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Conference Name: Peripheral Vascular Coding: How to comply with CMS to get full reimbursement

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Peripheral Vascular Coding: Howto Comply with CMS to Get Full

Reimbursement

A 90-minute interactive audioconference

Tuesday, October 12, 2004

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presents . . .STRATEGIESODING OMPLIANCEC CBRIEFINGS ON

ii Peripheral Vascular Coding: How to Comply with CMS to Get Full Reimbursement

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iiiPeripheral Vascular Coding: How to Comply with CMS to Get Full Reimbursement

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iv Peripheral Vascular Coding: How to Comply with CMS to Get Full Reimbursement

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Thank you for participating in our Peripheral Vascular Coding: How toComply with CMS to Get Full Reimbursement audioconference withPamela C. Hess, RHIA, ACS-OP, CPC, Yvonne Hoiland, CCS-P, CPC, CPC-H,RCC, and Lloyd Bittinger R.T.(R). We are excited about the opportunity tointeract with you directly and encourage you to take advantage of the oppor-tunity to ask our experts your questions during the audioconference. If youwould like to submit a question before the audioconference, please send itto [email protected] and provide the program date in the subjectline. We cannot guarantee your question will be answered during the pro-gram, but we will do our best to take a good cross section of questions.

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vPeripheral Vascular Coding: How to Comply with CMS to Get Full Reimbursement

Agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vi

About Your Sponsors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii

Speaker Profiles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .viii

Exhibit A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Presentation by Pamela C. Hess, ACS-OP, RHIA, CPC

Exhibit B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5Presentation by Lloyd Bittinger R.T.(R)

Exhibit C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Exhibit D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Article from Briefings on Coding Compliance Strategies:- Which line is it anyway? Peripheral, tunneled, or totally implanted

Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Contents

vi Peripheral Vascular Coding: How to Comply with CMS to Get Full Reimbursement

1. Introduction to peripheral vascular coding

2.Basic peripheral coding guidelines- review some simple coding methodologies - review concepts of the vascular tree

3.Frequent problem areas/common errors

4. Common peripheral coding guidelines

5. Live Q&A

Agenda

viiPeripheral Vascular Coding: How to Comply with CMS to Get Full Reimbursement

About HCPro, Inc.

HCPro is the premier healthcare information and resource provider on compliance and regulatory issues facedby hospitals, home-health organizations, nursing homes, physicians’ offices and other healthcare facilities.HCPro has launched a number of Web “supersites” that include tips, how-to information, “ask the expertcolumns,” free e-mail newsletters, and so much more.

About Briefings on Coding Compliance Strategies

Briefings on Coding Compliance Strategies provides information and advice on how to efficiently and effective-ly follow coding, documentation, and billing rules for health care organizations. This monthly publication offersideas from peers, consultants, and other professionals that make complying with Medicare and private insurancerules as painless as possible.With Briefings on Coding Compliance Strategies, readers receive the latest information on

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About your sponsors

viii Peripheral Vascular Coding: How to Comply with CMS to Get Full Reimbursement

Speaker profiles

Pamela C. Hess, ACS-OP, RHIA, CPC

Pamela C. Hess, RHIA, CPC, ACS-OP is a Director at Navigant Consulting, Inc. Nashville, Tennessee where sheprovides consulting services in the areas of charge description master billing, APC reimbursement and ICD-9-CM and CPT-4/HCPCS coding. Prior to joining Navigant, she was a partner and owner at The Wellington Group,LLC, Cleveland, OH. During her twenty-five plus years in health information management, coding and reim-bursement, she has consulted both nationally and internationally. Ms. Hess has provided consulting services tocompanies such as St. Anthony's Consulting, Inc., Commission on Professional and Hospital Activities in associ-ation with 3M Corporation coding software products, the Ministry of Defense in Saudi Arabia, National MedicalEnterprises, American Medical International and ORION Consulting, Inc. Ms. Hess was also President andfounder of Cambridge Consulting, Inc. During her work at St. Anthony's she was the original author of "TheHospital Chargemaster Guide". She has recently published “The CDM Tool-Kit” for DecisionHealth. In additionshe is currently the technical editor for “The APC Answerbook” and “APC Insider” published by DecisionHealth.Her publishing experience also includes numerous other books and newsletters on hospital and physician reim-bursement, coding and HIM services for St. Anthony Publishing, Inc. (Ingenix)

Yvonne Hoiland, CCS-P, CPC, CPC-H, RCC,

Yvonne Hoiland, CCS-P, CPC, CPC-H, RCC, is a senior coding consultant with Coding Continuum, Inc., aTucson, AZ–based consulting firm specializing in quality monitoring, compliance audits and education. Hoilandhas distinguished herself as an expert in the coding and auditing of Interventional Radiology as well as otherInterventional services, infusion therapy, and surgical procedures. Her clients include teaching and communityhospitals as well as large and small group practices. In addition to her consulting work, Hoiland is licensed bythe American Academy of Professional Coders to teach its professional medical coding curriculum and hastaught Coding Continuum, Inc., clients, as well as staff at a major teaching facility in the southwest and commu-nity-based students during the last three years. Hoiland’s previous work experience includes coding qualitymonitoring as well as staff and physician education at facilities in Idaho and Arizona. In addition, she has expe-rience in hospital-based settings, with primary emphasis on ambulatory surgery and ancillary service coding.

ixPeripheral Vascular Coding: How to Comply with CMS to Get Full Reimbursement

Lloyd Bittinger R.T.(R)Lloyd Bittinger R.T.(R) is with the Wellington Group, LLC. He has more than 30 years of experience in health-care. His experience includes 0 years in radiology administration managing all modalities of radiologic servicesin suburban and metropolitan hospitals. Bittinger has been directly responsible for developing and initiatingeducational programs for radiologic sciences and special procedure technology, and has served on the curricu-lum advisory committees for two community college systems. He specializes in perspective payment systems,Medicare reimbursement and regulatory compliance, APC and hospital reimbursement education, APC projectmanagement, and hospital departmental charge restructuring. He also is very active in several professional asso-ciations and supports them on a regular basis by providing educational presentations for seminars and othermeetings. Bittinger has spent the past seven years working in the healthcare consulting field. He is certified bythe American Registry of Radiologic Technologists and licensed in the Commonwealth of Virginia as a radiologictechnologist.

Exhibit A

Presentation by Pamela C. Hess, ACS-OP, RHIA, CPC.

EXHIBIT A

2 Peripheral Vascular Coding: How to Comply with CMS to Get Full Reimbursement

Basic Components of

Reimbursement

• Who is Medicare and why are these

guidelines used by everyone?

• Part A and Part B reimbursement

• Who sets coding guidelines, i.e., Medicare

vs. LMRPs?

• DRG vs. APC

• ICD-9-CM coding vs. CPT coding

Documentation for Interventional

Coding

• Reason procedure is performed

• Catheter access, route, additional injections

• Interventions such as PTCA, Stents

• Type of hemostasis performed

• Diagnoses and findings

3Peripheral Vascular Coding: How to Comply with CMS to Get Full Reimbursement

EXHIBIT A

Vascular Tree Concept

• Non-selective catheter placement

• Selective catheter placement

• Vascular families

– First order

– Second order

– Third order

Coding Tips

• Waiting for approval from D. Z:

• DO:

– Code each vascular family separately

– Code each approach from a different access siteseparately

– Code aorta placement 36200 instead of a non-selectivecode if the aorta has been entered

– Interventional Radiology Coding Reference, by Dr.David Zielske, Phone: 615-463-9573

EXHIBIT A


Procedure Code Methodology

• Reporting interventional procedures before 1992

and after 1992

– Combination codes

– Component codes - 70000 series & surgical component

• Do hospitals and physicians report identical

codes?

• How to monitor physician and hospital procedure

coding

Exhibit B

Presentation by Lloyd Bittinger R.T.(R).

EXHIBIT B


Arteriovenous (AV) Shunt, Upper Extremity

The most common diagnostic procedure codes for coding an upper extremity A-V shuntogram are:

75790 A-V shuntogram

36145 Catheter placement A-V dialysis

Coding guidelines:

o 75790 is an all inclusive code for imaging before, during and after intervention. It includes

the arterial inflow, the shunt itself, venous outflow and central venography to the level of the

right atrium.

o Do not code separately for the following, as they are included in 75790:

- 75825 inferior vena cava

- 75827 superior vena cava

- 75820 extremity venogram

- 75898 follow-up angiography

o Common interventional procedures associated with the A-V shuntogram are:

- 75960 percutaneous stent placement, initial vessel

- 75978 Venoplasty, percutaneous

- 75962 Brachiocephalic arterial angioplasty

- 75896 Infusion thrombolysis

o The surgical component, CPT code 36145, cannot be used more than twice.

o Do not code for ultrasound guidance, as it is included in 75790.

o Be aware of any Local Medical Review Policies that may apply.

Venous angioplasty and stent placement related to an upper extremity A-V shuntogram is

divided into 3 zones; only one charge can be made per zone:

1. Zone 1: Arterial anastamosis, intra-graft, venous anastamosis and outflow

veins to axillary vein

2. Zone 2: Subclavian and brachiocephalic veins

3. Zone 3: Superior vena cava

Code one venoplasty for contiguous lesions.

Add modifier -59 if more than one venoplasty or stent placement is performed.

Abdominal Aortography vs. Abdominal Aortography Plus Bilateral

Iliofemoral Lower Extremity

When an abdominal aortogram with runoff is performed with one injection/catheter placement, with

imaging performed from the abdomen down through the pelvis and/or lower extremities the

following CPT codes should be reported:

75630 Aortogram abdominal plus bilateral iliofemoral lower extremity

36200 Catheter placement abdominal aorta


EXHIBIT B

When an abdominal aortogram with runoff is performed with two injections/catheter placements,

with imaging performed of the abdomen, followed by the pelvis and/or lower extremities, the

following CPT codes should be reported:

75625 Aortogram abdominal

75716 Angiography extremity bilateral

36200 Catheter placement abdominal aorta (report only one time)

Occasionally, the physician may do the aortogram with runoff by selecting the right and left

common iliac arteries. In this case report the following CPT codes:

75625 Aortogram abdominal

75716 Angiography extremity bilateral

36245 Selective catheter placement, each first abdominal, pelvic, extremity order

36140-59 Catheter placement, extremity artery

Coding guidelines:

o Do not code 75736 (angiography pelvic, selective or supraselective) for an oblique view of

the pelvis. Use of this code requires the actual selection of a pelvic artery.

o Do not code 75775 (angiography, selective, additional vessel studied after basic

examination) without selective catheter placement.

o Do code 75774 for additional imaging after a basic examination is completed and more

selective catheter placement has been performed.

Insure that the radiographic report fully describes the entire procedure accurately as this may affect

the final coding. Angiographic coding should be based on documentation of the procedure.

Review of more complex coding issues

Review of fundamentals when charging for angioplasty and/or stenting procedures:

1. Upper extremity - as described above for an upper extremity A-V shuntogram.

2. Lower extremity: Venous angioplasty and stent placement is divided into 3 zones;

only one charge can be made per zone:

- Zone 1: Arterial anastamosis, intra-graft to external iliac vein

- Zone 2: External iliac and common iliac veins

- Zone 3: Inferior vena cava

3. Only one angioplasty and/or stent placement charge can be made for each vessel

separately treated. (Therefore, 3 lesions within a single superficial femoral artery

would only be coded as one angioplasty or stent placement. However, treatment of a

superficial femoral artery and a popliteal artery, or an external iliac artery and a

superficial femoral artery would be separately coded as separate procedures.)

EXHIBIT B


Charging for angioplasty and stenting procedures: These procedures may be separately charged if

documentation in the medical record supports the intent to perform angioplasty, but following

angioplasty stenting was required.

Stenting is not separately chargeable if the original intent of the procedure, as documented in the

medical record, is to place a stent and angioplasty is a component of the procedure, i.e., used to

place and/or expand the stent device. If the informed consent states that the procedure is for

angioplasty and stenting, then angioplasty cannot be separately charged. If the informed consent is

for angioplasty, but stenting was medically necessary, then both procedures may be charged.

Remember to charge for vascular closure device placement:

Procedure = G0269: Placement of occlusive device into either a venous or arterial access site.

(Medicare status indicator “N.”)

Device = C1760 (Medicare): Closure device, vascular (implantable/insertable), i.e., Perclose.

(Medicare status indicator “N.”)

Exhibit C

Reprinted with permission from Coding Continuum Inc.

EXHIBIT C


Upper ExtremitiContralateral or Femoral Approach

Current Procedural Terminology© 2003 American Medical Association. All Rights Reserved. ©2003 CODING CONTINUUM, INC.www.codingcontinuum.com


EXHIBIT C

Ipsilateral Upper Extremity

EXHIBIT C


Ipsilateral Lower Extremity

Exhibit D

Article from Briefings on Coding Compliance Strategies:—“Which line is it anyway? Peripheral, tunneled, or totally implanted”


EXHIBIT D

Which line is it anyway? Peripheral,

tunneled, or totally implanted

By Robert S. Gold, MD

(source: Briefings on Coding Compliance Strategies -January 2004)

Sometimes, it’s difficult to determine what kind of line was inserted into a patient and whether it deserves the

assignment of a CPT code.

Part of the problem is the discrepancy between the terminology physicians use and the terminology coders use.

Let’s take a look at the various options.

Peripheral IV line. A patient in the emergency department or the operating room who needs to receive

intravenous (IV) fluids or medications usually has an IV line inserted. It is most frequently inserted on the back of

the hand or on the forearm. It can also be inserted on the dorsum of the foot or behind the ankle bone. This is

routine IV access through a peripheral stick.

Sometimes a peripheral vein cutdown is performed on the forearm, upper arm, or the lower leg because the

patient’s superficial veins are not obvious.

With this approach, an incision is made, and a vein is then located and surrounded by a suture. An incision is

made into the vein, a plastic catheter is inserted, and the suture is tied around the catheter, holding it in place.

Then the skin is closed on either side of the catheter.

Central venous line. This is a large bore catheter inserted either because of the need for rapid infusion that

can’t be accomplished through a smaller venous access catheter, or the need to infuse irritative substances or

highly concentrated substances that require rapid dissolving by large volumes of blood that pass through central

veins.

The veins most frequently accessed for a central venous line are the subclavian, the internal jugular, and the

femoral (ICD-9-CM 38.93). This is done by direct stick; however, since the veins cannot be seen from the skin

surface, the clinician identifies landmarks to ensure success in catheterizing the vein.

The advantage of subclavian access is that the patient can change positions, while femoral access mandates that

the patient not stand and walk and the internal jugular doesn’t permit much movement of the head and neck.

The last two are most often used in massive trauma or around the time of surgery.

With the subclavian approach, the catheter can easily be tunneled over the chest wall and allowed to exit through

a separate site—four to six inches lower on the chest. Or, a physician can insert a totally implanted device on the

chest wall inside a separate incision.

With a tunneled catheter, the exit site of the catheter from the body is on the anterior chest wall, well below the

clavicle. With a totally implanted vascular access device (TIVAD), the entire catheter and the reservoir are all

below the skin (ICD-9-CM 86.09).

The port or reservoir is implanted at the level of the pectoralis major muscle and the catheter end plugs into the

side of the port. The access chamber has a diaphragm that can be pierced with a special needle for intermittent

delivery of medications. In fact, patients can treat themselves with total parenteral nutrition (TPN) through thistype of device when their intestinal tract doesn’t work. The patient plugs in the TPN at bedtime and runs it

through the night using a pump to deliver the right amount of nutrients at the right rate.

Special kinds of catheters used to measure cardiac function, such as the Swan-Ganz catheter that can be inserted

through the subclavian or jugular routes. With these catheters, a direct needle stick is performed. The cardiac

function catheters can have two or three lumens or passages.

The Swan-Ganz is eventually inserted into the access line and advanced into the superior vena cava, the right

atrium, the right ventricle, and out through the pulmonic valve into the pulmonary artery. A small balloon is

inflated and the end of the catheter advanced while the pressure of the right ventricle pushes the balloon along

deeper into the lung. X-rays at the bedside. Continuous pressure measurements from one of the open ends of the

catheter confirm its internal location. The balloon is deflated to check that the pressure goes up, reflecting

pulmonary artery pressure; then the balloon is again blown up and the pressure is checked to see that it drops,

reflecting left atrial back pressure.

EXHIBIT D


Peripherally inserted central catheter (PICC). This is a long line that is usually inserted through a peripheral

vein such as the basilic or cephalic vein and is threaded to the subclavian and, perhaps, into the superior vena

cava (ICD-9-CM 38.93). Unlike central lines whose insertion is limited to physicians and physician extenders with

special training and state practice act permission, a trained nurse or a venotomist can perform this technique. It

is necessary to ensure positioning of the catheter using a chest x-ray, as the length of the catheter can lead it

almost anywhere (opposite subclavian, brain, etc.). These devices can be tunneled to a nearby site and are

occasionally associated with TIVADs.

Totally implanted pump. Using the access of a subclavian or other large venous line, pumps can be inserted

subcutaneously at the end of the catheter, similar to the way a TIVAD reservoir is inserted.

These pumps can be filled periodically through a stick, as can a TIVAD. It is possible to infuse insulin into patients

whose devices can also measure blood sugars and deliver the correct amount of insulin to juvenile (Type 1)

diabetics.

Tunneled or TIVAD?

Usually, routine peripheral sticks are not even noted in the record. Physicians usually write a procedure note for

insertion of a PICC line or a subclavian.

When you see a report that describes an incision at the site of entry into the vein and talks about the catheter

exiting the skin elsewhere, it has been tunneled and nothing more.

On the other hand, if you see that it has been tunneled and another incision has been made on the chest wall,

the arm, or the abdominal wall, and the catheter has been tunneled to this site, plugged into a reservoir, and the

skin is closed over this reservoir, it’s a totally implanted device.

CPT in 2004

Beware that there are new CPT codes for insertions and removals or revisions of all or part of the device, and

each one is particular to whether it is tunneled or totally implanted and whether the patient is five and under or

six and older.

Editor’s note: Robert S. Gold, MD, founded DCBA, Inc., Atlanta, a consulting firm that provides audit and

education services to health care organizations in the areas of clinical documentation, data accuracy, corporate

compliance, and revenue management. He can be reached by phone at 770/216-9691 or by e-mail at

[email protected].

Resources


Other sites

Pamela C. Hess, RHIA, CPC, ACS-OPDirectorNavigant Consulting, Inc.Phone:260-437-33753322 West End Ave., Suite 115Nashville, TN 37203

Yvonne Hoiland, CPC, CPC-H, RCCCoding Continuum, Inc.Postal Mail 7320North La Cholla Blvd., Suite 154-306Tucson, AZ 85741Phone: 877/726-3348E-mail: [email protected]

Lloyd Bittinger R.T.(R)The Wellington Group, LLC9700 Rockside RoadValley View, OH 44125Phone: 703/765-8051

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At HCPro’s Healthcare Marketplace you’ll discover all of newsletters, books, videos, audioconferences, onlinelearning, special reports, and training handbooks that HCPro has to offer.

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RESOURCES

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Fall 2004

For more information call 800/801-6661, or visit us on the Web at www.greeley.comSelect seminars offer Category I CME, Nursing Contact Hours and NAMSS CEU’s

Education Program Schedule

L o e w s P h i l a d e l p h i a H o t e l , P h i l a d e l p h i a , P A

6th

The Problem Physician: How to assess and manage impaired, dyscompetent and disruptivephysicians

7-8th

Medical Staff Quality: How to improve peer review, patient safety, and clinical outcomesAdvanced Medical Staff Leadership Retreat I: How to resolve today’s toughest medical staff challenges

E l d o r a d o H o t e l , S a n t a F e , N M

21-22nd

Legal Issues for Medical Leadership: How to stay out of trouble and stay out of courtCredentialing and Privileging: What physician leaders and credentialing professionals mustknow today!

© 2004 The Greeley Company, a Division of HCPro is not affiliated in any way with the Joint Commission on Accreditation of Healthcare Organizations, which owns the JCAHO trademark.

O C T O B E R

T h e R i t z - C a r l t o n N e w O r l e a n s , N e w O r l e a n s , L A

4-5th

Patient Safety and Medical Error Reduction: How to identify and eliminate the real causesof medical error Advanced Medical Staff Leadership Retreat II: Leadership solutions for managing ongoing dilemmas

T h e R i t z - C a r l t o n P a l m B e a c h , P a l m B e a c h , F L

17th

VPMA Retreat: Opportunities, constraints, and challenges of the VPMA/CMO role

18-19th

Medical Executive Committee Institute: The essential training program for all medical staff leadersEffective JCAHO Survey Preparation for the Medical Staff

19-20th New Seminar!Department of Surgery Institute

N O V E M B E R

dial-in instructionshcmarketplace.com/supplemental/2881_acmaterials.pdf · peripheral vascular...

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