Naviga&ng the Road Map of Vascular Families

Naviga&ng the Road Map of Vascular Families AAPC Regional Conference Chicago, IL October 26, 2012 Presented by: David Dunn, MD, FACS CIRCC, CCVTC, CPC- H, CCC, CCS, RCC Na&onal Coding Standards Sources of informa3on - Centers for Medicare and Medicaid Services (CMS) Na3onal Coverage Determina3ons (NCDs) Provider Policy Manual January 1,2012 - Medicare Contractor s LMRPs /LCDs - American Medical Associa3on (AMA), CPT and CPT Assistant ar3cles, CPT Changes - Society of Interven3onal Radiology (SIR) - American College of Cardiology (ACC) - Other LCDs 2 General Recommenda&ons For Physician Dicta&ons State the history including prior diagnos3c studies and medical necessity State the vascular access site(s) State the vessels catheterized State the route of the catheter and the end posi3on State the vessels injected and findings of the areas imaged during these contrast injec3ons State the interven3ons performed and any complica3ons/ addi3onal treatments State the specific devices and specialty supplies used during the procedure 3 1

Vascular Imaging Coding Rules Four vascular systems that are coded separately Arterial Venous Pulmonary Portal 4 Two Interven&onal Coding Systems Imaging supervision & interpreta3on (S&I) - 70000 Series of CPT Procedure performed - 10000 69999 Series of CPT 5 Vascular Imaging Coding Rules Imaging S&I Code based on vessel or vascular system imaged (70000 series codes) Images that were taken and contributed to the study and were medically necessary Hard copies printed or available (PACS) Dicta3on describing the findings (this is mandatory and some3mes a limi3ng factor) 6 2

Vascular Families Vessel and all of its branches that originates from - Access vessel - Aorta - Vena cava 7 Normal Arch Arterial Anatomy - Detailed Transfemoral Approach 8 Catheter Placement Coding Rules Non- selec3ve - Vessel entered (femoral, brachial) - Aorta or vena cava - AV shunt - Direct caro3d puncture - Right heart or main pulmonary artery - Portal vein 9 3

Catheter Placement Codes Non- selecgve codes 36005 Injec3on for extremity venography 36010 Catheter placement vena cava 36013 Catheter placement main pulmonary artery 36100 Needle/Intracatheter placement caro3d artery 36120 Needle/Intracatheter placement retrograde brachial 10 Catheter Placement Codes Non- selecgve codes 36140 Catheter placement extremity artery 36147 Catheter placement AV dialysis shunt, ini3al- includes imaging 36148 Catheter placement AV dialysis shunt, addi3onal access for therapeu3c interven3on 36160 Catheter placement aorta, translumbar 36200 Catheter placement aorta 36481 Catheter placement into portal vein 11 Normal Arch Arterial Anatomy - Detailed Transfemoral Approach 12 4

Lower Extremity Arterial Anatomy Right Transfemoral Approach Antegrade Right Femoral Approach Retrograde Right Femoral Approach Non- selec&ve First order Second order Third order 13 Catheter Placement Coding Rules SelecGve - A branch off of the vessel entered or a branch off the aorta or vena cava - Non- selec3ve catheter placement is included in the selec3ve catheter placement code in all cases - Includes lesser order selec3ons in the same vascular family 14 Catheter Placement Codes SelecGve codes Arteries above the diaphragm - 36215 - First order selec3ve catheteriza3on in a vascular family - 36216 Second order selec3ve catheteriza3on in a vascular family - 36217 Third order or higher selec3ve catheteriza3on in a vascular family - 36218 Each addi3onal second order or higher selec3ve catheteriza3on in a vascular family 15 5

Catheter Placement Codes SelecGve codes Arteries below the diaphragm - 36245 First order selec3ve catheteriza3on in a vascular family - 36246 Second order selec3ve catheteriza3on in a vascular family - 36247 Third order or higher selec3ve catheteriza3on in a vascular family - 36248 Each addi3onal second order or higher selec3ve catheteriza3on in a vascular family 16 Catheter Placement Codes Code to highest order selec3on within a vascular family. Use code 36218 or 36248 for each addi3onal selec3on within the same vascular family. Code for each vascular family selected using the same guidelines. Code separately for each access using the same guidelines. 17 Non- selec&ve First order Second order Third order Normal Arch Arterial Anatomy - Detailed Transfemoral Approach 18 6

Non- selec&ve First order Second order Third order Variant Arch Anatomy Common Origin of LeL Common Caro&d and Right Brachiocephalic Arteries Transfemoral Approach 19 Non- selec&ve First order Second order Third order Variant Arch Anatomy Bovine Transfemoral Approach 20 Non- selec&ve First order Second order Third order Variant Arch Anatomy Aberrant Right Subclavian Artery Transfemoral Approach 21 7

Non- selec&ve First order Second order Third order Variant Arch Anatomy Separate LeL Vertebral Origin Transfemoral Approach 22 Non- selec&ve First order Second order Third order Normal Arch Arterial Anatomy Right Transbrachial Approach 23 Non- selec&ve First order Second order Third order Visceral and Renal Arterial Anatomy Transfemoral Approach 24 8

Lower Extremity Arterial Anatomy Right Transfemoral Approach Non- selec&ve First order Second order Third order Antegrade Right Femoral Approach Retrograde Right Femoral Approach 25 Vascular Imaging Coding Rules Procedures that must be done selecgvely (requires documentagon that catheter placement is in the vessel being imaged) External caro3d (75660, 75662) Renal venous system ( 75831, 75833) Adrenal arteries and venous system (75731, 75733, 75840, 75842) Pulmonary arteries - separate codes for selec3ve (75741, 75743) and non- selec3ve (75746) 26 Vascular Imaging Coding Rules AddiGonal procedures that must be done selecgvely Selec3ve renal artery angiography First order 36251 unilateral 36252 bilateral Superselec3ve 36253 unilateral 36254 bilateral These codes include catheter placement(s), any accessory renal artery(s), contrast injec3on, imaging, S&I, pressure measurements, and flush aortogram if performed. 27 9

Vascular Imaging Coding Rules AddiGonal procedures that must be done selecgvely Visceral arteries (75726) Spinal arteries (75705) Pelvic arteries (75736) Each addi3onal vessel studied afer basic exam (75774) 28 29 30 10

Catheter Placement Codes Portal System 36481 Access to portal vein by any method Venous System 36011 First order selec3ve catheteriza3on in a vascular family 36012 Second order or higher selec3ve catheteriza3on in a vascular family and addi3onal second order or higher selec3ve catheteriza3ons in the same vascular family 31 Catheter Placement Codes Pulmonary System 36013 Right heart or main pulmonary artery 36014 Lef or right pulmonary artery 36015 Segmental or subsegmental artery and addi3onal segmental or subsegmental arterial catheteriza3ons in the same vascular family 32 Portal Venous Anatomy 33 11

Non- selec&ve First order Second order Venous Anatomy Right Transfemoral Approach 34 Coding Rules Do code to where the 3p of the catheter is. Do code 36200 (aorta catheter placement) over other non- selec3ve codes (36140, 36120). Do code each of the four vascular systems separately: arterial, venous, portal, pulmonary. Do code each vascular family separately, using modifiers to dis3nguish the different vessels. Within a vascular system, code catheter placement from each access separately. 35 Coding Rules Do not code for reforming catheters. Do not code access site separately (sheath). Do not code for where the 3p of the wire is. Do not code for catheter placement in the aorta (36200) once a selec3ve catheteriza3on has occurred (e.g., renal selec3ve, 36245) unless there has been a separate puncture. 70,000 imaging S&I codes include fluoroscopy and ultrasound guidance. Do not use - 50 modifier for above diaphragm selec3ve catheter placement codes 36215, 36216, or 36217. 36 12

Procedures That Include Catheter Placements 37182 Inser3on TIPS 37183 Revision of TIPS 37215 Cervical caro3d artery stent with distal protec3on 37216 Cervical caro3d artery stent without distal protec3on 0075T Extracranial vertebral or intrathoracic caro3d stent 0076T Extracranial vertebral or intrathoracic stent, each addi3onal vessel 36251-36254 Selec3ve renal angiography (New for 2012) 37191-37193 Inser3on, reposi3on, and retrieval of vena cava filter (New for 2012) 37 Procedures That Include Catheter Placements 37210 Uterine fibroid emboliza3on 61623 Endovascular temporary balloon occlusion 61630 Balloon angioplasty, intracranial 61635 Intravascular stent(s), intracranial 61640 Balloon dilata3on, intracranial vasospasm 61641 Balloon dilata3on, each addi3onal vessel - same vascular family 61642 Balloon dilata3on, each addi3onal vessel - different vascular family Star3ng in 2011 New lower extremity revasculariza3on codes 37220 through 37235 include catheter placement and vascular closure device placement and associated imaging. 38 General Recommenda&ons for Physician Dicta&ons State the history including prior diagnos3c studies and medical necessity State the vascular access site(s) State the vessels catheterized State the route of the catheter and the end posi3on State the vessels injected and findings of the areas imaged during these contrast injec3ons State the interven3ons performed and any complica3ons/ addi3onal treatments State the specific devices and specialty supplies used during the procedure 39 13

Diagnos&c Imaging of the Arterial System 40 Renal and Variant Renal Arterial Anatomy 41 Basic Coding Case 1: Non- selec3ve bilateral renal arteriogram with catheter placement in aorta. 36200 Catheter placement in the aorta 75625 Abdominal aortography, S&I 42 14

Basic Coding Case 2: Unilateral renal arteriogram with catheter placement in main renal artery. 36251 Unilateral 1 st order selec=on; includes catheter selec=on, imaging, accessory renal angiography, and pressures, if performed 43 Basic Coding Case 3: Bilateral renal arteriogram with catheter placements in 2 nd and 3 rd order branches. 36254 Bilateral superselec=ve; includes catheter selec=on, imaging, accessory renal angiography, and pressures, if performed 44 Basic Coding Case 4: Bilateral renal arteriogram with catheter placement in both main renal arteries and three accessory renal arteries. 36252 Bilateral 1 st order selec=ve; includes all accessory renal angiography, catheter selec=ons, imaging, and pressures, if performed 45 15

Visceral and Renal Arterial Anatomy Transfemoral Approach 46 Basic Coding Case 5: Non- selec3ve catheter placement in the aorta with imaging of the aorta with addi3onal lateral aortogram to bejer see the origins of the celiac, SMA, and IMA vessels. 36200 Catheter placement in the aorta 75625 Abdominal aortography, S&I 47 Basic Coding Case 6: Non- selec3ve abdominal aortogram followed by selec3ve catheter placement and imaging of the celiac trunk. 36245 1 st order selec=ve below the diaphragm 75726 Selec=ve visceral angiography, S&I 48 16

Basic Coding Case 7: Selec3on and imaging of the celiac trunk, SMA, and IMA. 36245 1 st order selec=ve below the diaphragm 36245-59 1 st order selec=ve below the diaphragm 36245-59 1 st order selec=ve below the diaphragm 75726 Selec=ve visceral angiography, S&I 75726-59 Selec=ve visceral angiography, S&I 75726-59 Selec=ve visceral angiography, S&I 49 Lower Extremity Arterial Anatomy Right Transfemoral Approach Antegrade Right Femoral Approach Retrograde Right Femoral Approach Non- selec&ve First order Second order Third order 50 Basic Coding Case 8: Abdominal aortography with run- offs from one catheter posi3on. 36200 Catheter placement aorta 75630 Abdominal aortogram and ileofemoral run- offs, S&I 51 17

Basic Coding Case 9: Abdominal aortography followed by catheter reposi3oning to the bifurca3on, oblique views of the pelvis for ileofemoral run- off, selec3ve catheter placement to each common femoral with selec3ve unilateral run- offs to complete the study. 36246 Selec=ve contralateral common femoral catheter placement 75625 Abdominal aortography 75716 Bilateral lower extremity run- off 52 Basic Coding Case 10: Common femoral antegrade approach with selec3on and injec3on of SFA, anterior and posterior 3bial, and peroneal arteries for staged unilateral run- off imaging. 36247 3 rd order selec=ve below the diaphragm 36248 x 2 Each addi=onal 2 nd order or higher selec=ve catheteriza=on 75710 Unilateral, lower extremity run- off 53 Basic Coding Case 11: Right common femoral access followed by aortogram from the renal level. The catheter was pulled back to the bifurca3on for a complete bilateral run- off. A lef superficial femoral artery stent was placed afer a subop3mal angioplasty was performed. 37226 Revasculariza=on, femoral/popliteal with stent placement(s), includes angioplasty within same vessel when performed includes catheter selec3on and vascular closure device if performed 75625-59 Aortogram 75716-59 Bilateral extremity angiogram 54 18

Basic Coding Case 12: Right common femoral access followed by selec3ve bilateral renal angiogram. The catheter was pulled back to the bifurca3on for a complete bilateral run- off. A lef superficial femoral artery stent was placed afer a subop3mal angioplasty was performed. 37226 Revasculariza=on, femoral/popliteal with stent placement(s), includes angioplasty within same vessel when performed includes catheter selec3on for stent placement and vascular closure device if performed 36252 Bilateral 1 st order renal selec=ve angiography 75716-59 Bilateral extremity angiogram 55 Upper Extremity Arterial Anatomy Transfemoral Approach 56 Upper Extremity Arterial Anatomy Antegrade/Retrograde Brachial 57 19

Basic Coding Case 13: Retrograde brachial. 36120 Needle/catheter placement retrograde brachial 75658 Brachial angiography, retrograde 58 Basic Coding Case 14: Selec3ve right subclavian angiography from a femoral approach. 36216 2 nd order selec=ve above the diaphragm 75710 Unilateral extremity angiography, S&I 59 Basic Coding Case 15: Selec3ve bilateral subclavian angiography from a femoral approach. 36215-59 1st order selec=ve above the diaphragm 36216 2 nd order selec=ve above the diaphragm 75716 Bilateral extremity angiography, S&I 60 20

Normal Arch Arterial Anatomy - Detailed Transfemoral Approach 61 Cerebral Arterial Anatomy Transfemoral Approach 62 Basic Coding Case 16: Arch injec3on with cervicocerebral arch imaging. 36200 Catheter placement aorta 75650 Arch aortogram S&I 63 21

Basic Coding Case 17: Selec3ve bilateral caro3d cervical and caro3d cerebral imaging with selec3ve lef vertebral imaging. 36215-59 1 st order selec=ve above diaphragm 36216-59 2 nd order selec=ve above diaphragm 36216 2 nd order selec=ve above diaphragm 75680 Bilateral cervical caro=d angiogram, S&I 75671 Bilateral cerebral caro=d angiogram, S&I 75685 Vertebral angiogram, S&I 64 Basic Coding Case 18: Selec3ve bilateral caro3d cervical and caro3d cerebral imaging with selec3ve right vertebral catheter placement and imaging, bovine arch. 36218 Each addi=onal selec=ve above diaphragm 36218 Each addi=onal selec=ve above diaphragm 36217 3 rd order selec=ve above diaphragm 75680 Bilateral cervical caro=d angiogram, S&I 75671 Bilateral cerebral caro=d angiogram, S&I 75685 Vertebral angiogram, S&I 65 Venous Anatomy Right Transfemoral Approach 66 22

Basic Coding Case 19: Inferior vena cavagram via catheter placement in the vena cava. 36010 Catheter placement vena cava 75825 Inferior vena cavagram, S&I 67 Basic Coding Case 20: Inferior vena cavagram and selec3ve bilateral renal venogram. 36011-50 1 st order selec=ve, venous 75825 Inferior vena cavagram, S&I 75833 Bilateral renal venogram, S&I 68 Venous Anatomy Right Transfemoral Approach 69 23

Basic Coding Case 21: Main pulmonary artery catheter placement and imaging. 36013 Catheter placement main pulmonary artery 75746 Pulmonary angiogram, non- selec=ve, S&I 70 Basic Coding Case 22: Selec3ve right and lef main pulmonary artery catheter placement and imaging. 36014-50 Catheter placement segmental / subsegmental pulmonary artery 75743 Bilateral pulmonary angiogram, S&I 71 Lower Extremity Venous Anatomy Right Transfemoral Approach 72 24

Basic Coding Case 23: Bilateral lower extremity venograms from foot or popliteal injec3ons. 36005-50 Needle placement extremity vein 75822 Bilateral extremity venogram, S&I 73 Right Upper Extremity Venous Anatomy Ipsilateral Approach Transfemoral Approach 74 Basic Coding Case 24: Unilateral upper extremity venography from a femoral approach. 36011 or 36012 1 st or 2 nd order selec=ve venous 75820 Unilateral extremity venogram, S&I 75 25

Portal and Hepa&c Venous Anatomy 36481 Access to portal vein by any method 75885 Portal venography with pressures 75887 Portal venography without pressures 36011 or 36012 1 st or 2 nd order venous 75889 Hepa3c venography with pressures 75891 Hepa3c venography without pressures 76 Portal Venous Anatomy 77 Descending Thoracic Aorta Right Transfemoral Approach 78 26

Variant Visceral Arterial Anatomy 79 Celiac Artery Detailed Anatomy 80 Superior and Inferior Mesenteric Arteries Detailed Anatomy 81 27

Oblique Pelvic Anatomy Contralateral Femoral or Brachial Approach 82 External Caro&d Arterial Anatomy Transfemoral Approach 83 Cerebral Venous Anatomy - Transfemoral Approach 84 28