Intro: Slide 1. Slide 2. Slide 3. Basic understanding of interventional radiology. Gain knowledge of key terms and phrases

Transcription

1 Slide 1 Intro: PRESENTED BY: Selena M. Moore, AAS, CCS, CPC HIMS Physician Liaison Coder This is a modified/updated presentation that was originally written by: Rosemary Waligorski, RHIT, CCS, RCC and Wendy Block, CPC, RCC, CIRCC 1 Slide 2 Basic understanding of interventional radiology Gain knowledge of key terms and phrases Practice participate in case examples and exercises 2 Slide 3 Interventional radiology is the non-surgical treatment using radiologic imaging, with contrast, to guide instruments (catheters, balloons, etc) through the body s blood vessels and other organs. This type of procedure is done for both diagnostic and therapeutic procedures and is usually done on an outpatient basis. Some common types of procedures done in interventional radiology include: 1. Angiography 2. Angioplasty 3. Atherectomy 4. Stent insertion 5. Biopsies 6. Occlusion procedures 3

2 Slide 4 Four Critical Elements 1. Demographics 2. Clinical information 3. Body of the Report 4. Impression 4 Slide 5 Angiography Pictures taken of a blood vessel Antegrade with the flow Bifurcation a splitting or forking of vessels into two separate vessels Bovine Arch anomaly in the vessels coming off the aortic arch where the left common carotid actually comes off the right innominate artery instead of off the aorta Catheter instrument used in most percutaneous interventional radiology procedures Contralateral opposite side First order primary vascular branch 5 Slide 6 Great Vessels those vessels that come off the aortic arch in normal anatomy; the brachiocephalic, common carotid, and left subclavian Guiding angiogram imaging taken of vessel that the catheter is in so that the physician can verify where they re at and where they still need to go Ipsilateral same side Non-select catheter placement catheter positioned in the aorta (from anywhere outside of the aorta) or placement in the access vessel itself without manipulation into another vessel 6

3 Slide 7 Retrograde against the flow Select catheter placement catheter that is threaded: Into a vessel off the vessel accessed The aorta Vena Cava Vascular families each separate set of vessels: Off the vessel accessed Off the Aorta Off the Vena Cava 7 Slide 8 Documentation of Seven Key Components 1. The approach 2. All Vessels Catheterized 3. All Vessels visualized and interpreted 4. Each Catheter s end Position 5. Abnormal Anatomy 6. A Description of all procedures performed in each vascular system 7. Documentation of all therapies performed 8 Slide 9 Code to the final catheter placement per vascular family Do not code to where the wire is placed Select catheter placement always takes precedence over non-select unless a second access is obtained Code each vascular family separately Code only one select catheter placement from each vascular family ( & ) Make sure the proper codes are being used for catheter placement in regards to anatomy Above the diaphragm Below the diaphragm

4 Slide 10 1 Approach: Determines level of difficulty vessel ordering A coder cannot determine vessel ordering without identification of the access point Example: Selective catheter placement of the right common carotid, right vertebral, right internal mammary, right thyrocervical trunk, and right costocervical trunk. 10 Slide 11 The Approach Femoral Approach RT Axillary Approach CPT RVU CPT RVU RT Vertebral RT INT Mammary RT Thyrocervical RT Costocervical RT Common Carotid Total RVU s Slide All Vessels Catheterized (catheter movement) Document where the catheter was placed. Each vessel selected for evaluation and/or treatment should be documented. Example: From a RT common femoral artery approach, a complete abdominal aortogram and bilateral extremity arteriogram was performed. Catheter was placed in the proximal aorta for the abdominal aorta imaging, the catheter was then pulled down to the bifurcation of the aorta for bilateral extremity imaging Catheter in aorta Abdominal aortogram Bilateral extremity arteriogram 12

5 Slide All vessels visualized and interpreted Important for selection of supervision and codes. Certain supervision and codes require selective catheterization of the vessel studied. Example: Requiring documentation of selective catheterization. CPT Angiography, external carotid, unilateral, selective, radiological supervision and Example: Not requiring documentation of selective catheterization. CPT Angiography, carotid cerebral, unilateral, supervision and. 13 Slide Each catheter s end position The catheter(s) end position determines the final ordering of the case. Identify the name of the vessel catheterized 14 Slide Abnormal Anatomy o Clearly document abnormal anatomy describe vessel location. o Abnormal anatomy may change vessel ordering and subsequently the procedure codes. 15

6 Slide 16 Abnormal Anatomy Example: From a common femoral artery approach, and arch study was performed, the catheter was placed in both common carotids with imaging of each. Normal Anatomy Bovine Arch CPT Description CPT Description RT common carotid RT common carotid LT common carotid LT common carotid Arch Study Arch Study Bilateral Carotids Bilateral Carotids 16 Slide A description of all procedures performed in each vascular system Each vascular system is separately coded 17 Slide Documentation of All Therapies Performed All therapies need to be documented for accurate coding. Angioplasty Stenting Infusion Embolization Arthrectomy 18

7 Slide 19 Other important information to include: Reduced Service Discontinued Service Unusual Circumstance Unusual Complication Was a diagnostic study previously performed? 19 Slide 20 Road-mapping this is NOT imaging Verification of catheter placement is NOT imaging In, engaged, cannulated, in the mouth of, in the orifice of, in the ostia; these describe the catheter being IN the vessel the physician is referring to or maybe getting ready to image At, near, to, proximal to; these are words that describe the catheter NOT being in the vessel the physician is referring to 20 Slide Introduction of needle or intracatheter; retrograde brachial artery extremity artery Introduction of catheter, aorta Selective catheter placement arterial system: each first order thoracic or brachiocephalic branch, within a vascular family initial second order thoracic or brachiocephalic branch, within a vascular family 21

8 Slide initial third order or more selective thoracic or brachiocephalic branch, within a vascular family additional second order, third order and beyond, thoracic or brachiocephalic branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriate) 22 Slide Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch, within a vascular family (list in addition to code for initial second or third order vessel as appropriate) 23 Slide Aortography, thoracic, by serialography, radiological supervision & Aortography, abdominal, serialography, radiological supervision and Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision and Angiography, cervicocerebral, catheter, including vessel origin, radiological supervision and Angiography, external carotid, unilateral, selective, radiological supervision and 24

9 Slide Angiography external carotid, bilateral, selective radiological supervision and Angiography, carotid cerebral, unilateral, radiological supervision and Angiography carotid cerebral, bilateral, radiological supervision and Angiography, carotid, cervical, unilateral, radiological supervision and Angiography, carotid, cervical bilateral, radiological supervision and 25 Slide Angiography, vertebral, cervical, and/or intracranial, radiological supervision and Angiography, spinal, selective, radiological supervision and Angiography, extremity, unilateral, radiological supervision and Angiography, extremity, bilateral, radiological supervision and 26 Slide Angiography, renal, unilateral, selective (including flush aortogram, radiological supervision and ) Angiography, renal, bilateral, selective (including flush aortogram), radiological supervision and Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision and Angiography, pelvic, selective or supraselective, radiological supervision and Angiography, selective, each additional vessel studied after basic examination, radiological supervision and (list separately in addition to code for primary procedure 27

10 Slide 28 To code/charge CPT 75774, it is required that additional imaging beyond the basic exam is performed after an additional level of catheter selectivity is documented for the exam. It is not appropriate to assign when images are obtained to complete the initial runoff exam, i.e. step-table, even if more selective catheter placement is performed. Documentation of the clinical indication for needing to do so, e.g. poor visualization, occlusive disease, anatomical variants, etc., as well as imaging findings is also required. 28 Slide 29 Unless otherwise specified, all access is through the femoral artery All findings are assumed reported unless otherwise stated 29 Slide Catheter placement in aorta for abdominal aortogram 2. Catheter placement in aorta for bilateral renal artery and abdominal aortogram 3. Catheter placed in aorta and bilateral renal arteries for angiograms 4. Catheter placement in aorta for abdominal aortogram. Catheter then placed in the celiac trunk, inferior mesenteric artery, and superior mesenteric artery; contrast injected and images taken. 30

11 Slide Left femoral artery accessed, contrast injected for lower extremity angiography 6. Left femoral artery accessed, catheter threaded up, over the abdominal aorta into the common iliac artery, contrast injected for angiography of the right lower extremity 31 Slide Left femoral artery accessed; catheter threaded up into the aorta and placed at the bifurcation contrast injected for bilateral lower extremity angiography 8. Femoral artery accessed. Catheter placed in contralateral common femoral artery for lower extremity angio. Catheter then pulled back to ipsilateral common iliac and contrast injected for lower extremity angio 32 Slide Catheter threaded into the right subclavian for upper extremity angiography 9. Catheter placed in the right brachiocephalic artery and the left subclavian artery. Upper extremity angiography performed 11. Access in the right retrograde brachial artery. Upper extremity angio performed. 33

12 Slide Access in the right brachial artery for upper extremity angiography. Catheter then threaded up, into, and over the aortic arch and into the left subclavian for upper extremity angiography 13. Catheter placed in the aortic arch and aortogram performed showing patent origins of the right brachiocephalic, left common, and left subclavian vessels. Slight tortuosity seen in the arch itself. 34 Slide Same Catheter placed in the aortic arch. Contrast is injected and angiography is taken of the bilateral common carotids and bilateral internal carotids. 15. Same as number 14 with the addition of the external carotid arteries 35 Slide Catheter threaded through the aortic arch and placed in the right and left internal carotid arteries and the left vertebral artery for angiography 17. Catheter placed in the right vertebral, right internal carotid, left internal carotid for angiography. Catheter placed in the left subclavian for angio of left vertebral. 36

13 Slide Catheter placed in the bilateral common carotid arteries for angiography. Then the catheter was placed in the bilateral external and internal carotid arteries for angiography. 19. Catheter placed in: right vertebral, right external & internal carotids, left internal and external carotids, and left vertebral arteries where imaging of all these vessels were done and images reported 37 Slide Local anesthesia provided to patient before procedure began. Right common femoral artery was prepped and draped in a sterile fashion then accessed with small nick incision. Multiple attempts were made to advance the wire and catheter but because of the occluded right external iliac artery, catheters were withdrawn and attention turned to the left groin. Using the same technique as the right groin, access into the left femoral artery was obtained. Catheter was then threaded up into the abdominal aorta to the level of the renal arteries. Aortography was performed with run-off down to the bilateral common femorals Images were obtained, after which all catheters were withdrawn and hemostasis obtained through manual pressure. 38 Slide From RT groin access, an abdominal aortogram is performed via cath placement in the abdominal aorta and injection above the renal arteries w/ findings documented followed by BLE angiography via cath movement to the bifurcation and injection revealing an abnormality of the RT popliteal artery. The catheter is pulled back into the RT femoral artery and additional injection or imaging is performed of the popliteal artery. 39

14 Slide Utilizing Seldinger technique and 1% Xylocaine for local anesthesia, a #5 French pigtail catheter was inserted via the right common femoral artery and advanced into the aortic arch where arch aortography was performed. Bilateral carotid arteriograms and bilateral vertebral arteriograms were performed after selective catheterization. The following catheters were utilized: JB2 in the right common carotid, Simmons I in the left common carotid, and a #5 French vertebral catheter in both vertebral arteries. The catheters were removed and hemostasis obtained. The patient tolerated the procedure well. There were no apparent complications (cont) 40 Slide Arch aortography: Shows normal orientation of the great vessels, with the left common carotid notably tortuous proximally. No other focal abnormalities are seen. 2. Right carotid arteriogram: There is approximately 40% narrowing of the junction of the right common carotid with the internal carotid from a small posterior located plaque. Otherwise, the right extracranial internal carotid appears unremarkable. The right external carotid appears unremarkable. There is noted a 7 x 6.5 mm aneurysm originating form the distal internal carotid near the level of the origin of the ophthalmic artery. The aneurysm projects medially and posteriorly. The right anterior and middle cerebral arteries appear unremarkable. 3. Left carotid arteriogram: No focal abnormalities are seen. No extracranial or intracranial abnormalities are evident. No aneurysms are identified. 4. Left vertebral arteriogram: No focal abnormalities are seen. No aneurysm is evident. The basilar tip is unremarkable. No aneurysms are seen around the region of the posterior inferior cerebellar arteries. 5. Right vertebral arteriogram: No focal abnormalities are identified. No aneurysms are seen. The basilar tip is unremarkable 41 Slide 42 Central Venous Access Procedures Be sure to Document: The termination site of the catheter/device Location of Insertion Type of Procedure Performed Was it with a subcutaneous port or a pump? Type of guidance and imaging. 42

15 Slide 43 Fluoroscopic Guidance for Central Venous Access Device Fluoroscopic guidance for central venous access device placement, replacement, or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and, and radiographic documentation of final catheter position. 43 Slide 44 Ultrasound Guidance for Vascular Access Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected patency, concurrent real-time visualization of vascular needle entry, with permanent recording and reporting. 44 Slide 45 Your documentation needs to be complete and accurate. Coding assignments are solely based on documentation. Accurate documentation results in optimal coding. 45

16 Slide , , , 36215, 36215, 75726, 75726, , , , , , , 36215, , , , , 75680, Great Job! , 75680, , 36216, 36216, 75671, 75685, , 36218, 36216, 36215, 75671, 75685, , 36218, 36216, 36218, 75680, 75671, , 36218, 36218, 36216, 36218, 36216, 75662, 75671, 75680, 75685, , 36200, , 75625, , 36218, 36215, 36216, 75650, 75671, 75680, 75685, Great Job! 46 Slide 47 Renal catheterization and imaging New codes opposed to 2011 you could code for each cath placement ) plus imaging (75722 and 75724). In 2012 only one of the new codes are reported which included the cath placement, imaging and moderate sedation. Paracentesis New Codes in 2012 ( ) You assign the codes based on whether or not they were performed w/ imaging. Also note there is a new code for peritoneal lavage Vena Cava Filters New CPT codes in 2012 are Cath placement, imaging and moderate sedation is now bundled into one code! Code selection is based on whether is was an insertion, repositioning, or retrieval. It does not matter whether filter is IVC or SVC. (37620&75940 )now deleted. Moderate Sedation 2012 MS is now bundled into percutaneous liver biopsy 47 Slide 48 48

17 Slide 49 AMA, CPT 2012 Professional Edition, Expert 2011 ICD-9 CM for Physicians Volumes 1&2, 2012 American College of Radiology Society of Interventional Radiology CMS 49 Slide 50 Selena M. Moore, AAS, CCS, CPC 50