thrombin injection (36002) 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 9 Embolization New codes include: All associated radiological supervision and interpretation Intra-procedural guidance and road mapping Imaging necessary to document completion of the procedure Moderate sedation 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 10 5

6 Embolization Catheter placement(s) separately reportable , True diagnostic studies may be separately reportable (i.e , 75726) Dx vs. Tx rules apply Other reported codes may require the appropriate modifier (e.g., modifier 59) 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 11 New Codes for Vascular Embolization and Occlusion 4 new codes were created in CPT 2014 to describe these services. The codes and full descriptors are as follows: Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (e.g., congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles) Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; arterial, other than hemorrhage or tumor (e.g., congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms) Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for arterial or venous hemorrhage or lymphatic extravasation 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 12 6

7 How to Use Each Embo Code Vascular Embolization and Occlusion Summarized: Code 37241: Use this code when embolization or occlusion procedures (other than hemorrhage) are performed in the venous circulation. Typical scenarios in which this code may be appropriate would be treating venous malformations, visceral varices, varicocele's or capillary hemangiomas. This code has utility when treating side branches of the outflow vein on a dialysis patient, varicose ovarian veins or gonadal vein embolizations MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 13 How to Use Each Embo Code Vascular Embolization and Occlusion Summarized: Code 37242: Use this code when embolization or occlusion procedures are performed for arterial conditions other than hemorrhage or tumor. Examples could be arteriovenous malformations (AVMs) and arteriovenous fistula (congenital or acquired). Pseudoaneurysm or aneurysm embolization would also be defined by CPT Do not use this code for embolization of the tumor (instead assign CPT 37243). Pseudoaneurysm treatment via injection should be defined by CPT (injection procedures [e.g., thrombin] for percutaneous treatment of extremity pseudo-aneurysm. If embolization must be performed prior to another planned intervention, this code would also be assigned. Consider the scenario of aortic endograft placement and embolization of the internal iliac artery. In this instance CPT is correctly assigned MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 14 7

8 How to Use Each Embo Code Vascular Embolization and Occlusion Summarized: Code 37243: Use this code when embolization or occlusion procedures are performed for the main purpose of achieving organ infarction for ischemia as well as tissue ablation. One may find this code being used most often for treatment of uterine fibroids or chemoembolization or radioembolization of the liver. Use of does not negate one's ability to assign additional codes that may be used to describe discrete services performed as part of the embolization such as the administration of chemotherapy (96420) or the actual delivery of the radiopharmaceutical (79445) MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 15 Uterine Artery Embolization When elective (i.e. for fibroids) Use (i.e. instead of old code 37210) When emergent (i.e.- post partum bleed, post op bleed, tumor, ectopic) Use (i.e. instead of old codes / 75894) 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 16 8

9 How to Use Each Embo Code Vascular Embolization and Occlusion Summarized: Code 37244: Use this code to define embolization for treatment of vascular or lymphatic extravasation or hemorrhage. Typical use of this code would be embolization to treat a G.I. bleed or trauma (i.e., fractured pelvis from a motor vehicle accident). Additional uses could be embolization of bronchial arteries for hemoptysis or female patients for postpartum hemorrhage. Less common but still applicable with this code would be embolization of the thoracic duct for chylous effusion MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 17 Stent vs. Embolization Vascular Embolization and Occlusion Summarized: Stents may be covered or noncovered. Stents may be used in several ways and confusion may arise when stents are used to treat and aneurysm. CPT states the following: Intravascular stents, both covered and uncovered, are a class of devices that may be used as part of an embolization procedure. As such, there is the potential for overlap among codes used for placement of vascular stents in those used for embolization. When a stent is placed for the purpose of providing a latticework for deployment of embolization coils, such as for embolization of an aneurysm, the embolization code is reported and not the stent code. If a covered stent is deployed as the sole management of an aneurysm, pseudoaneurysm, or vascular extravasation, then the stent deployment code should be reported and not the embolization code MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 18 9

10 Stent vs. Embolization Vascular Embolization and Occlusion Summarized: As in previous years, only a single embolization should be reported when treating a single operative / surgical field. CPT states "the area immediately surrounding and directly involved in a treatment/procedure". For example, if four discrete vessels were treated by embolization in the liver, even though four vessels were treated this would be considered a single area and only one embolization code should be submitted. Conversely, if two separate organs were treated by embolization (i.e. right and left kidneys) these would each be separately coded. Per CPT Assistant, Nov 2013, two separate liver lesions (right and left lobe) may report code for the first lesion and modifier 59 for the second lesion. Finally, CPT states the following: "There may be overlapping indications for an embolization procedure. The code for the immediate indication for the embolization should be used. For instance, if the immediate cause for embolization is bleeding in a patient with an aneurysm, report 37244" MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 19 Vascular Embolization and Occlusion Remember: For sclerosis of veins or endovenous ablation of incompetent extremity veins, see Do not report in conjunction with 36468, 36470, 36471, , 75894, in the same surgical field. For percutaneous treatment of extremity pseudoaneurysm, use Do not report in conjunction with 75894, in the same surgical field. For embolization procedures of the central nervous system or head and neck, see 61624, 61626, For transcatheter therapies see 37200, 37202, , , 61624, MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 20 10

11 Vascular Embolization and Occlusion Summarized: Codes do not replace options 61624, or These new codes also exclude venous procedures defined by codes 36468, and (i.e., ablation, sclerotherapy, telangiectasia of the extremity/skin). Included in the new embolization codes are the S and I component and all intraprocedural as well as post procedural imaging of the area treated by embolization. As such, there is no S and I code for the embolization itself that should be submitted in addition to codes Moderate / conscious sedation is also considered bundled into these procedures. Not included in the new embolization codes and still separately codable are services such as the selective or nonselective catheter placements, ultrasonic guidance for vascular access, true full and complete diagnostic angiography with (modifier 59) and services such as chemotherapy administration (96420) or the injection / administration of a radiopharmaceutical (79445) MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 21 AV Shunt Procedures - New 2014 Narrative Language Summarized: This language defines the appropriate methodology to code when intravascular stents are placed either with or without angioplasty on a dialysis patient. This language was updated as the codes previously used to define intravascular stent placement (75960, 37205, 37206, 37207, 37208) have been deleted in CPT The new codes defining intravascular stent placement with or without angioplasty range from Unchanged from previous years is the CPT definition of "segments" of the dialysis shunt. As the AV shunt is considered to be a vein, any stent deployed from the periarterial anastomosis through the SVC would be considered to be venous. If a stent is placed at the arterial anastomosis, this is considered to be an artery and the arterial stent placement code of would be assigned. If at the same encounter a stent is placed at the arterial anastomosis and then an additional stent is placed in the central venous circulation, in addition to code (initial artery) the code (transcatheter placement of an intravascular stent, each additional vein) would also be submitted MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 22 11

12 AV Shunt Procedures - New 2014 Narrative Language Summarized: A second new paragraph has also been added to this section. This change relates to the deletion of the previous embolization code (37204) and the creation of a new embolization code specific to venous lesions, Code is inclusive of radiological supervision and interpretation and as such, CPT code should not be assigned in addition to MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 23 Multiple Embolizations Only one embolization code should be reported for each surgical field (i.e., the area immediately surrounding and directly involved in a treatment/procedure). For example, embolization of one or more venous side branches in a single arm for a patient with a dialysis arteriovenous fistula is reported with only once per session. Embolization procedures performed at a single setting and including multiple surgical fields (e.g., a patient with multiple trauma and bleeding from the pelvis and the spleen). May be reported with multiple embolization codes with the appropriate modifier (i.e. modifier 59) MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 24 12

13 Embolization and AV Grafts This additional work may be separately reported using the appropriate selective venous catheterization codes (36011 and 36012). The embolization may be reported using once irrespective of the number of branches embolized MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 25 Embolization Example #1 22 year old male with history of a large scrotal varicocele referred for embolization R CFV accessed with ultrasound guidance 7 Fr sheath placed 5 Fr Cobra catheter advanced into left renal vein and renal venogram performed Reflux into the left gonadal vein demonstrated 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 26 13

14 Embolization Example #1 Catheter advanced down left gonadal vein and contrast injected Multiple coils deployed along its length Sotradecol injected also Completion angio performed Hemostasis achieved by direct compression 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 27 Embolization Example #1 - Codes Ultrasound guided access Documentation requirements: patency confirmed, permanent image, directly punctured Image with needle in the vein? Catheter into left renal vein and inject 75831, unilateral selective renal venography Catheter into left gonadal vein and inject? No additional S&I code Embolization? Sotradecol? No separate charge Completion angio?- No, included in embo codes 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 28 14

15 Embolization Example #2 63 year old male with aortic aneurysm for aortic stent graft placement Pre-procedure planning confirms need for pre-operative embolization of the left hypogatric (internal iliac) artery 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 29 Embolization Example #2 R CFA accessed and sheath placed Pigtail into lower abdominal aorta where a pelvic arteriogram is performed Cobra C2 into left common iliac artery with arteriography Left hypogastric artery selected and selective arteriogram performed Embolization of hypogastric artery with multiple detachable coils performed Follow up angio from common iliac artery confirms favorable result 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 30 15

16 Embolization Example #2 - Codes Aorta selection and pelvic arteriogram / 75625?- Only assign S&I code if truly diagnostic will be included in ultimate most distal selective catheter placement code assigned ?- Only assign if truly diagnostic. Common iliac artery injection- Selective cath code will be overridden by higher degree of selectivity. Selection of hypogastric artery and injection with contrast? This is highest degree of selectivity reached. Embolization Completion angio from common iliac?- No, included in embo code MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 31 Embolization Example #3 55 year old male with hepatocellular carcinoma on CT and MR chemoembolization requested R groin access Celiac artery and SMA selection and arteriography Catheter into common, then proper, then right hepatic artery with angio at each location Catheter further advanced into a branch of the right hepatic artery 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 32 16

17 Embolization Example #3 A combination of chemotherapeutic agents and embolic agent is administered until near stasis achieved No formal completion angio performed System removed and Mynx device used to achieve hemostasis in the groin 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 33 Embolization Example #3 - Codes Celiac and SMA selections / arteriograms?- Assign for each separate vascular family if truly diagnostic Common, proper, right hepatic and sub-selective hepatic placement and angio?- Possible assignment of if each vessel selectively imaged and diagnostically studied Chemo administration? Embolization? No completion angio? Modifier -52?- No, included in embo code 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 34 17

18 Embolization Example #4 28 year old female post partum with acute vaginal bleeding and hemodynamic instability Emergent uterine artery embolization requested R groin access and catheter to aorta for pelvic arteriogram I then selected and embolized both uterine arteries with Embospheres 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 35 Embolization Example #4 - Codes Selective catheterizations / diagnostic angio pelvic, common iliac, anterior division, uterine, further?- Selective pelvic angio is Possible assignment of for each additional vessel selectively studied after basic examination if documentation criteria are met Embolization: What if elective UFE? 37210?- No, deleted for See for UFE MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 36 18

19 Embolization - Overlapping Indications There may be overlapping indications for an embolization procedure. The code for the immediate indication for the embolization should be used. For example, if the immediate cause for embolization is bleeding in a patient with an aneurysm, report 37244, rather than MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 37 Stent Placement Stent codes identified along with as potentially misvalued by 75% reported together screen. 4 new codes created for percutaneous vs. open stent placement. Old codes and deleted MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 38 19

20 Stents - Clinical Types of stents Metallic Nitinol Self expanding Balloon expandable Bare Metal Covered Drug eluting 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 39 Stent Code New codes created for stents for revascularization (with or without angioplasty) for vessels other than: LE extremity ( ) Cervical carotid ( ) Intra-cranial (61635) Intracoronary (9292x or C9600-C9608) Vertebral or intrathoracic carotid (0075T-0076T) Open retrograde intrathoracic carotid or innominate (36217) 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 40 20

21 Intravascular Stent Placement Intravascular Stent Placement with or without Angioplasty - New Codes 4 new codes have been created in CPT 2014 for these services. The codes and descriptions are as follows: Transcatheter placement of an intravascular stent(s) (except lower extremity, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; initial artery Transcatheter placement of an intravascular stent(s) (except lower extremity, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; each additional artery (List separately in addition to code for primary procedure) 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 41 Intravascular Stent Placement Intravascular Stent Placement with or without Angioplasty - New Codes Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; initial vein Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; each additional vein (List separately in addition to code for primary procedure) 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 42 21

22 Intravascular Stent Placement Summarized: Codes and define stent placement in an artery. Codes and define stent placement in a vein. Codes and define initial stent placement in the respective vessels and codes and define stent placement in each additional vessel. Codes can be used for open or percutaneous procedures MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 43 Intravascular Stent Placement Intravascular Stent Placement with or without Angioplasty - New Codes Summarized: Like other interventions, if multiple devices are placed in the same vessel, only a single intervention should be coded. If a lesion is contiguous or "bridges" from one named vessel into another named vessel and both vessels can be treated simultaneously with the deployment of one device, only a single intervention should be coded. If both vessels are treated individually, each intervention should be separately coded. These codes ( ) include any angioplasty that may be performed at the same encounter in the same vessel treated by intravascular stent placement. There is no S and I code that should be assigned in addition to the bundled/collapsed surgical code for the stent placement. Moderate / conscious sedation is also considered to be bundled into these procedures MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 44 22

23 Intravascular Stent Placement Intravascular Stent Placement with or without Angioplasty - New Codes Summarized: These codes include closure of the arteriotomy by pressure or placement of a closure device as well as standard closure of the puncture by suture. Completion angiography performed to assess the efficacy of the stent placement(s) is considered inclusive to these procedures and should not be separately charged. These codes do not include nonselective or selective catheterizations nor other interventions that may be performed at the same encounter on the same patient in the same anatomic area. Examples of other potential codeable interventions include mechanical thrombectomy, thrombolytic therapy or IVUS. Likewise, these codes do not include ultrasonic guidance for vascular access (76937) or true full and complete diagnostic angiography. Extensive repair or replacement of an artery could be separately coded if performed and documented (35226 or 35286) MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 45 Intravascular Stent Placement Intravascular Stent Placement with or without Angioplasty - Summarized: Stents may be covered or noncovered. Stents may be used in several ways and confusion may arise when stents are used to treat an aneurysm. CPT states the following: Intravascular stents, both covered and uncovered, are a class of devices that may be used as part of an embolization procedure. As such, there is the potential for overlap among codes used for placement of vascular stents and those used for embolization. When a stent is placed for the purpose of providing a latticework for deployment of embolization coils, such as for embolization of an aneurysm, the embolization code is reported and not the stent code. If a covered stent is deployed (i.e.., pipeline) as the sole management of an aneurysm, pseudoaneurysm, or vascular extravasation, then the stent deployment code should be reported and not the embolization code MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 46 23

24 Stent Placement With endografts (TEVAR, EVAR,FEVAR) Only report stent codes when the treatment is OUTSIDE the target treatment zone of the endoprosthesis. For stenting of visceral arteries in conjunction with fenestrated endovascular repair, use MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 47 New Stent Codes Special instructions are found in CPT parenthetical for effects on AV shunt study and selective cath studies as well as for EVLT and ablation MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 48 24

25 Stents and Embolization When a stent is placed for the purpose of providing a latticework for deployment of embolization coils, such as for embolization of an aneurysm The embolization code is reported and not the stent code. For example, Neuroform stent If a covered stent is deployed as the sole management of an aneurysm, pseudoaneurysm, or vascular extravasation: The stent deployment code should be reported and not the embolization code MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 49 Stents and AV Grafts The same rules used for angioplasty apply to stent placements for AV dialysis shunts with respect to the number of interventions reported for each patient MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 50 25

26 Stents and AV Grafts Either or is reported once to describe all work of stenting lesions within the defined AV dialysis shunt segment from the peri-arterial anastomosis through the axillary and cephalic veins, regardless of the number of stents placed or the number of discrete lesions treated within that vessel segment MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 51 Stents and AV Grafts Code is reported for placement of AV access stent unless the treated lesion includes the peri-anastomotic region. This perianastomotic region is considered an artery and therefore is reported instead of MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 52 26

27 Stents and AV Grafts If additional stenting is required for central venous stenosis, this may be reported as an additional stent placement (37239), describing all the work of stent placement within the central venous segment. Possible Problems: No cross-reference in CPT after code stating to use with What if arterial anastomosis is treated by angioplasty and venous anastomosis is treated by stent placement? CPT hierarchy states that arterial lesion treatment is primary over venous lesion MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 53 Stent Placement - Example #5 62 year old male with MRA showing high grade stenosis of right renal artery R groin access using ultrasound Aortogram Right renal artery selected and angio performed; pressures taken Right sided hemodynamically suspicious ostial stenosis found Left renal looks suspicious so selected also with angio and pressures. No treatment necessary on the left 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 54 27

28 Stent Placement - Example #5 Exchange to long sheath Heparin 5000 units administered 6mm x 4 cm balloon expandable stent deployed Angioplasty performed Follow-up angio and pressure measurements Mynx for hemostasis after procedure 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 55 Stent Placement - Example #5 Ultrasound guided access?- Only assign if all 4 documentation criteria are met Bilateral renal artery selection and angiography? Stent? Angioplasty?- No, included in stent placement code Follow-up angio? - No, included in stent placement code Mynx?- G0269. Consider differences in hospital and physician billing 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 56 28

29 Stent Placement - Example #6 68 year old female with post-prandial pain CTA suggests celiac and SMA stenoses Aortogram and then selective SMA angiography with pressures Celiac and SMA stenoses appears significant Long sheath placed 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 57 Stent Placement - Example #6 Attention focused on celiac where a balloon expandable stent deployed Follow up angio and pressures show good result Attention focused on SMA where angioplasty with a 5mm balloon performed Gradient persists and a flap is suspected Balloon expandable stent then follows with a good result 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 58 29

30 Stent Placement - Example #6 Celiac stent? Celiac angioplasty?- No, included in stent placement code SMA stent? SMA angioplasty?- No, included in stent placement code Celiac and SMA selection and angiography?- Both are separate vascular families, so if documentation criteria are met, assign and for each, modify as appropriate based upon payer directives. Current MUE for is MPFS shows CPT with a multiple surgery indicator of 1 meaning that the code will be paid at 150% when reported more than once MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 59 Stent Placement - Example #7 45 year old male with right arm AV shunt Recurrent venous anastomosis stenoses requiring frequent angioplasty Graft accessed and Fistulogram performed Angioplasty of anastamosis performed but narrowing remains 8mm covered stent deployed to treat stenosis 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 60 30

31 Stent Placement - Example #7 AV shunt access?- Not separately codeable Fistulogram? includes access, injection(s) and diagnostic imaging Angioplasty?- No, bundled/collapsed into stent placement code Stent? , Initial venous stent placement including angioplasty 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 61 Fenestrated Visceral Aortic Graft Placement Endovascular Repair of Visceral Aorta Using a Fenestrated Graft (FEVAR) - New Codes Eight new codes have been added to CPT 2014 for these services. The codes and descriptors are as follows: Endovascular repair of visceral aorta (e.g., aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including one visceral artery endoprosthesis (superior mesenteric, celiac or renal artery) Endovascular repair of visceral aorta (e.g., aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including two visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 62 31

32 Fenestrated Visceral Aortic Graft Placement Endovascular Repair of Visceral Aorta Using a Fenestrated Graft (FEVAR) - New Codes The codes and descriptors are as follows: Endovascular repair of visceral aorta (e.g., aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including three visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) Endovascular repair of visceral aorta (e.g., aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including four or more visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 63 Fenestrated Visceral Aortic Graft Placement Endovascular Repair of Visceral Aorta Using a Fenestrated Graft (FEVAR) - New Codes The codes and descriptors are as follows: Endovascular repair of visceral aorta and infrarenal abdominal aorta (e.g., aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including one visceral artery endoprosthesis (superior mesenteric, celiac or renal artery) Endovascular repair of visceral aorta and infrarenal abdominal aorta (e.g., aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including two visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 64 32

33 Fenestrated Visceral Aortic Graft Placement Endovascular Repair of Visceral Aorta Using a Fenestrated Graft (FEVAR) - New Codes The codes and descriptors are as follows: Endovascular repair of visceral aorta and infrarenal abdominal aorta (e.g., aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including three visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) Endovascular repair of visceral aorta and infrarenal abdominal aorta (e.g., aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including four or more visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 65 Fenestrated Visceral Aortic Graft Placement Completely new introductory language for codes fenestrated endovascular repair of the visceral and infrarenal aorta (FEVAR) EVAR = EndoVascular Aneursym Repair TEVAR = Thoracic EndoVascular Aneursym Repair FEVAR = Fenestrated EndoVascular Aneursym Repair This procedure extends the ability to treat aneurysms that have no neck or extended neck MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 66 33

34 Fenestrated Visceral Aortic Graft Placement Completely new introductory language for codes fenestrated endovascular repair of the visceral and infrarenal aorta (FEVAR) Summarized: The celiac, superior mesenteric and renal arteries are known as the visceral aorta. The thoracic aorta begins at the level of the aortic valve and ends just proximal to the celiac artery. The main body of the fenestrated graft is placed within the visceral aorta. Fenestration's (i.e., "openings") within the fabric of the graft allow for selective catheterization of the renal arteries or visceral arteries. These openings allow for subsequent placement if need be of an endoprosthesis to allow flow to continue to the visceral artery(s). These additional endoprosthesis could be either bare metal or covered stents. Codes are used to define the placement of a fenestrated endovascular graft in the visceral aorta. These codes describe procedures in which the graft is placed either alone or in combination with a graft placed for an infrarenal aortic aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma or traumatic disruption MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 67 Fenestrated Visceral Aortic Graft Placement Completely new introductory language for codes fenestrated endovascular repair of the visceral and infrarenal aorta (FEVAR) The ultimate code selected and submitted is based upon the procedure performed within the aorta. Codes describe procedures within the visceral aorta involving one, two, three or four or more additional endoprosthesis into the visceral arteries. Of key importance, codes do not extend into the common iliac arteries. Codes describe procedures within the visceral aorta involving one, two, three or four or more additional endoprosthesis into the visceral arteries. Of key importance, codes extend through the infrarenal aorta into the common iliac arteries. This infrarenal component can be one of several types. Whether it be a bifurcated unibody device, a modular bifurcated device with one or two docking limbs or and aorto uniiliac (AUI) or aorta unifemoral (AUF) device, codes are still valid MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 68 34

35 Fenestrated Visceral Aortic Graft Placement Completely new introductory language for codes fenestrated endovascular repair of the visceral and infrarenal aorta (FEVAR) It would be inappropriate to code separately for the placement of unilateral or bilateral docking limbs (based upon the type of device used) as codes already include this. As such, do not report codes or if proximal (aortic) or distal (common iliac arteries) are placed at the same clinical encounter. If these distal extension prostheses terminate in vessels such as the internal iliac (i.e. hypogastric), external iliac or common femoral arteries, codes and may be assigned. As evident from the codes and their descriptors, these codes ( ) describe the total number of visceral and or renal arteries that are treated by endoprosthesis placement through the aortic fenestration(s). Unlike codes for thoracic aortic endograft (TEVAR) and abdominal aortic endograft (EVAR) treatments, codes (FEVAR) include nonselective and selective catheter placements. As such, it would be in appropriate to assign codes from the selective range ( ) or the nonselective aortic placement (36200) when catheters/devices are placed into renal and/or visceral arteries for placement of the grafts) MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 69 Fenestrated Visceral Aortic Graft Placement Completely new introductory language for codes fenestrated endovascular repair of the visceral and infrarenal aorta (FEVAR) It is appropriate however to assign selective catheterization codes ( ) if vessels outside of the target/treatment/landing zone (i.e. internal iliac arteries) or other vessels outside of this area are engaged and treated. Per CPT 2014, codes do not include moderate / conscious sedation. Like EVAR and TEVAR procedures, if other interventional procedures (i.e., angioplasty) are performed within the target/treatment/landing zone at the time of the FEVAR, this is not separately codable. Again, like EVAR and TEVAR procedures, fluoroscopy is not separately codable. Unlike EVAR and TEVAR procedures, there are not discrete S&I codes that would be used in conjunction with the surgical component (i.e., ) as these codes are bundled / collapsed to include both the supervision and interpretation as well as the surgical component of the procedure. All angiography performed during and post FEVAR procedure at the same encounter are considered included in codes MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 70 35

36 Fenestrated Visceral Aortic Graft Placement Completely new introductory language for codes fenestrated endovascular repair of the visceral and infrarenal aorta (FEVAR) Not bundled into codes is the cut down procedure to gain initial vascular access (34812). As such, this may be assigned in addition to the FEVAR itself. CPT instructions clearly state that if extensive repair of an artery is performed, this may be separately reported with either code or If at the same encounter in which the FEVAR is performed it is also necessary to treat a thoracic aortic aneurysm (i.e., TEVAR), this procedure is not considered to be inclusive in codes and could be separately codable using the appropriate codes from the and series of options. Similarly, if an abdominal aortic aneurysm is treated which does not require additional endoprosthesis being placed through a fenestration, one should default back to the EVAR codes found in the and series MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 71 Fenestrated Visceral Aortic Graft Placement Completely new introductory language for codes fenestrated endovascular repair of the visceral and infrarenal aorta (FEVAR) Finally, if at the same encounter as the FEVAR interventional procedures such as embolization, IVUS, angioplasty are performed in vessels that lie outside of the target / treatment / landing zone of the vessels treated by FEVAR, these may be separately coded MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 72 36

37 Fenestrated Visceral Aortic Graft Placement When performing FEVAR, remember: Do not report in conjunction with 34800, 34802, 34803, 34804, 34805, , 35081, 35102, 35452, 35472, Do not report in conjunction with 34800, 34802, 34803, 34804, 34805, , 35081, 35102, 35452, 35472, Do not report in conjunction with 37236, for bare metal or covered stents placed into the visceral branches within the endoprosthesis target zone For placement of distal extension prosthesis(es) terminating in the internal iliac, external iliac, or common femoral artery(s), see , 75953, 0254T, 0255T Use in conjunction with only when are performed outside the target/treatment zone of the endoprosthesis 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 73 Fenestrated Visceral Aortic Graft Placement When performing FEVAR, remember: Do not report in conjunction with Do not report in conjunction with for ipsilateral services Do not report in conjunction with Do not report codes for snorkeling or scalloped graft procedures (scalloped means a slight cut in graft ) Scalloped vessels separately treated are separately codeable (i.e., cath placements, stent deployment, etc.) 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 74 37

38 Deleted 2014 Codes Relevant to Radiology Transcatheter placement of an intravascular stent(s) (except coronary, carotid, vertebral, iliac, and lower extremity arteries), percutaneous; initial vessel Transcatheter placement of an intravascular stent(s) (except coronary, carotid, vertebral, iliac, and lower extremity arteries), percutaneous; each additional vessel (List separately in addition to code for primary procedure) Transcatheter placement of an intravascular stent(s) (except coronary, carotid, vertebral, iliac and lower extremity arteries), open; initial vessel Transcatheter placement of an intravascular stent(s) (except coronary, carotid, vertebral, iliac and lower extremity arteries), open; each additional vessel (List separately in addition to code for primary procedure) These codes are now described by codes found in the series MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 75 Deleted 2014 Codes Relevant to Radiology 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 Uterine fibroid embolization (UFE, embolization of the uterine arteries to treat uterine fibroids, leiomyomata), percutaneous approach inclusive of vascular access, vessel selection, embolization, and all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the procedure These codes are now encompassed in options in the series MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 76 38

39 Deleted 2014 Codes Relevant to Radiology 0078T Endovascular repair using prosthesis of abdominal aortic aneurysm, pseudoaneurysm or dissection, abdominal aorta involving visceral branches (superior mesenteric, celiac and/or renal artery[s]) 0079T Placement of visceral extension prosthesis for endovascular repair of abdominal aortic aneurysm involving visceral vessels, each visceral branch (List separately in addition to code for primary procedure) 0080T Endovascular repair using prosthesis of abdominal aortic aneurysm, pseudoaneurysm or dissection, abdominal aorta involving visceral vessels (superior mesenteric, celiac and/or renal artery[s]), radiological supervision and interpretation 0081T Placement of visceral extension prosthesis for endovascular repair of abdominal aortic aneurysm involving visceral vessels, each visceral branch, radiological supervision and interpretation (List separately in addition to code for primary procedure) These codes have been replaced by Category l codes MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 77 Case Example #1 Visceral Angiography with Angioplasty and Stenting Procedure notes: Via the left femoral artery approach a 6 French short sheet was inserted retrograde. This sheath was then exchanged for a 7 French Ansel 1 sheath. Injections: Superior mesenteric artery cannulated, angiography with runoff performed from left femoral approach. Celiac artery cannulated with angiography and runoff performed from the left groin approach. Post balloon inflation angiography performed from the left femoral arterial access. Preintervention angiography performed from left femoral arterial access. Post balloon inflation angiography performed from left femoral arterial access. Post stent deployment angiography performed from left femoral arterial access. Sheath removed, Starclose deployed successfully MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 78 39

40 Case Example #1 Findings: Selective celiac and superior mesenteric artery angiography with PTA of the celiac and combined PTA and stenting of the SMA. All studies were performed from a retrograde left common femoral artery approach. Celiac artery had been previously stented and there was a moderate residual 40 50% stenosis within the stented segment. Following balloon angioplasty, the celiac artery was widely patent with less than 20% residual stenosis present. The superior mesenteric artery had a complex 80 90% calcified stenosis in the proximal segment. Following balloon angioplasty and stenting, the SMA was widely patent with less than 20% residual narrowing Codes: (x2), (x2), 75966, 35471, 37236, G MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 79 Case Example #2 Ultrasound Guided Access of the Right Femoral Vein, Selective Catheterization of the Left Ovarian Vein, Left Renal Venogram, Left Ovarian Vein Venogram and Pelvic Venogram, Chemical Ablation and Embolization of Pelvic Varicosities and Caudal Embolization of the Left Ovarian Vein Indications for procedure: The patient has a history of pelvic pain and pelvic congestion syndrome with ovarian vein reflux and pelvic varicosities. Patient presents for embolization. Description of procedure: The right groin was prepped and draped in the usual sterile fashion. The femoral vein was patent on ultrasound and we accessed it using ultrasonic guidance with a micropuncture kit. The sheath was placed. Using a cobra catheter, we selectively entered into the left renal vein. The left renal venogram showed that the renal vein was patent with no compression MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 80 40

41 Case Example #2 Description of procedure (continued): We selectively entered into the left ovarian vein, advance the glide catheter with the glide wire down into the pelvis and did a pelvic venogram which showed extensive pelvic varicosities. Left ovarian vein was dilated up to 10 mm in size with reflux. Then, 1% sodium tetracycline sulfate (STS) was used to create a foam diluted with contrast and 1:3 parts air. We next injected pelvic varicosities with sodium tetracycline sulfate a total of six ML of foam was used to embolize the pelvic varicosities. After completing this, a venogram showed that there was stagnant flow with not much filling of the varicosities. We then proceeded to embolized the left ovarian vein with 10 mm x 14 mm coils. A total of three coils are used to embolized the entire ovarian vein. We stopped about 5 cm from the origin of the ovarian vein. A completion venogram showed occlusion of the ovarian vein with no further reflux or flow into it. The renal vein was patent in there was good flow into the cava. At this point, we terminated the procedure. The sheath was removed from the groin. Of note, a 7 French Hopkins hook was used and selectively placed in the origin of the left renal vein to do the procedure. Pressure was held in the groin for 10 min. with good hemostasis. I was present throughout the procedure MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 81 Case Example #2 Codes: 36012, 75831, 75820, MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 82 41

42 Thank you for your participation! 2014 MEDLEARN PUBLISHING / A DIVISION OF PANACEA HEALTHCARE SOLUTIONS 83 42