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Conference name: Interventional Radiology: Accurate Coding for Appropriate Reimbursement

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Interventional Radiology:Accurate Coding for Appropriate

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A 90-minute interactive audioconference

Tuesday, March 13, 2007

ii Interventional Radiology: Accurate Coding for Appropriate Reimbursement

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iiiInterventional Radiology: Accurate Coding for Appropriate Reimbursement

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iv Interventional Radiology: Accurate Coding for Appropriate Reimbursement

Dear Colleague,

Thank you for participating in our “Interventional Radiology: AccurateCoding for Appropriate Reimbursement” audioconference with JimCollins, CPC, CHCC, ACS-CA, and Yvonne Hoiland, CCS-P, CPC-H,RCC, CPC, PMCCI, moderated by Brian Murphy, CPC-A. We are excitedabout the opportunity to interact with you directly and encourage you toask our experts your questions during the audioconference. If you wouldlike to submit a question before the audioconference, please send it [email protected] and provide the program date in the subject line. Wecannot guarantee that your question will be answered during the program,but we will do our best to take a good cross section of questions.

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vInterventional Radiology: Accurate Coding for Appropriate Reimbursement

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

Speaker profiles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii

Exhibit A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Presentation by Jim Collins, CPC, CHCC, ACS-CA

Exhibit B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Presentation by Yvonne Hoiland, CCS-P, CPC-H, RCC, CPC, PMCCI

Exhibit C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36A set of anatomical drawings

Exhibit D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41Billing guides for arterial placement and sequential interventions

Exhibit E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47Coding and audit tool for interventional radiology procedures

Exhibit F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49Pair of recent articles from HCPro’s JustCoding.com

Exhibit G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58List of useful industry acronyms

Exhibit H . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63Answers to case studies

Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65

Contents

vi Interventional Radiology: Accurate Coding for Appropriate Reimbursement

Agenda

I. Guidelines for interventional radiology

II. New code for 2007: Uterine fibroid embolization

III. Billing for different components of diagnostic studies,including case studies

A. Review of interventional radiology anatomy and diagramsB. Catheter position placements/imaging guidelinesC. Proper coding of diagnostic studiesD. Procedural coding, including:

i. Angioplastiesii. Atherectomiesiii. Stent insertionsiv. Embolizationsv. Other problematic procedures

IV. Correct coding initiative (CCI) edits, including the properand improper applications of modifiers -59, -LT, and -RT

A. Physician billingB. Facility billing

V. Live Q&A

viiInterventional Radiology: Accurate Coding for Appropriate Reimbursement

Speaker profiles

Jim Collins, CPC, CHCC, ACS-CA

Jim Collins is president of The Cardiology Coalition. He directs the firm’s compliance and revenue enhance-ment services, writes the highly acclaimed Cardiology Coalition Member Newsletter, and develops each ofthe organization’s online coder proficiency tests. He has over 14 years of experience working closely withphysicians to achieve optimum profitability and regulatory compliance. He limits his practice to cardiology andis a nationally recognized expert in each of the cardiology sub-specialties.

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

Yvonne Hoiland is an instructor and senior consultant for Coding Continuum, Inc., in Tucson, AZ, where sheconducts audits and operational assessments; provides education to coders, clinicians, and ancillary person-nel; and works on litigation matters on behalf of both plaintiffs and defendants. Previously, she was the quali-ty improvement coordinator for a 365-bed university-affiliated teaching facility with hospital-based outpatientclinics. She supervised a staff of 17 inpatient and outpatient coders and implemented a point-of-service/prod-uct line coding model in high revenue-generating areas, including the ED, interventional radiology, cardiaccatheterization, electrophysiology lab, and endoscopy lab. She is a nationally recognized expert in the area ofinterventional coding, providing coding expertise at local, state, and national conferences, including AHIMAand AAPC.

Exhibit A

Presentation by Jim Collins, CPC, CHCC, ACS-CA

EXHIBIT A

2 Interventional Radiology: Accurate Coding for Appropriate Reimbursementw .cardiol gy t n m 1

Peripheral Vascular Catheterization and Diagnostic Angiography

Jim Collins, CPC, CHCC, ACS-CAThe Cardiology Coalition

2

Peripheral Vascular Procedures

3Interventional Radiology: Accurate Coding for Appropriate Reimbursement

EXHIBIT A

w .cardiol gy t n m 2

3

Component Coding

4

EXHIBIT A


5

Cath Placement

Non-selective: Movement towards or into the aorta from any access point.

the access site and the aorta.

selective.

6

3620036100

36120

36140

36145

36160


EXHIBIT A


7

Sample 36140 & 36200

© 2006 The Cardiology Coalition, All Rights Reserved

8

Selective Cath Placement

EXHIBIT A


9

36245 & 36245


10

ABOVE THE DIAPHRAGM

36215 first order36216 initial second order36217 initial third order

BELOW THE DIAPHRAGM 36245 first order36246 initial second order36247 initial third order


EXHIBIT A


11

Ultimate catheter

placement36217


Access sitelower extremity

Access site lower extremity

Catheter placement

36217

Off the “beaten path”report with 36218


EXHIBIT A


13

nd , 3 ,

36218

36248

*American Medical Association

14



EXHIBIT A


15

Cath Placement Modifiers

st

nd

st nd

*Correct Coding Initiative Edits

EXHIBIT A


17

Key Aortic Terms

A. Aortic root/ascending aortaB. Aortic archC. Thoracic aorta/descending aortaD. Abdominal aortaE. Aorto-iliac bifurcation

F. Common iliac arteryG. External iliac & common femoralH. Superficial Femoral Artery (SFA)


18

Aortography75600radiological supervision and interpretation

75605supervision and interpretation 75625supervision and interpretation 75630extremityinterpretation 75650


EXHIBIT A


19

Carotid Angiography

75660 selective

75662 selective

75665

75671

75676

75680

20

75722 selective

75724 selective

75710

75716

EXHIBIT A


21

Other Specific Arteries

selective

)

22

selective


EXHIBIT A


23

Cath placement forfirst study

Area studied by1st injection

Cath placement forsecond study

Area studiedby 2nd

injection—bilateral


24

75625 – Abdominal only

75716 –bilateral LE

Both cath placementsare non-selective

36200 into aorta


EXHIBIT A


25

Cath placementfor study

Areastudied =Abdominalaorta andbilateral LE


26

Still non-selective36200 – into aorta

75630 –Abdominalaorta andbilateralR.O.



EXHIBIT A


27

Cath placementfor first study

Area studied by1st injection

Cath placement forsecond study

Areastudied by2nd

injection—bilateral

Cath placement forthird study (ext. Iliac)

Areastudiedby 3rd

injection © 2006 The Cardiology Coalition, All Rights Reserved

28

75625 – Abdominal only

75716 –bilateral LE

Cath placement = 36246study = 75774


Exhibit B

Presentation by Yvonne Hoiland, CCS-P, CPC-H, RCC, CPC, PMCCI


EXHIBIT B

1

Interventional RadiologyInterventions

Yvonne Hoiland, CCS-P, CPC, CPC-H, RCCSenior Consultant

Coding Continuum, Inc.

22

New for 2007� Uterine artery embolization – 37210� 37210 includes all catheterizations

and intraprocedural imaging required for a UFE procedure toconfirm the presence of previouslyknown fibroids and to roadmapvascular anatomy to enable appropriate therapy

� Prior to 2007 change� Coded for catheter placement� Coded for embolization� Coded for radiological guidance and

supervision

EXHIBIT B

18 Interventional Radiology: Accurate Coding for Appropriate Reimbursement2

33

Radiographic Findings:With the patient in the supine position, using the normal aseptic technique andunder local anesthesia, the right common femoral artery was entered with a singlewall needle. Over a 0.035 J guidewire, the needle was removed and replaced with a 5 French sheath with introducing dilator. Upon removing the dilator, a 4 Frenchpigtail catheter was advanced to the level of the aortic bifurcation and a pelvicaortogram was performed.

Following catheter exchange through the sheath, a 5 French Levin catheter wasadvanced into the distal abdominal aorta. With the aid of 0.035 Glidewire, it wasdirected into the left common iliac artery and then into the internal iliac artery.From this point, the left uterine artery was selectively catheterized. A 3 French Mass Transit catheter over a long 0.018 guidewire was advanced into the mid leftuterine artery and arteriography was performed. This was followed byembolization with 500 to 700 micron Contour Embospheres, totaling 3.5 vials.Repeat arteriography was then performed.

Case Study #1

44

Radiographic Findings (continued):The microcatheter was then withdrawn from the uterine artery and removed. The5 French Levin catheter was also withdrawn into the common iliac artery and,over a 0.035 Glidewire, advanced into the external iliac artery. A Waltman loopwas then formed in the distal abdominal aorta and redirected into the rightcommon iliac artery and eventually into the internal iliac artery. Angiogram wasperformed.

With the aid of the Mass Transit microcatheter and its Glidewire, the right uterine artery was then selectively catheterized and arteriography was performed.Embolization with 4.5 vials of 500 to 700 micron Contour Embospheres then wasperformed. An additional one third of a vial of 700 to 900 micron ContourEmbospheres was then utilized for additional embolization. The Waltman loopwas then reduced and the catheter and microcatheters were removed.

Case Study #1 (cont’d)


EXHIBIT B

3

55

Through the sheath and over a guidewire, a 4 French pigtail catheter was thenreadvanced into the distal abdominal aorta and repeat arteriography wasperformed. The catheter and sheaths were then removed and adequate hemostasiswas achieved. Overall, the patient tolerated the procedure well.

Radiographic Report:The initial pelvic aortogram demonstrates a large dominant right uterine arterycoursing over the fundus of the uterus and an enhancing and densely blushingmass, representing the dominant uterine leiomyoma. The left uterine artery isslightly smaller and fills in a more delayed fashion. Neither ovary is visualized.Selective injection with a 5 French Levin catheter into the left uterine arterydemonstrates a serpiginous course of the uterine artery with multiple branchesseen filling predominantly the inferolateral aspect on the left side of the uterus.


66

Following embolization, there is slow antegrade flow demonstrated in the mainleft uterine artery with only small collaterals noted far laterally. The right uterineartery is enlarged and demonstrates a large diameter branch coursing over thedome of the fibroid with multiple collaterals seen, especially inferomedially.These cross the midline and extend to the left.

Following embolization, a small amount of antegrade, slow flow into the residualmain right uterine artery is visualized, while the dominant left branch is notdemonstrated. The repeat pelvic aortogram shows nonvisualization of the leftuterine artery with a trace on slow antegrade flow into the right uterine artery.

Impression:Bilateral uterine artery embolization for fibroids.


EXHIBIT B


77

37205 Transcatheter placement of an intravascular stent(s), (except coronary, carotid, and vertebral vessel), percutaneous; initial vessel

37206 each additional vessel

37207 open; initial vessel

37208 each additional vessel

75960 Transcatheter introduction of intravascular stent(s), S&I, each vessel

Stents

88

Guidelines—Surgical Codes

� Catheter placement should be coded in addition to the stent

� Stents should be coded for each vesselseparately treated

� Multiple lesions in a single vessel would be coded only once

� Inflation of a positioning balloon during stentingshould not be coded as balloon angioplasty

� Angioplasty performed as a method of stentdeployment is not coded separately


EXHIBIT B

5

99

� Angiography for guidance and documentation isincluded in stent placement

� Diagnostic angiography may be coded even ifperformed on the same date

� Follow-up angiography is not coded separately

Guidelines—Radiology Codes

1010

Procedure:1. Bilateral selective renal angiogram.2. Stent in the left renal artery.

Procedure:The patient was brought to the Special Procedures Laboratory in thepostabsorptive state. Informed consent was obtained. The right groin wasprepped and draped in the usual sterile fashion. Local anesthesia was achieved with infiltration of 1% Lidocaine. The right femoral artery was cannulated withan 18-gauge needle, the wire was placed and 6 French sheath was used. A 6French internal mammary artery guiding catheter was used and bilateralselective renal angiograms were performed. These were then removed and left renal artery, diagnostic guiding type, RDC catheter was used and the left renalartery was selectively engaged.

Case Study #2

EXHIBIT B


1111


A 0.014 Supracore wire was used and the lesion was crossed. A 6.0 x 18 mmballoon expandable Racer stent was introduced. This was expanded around 8atmospheres of pressure which is nominal. Angiography now revealed anexcellent result with no residual stenosis. The hemodynamics have revealed a 30mm gradient, which was resolved to less than 10 mm. The patient tolerated theprocedure well.

1212


Angiographic Findings:The right renal artery has a posterior take-off, which is widely patent with only

75% ostial stenosis is noted with above mentioned pressure gradient. Postprocedure angiogram revealed an excellent result and no dissection, and goodflow. The renal artery because it was very tortuous, did have some straightening.The patient tolerated the procedure well. Hemostasis was obtained and she left the catheterization laboratory in stable condition.


EXHIBIT B

7

1313

Angioplasty

35470 PTA; tibioperoneal trunk or branches, each vessel

35471 renal or visceral artery35472 aortic35473 iliac35474 femoralpopliteal35475 brachiocephalic trunk or branches, each vessel35476 venous

75962 PTA, peripheral artery, S&I75964 each additional peripheral artery75966 renal or other visceral artery, S&I75968 each additional visceral artery75978 venous, S&I

1414

� Code for catheter placement in addition to PTA� PTA should be coded for each vessel treated� Multiple lesions in a single vessel would be

coded only once� If angioplasty and atherectomy performed on

the same vessel, both procedures should becoded if medical necessity is supported

� Inflation of a positioning balloon duringatherectomy should not be coded as balloonangioplasty


EXHIBIT B


1515

� Angiography for guidance and documentation isincluded in angioplasty


� Follow-up angiography is not coded separately� Radiological S&I codes can be used with both

open and percutaneous angioplasty codes


1616

Procedure:After informed consent was obtained, the right groin was pepped and draped in theusual sterile fashion. Under local anesthetic and during continuous pulse oximetrymonitoring and automated blood pressure cuff monitoring, the right groin was enteredusing a micropuncture technique. A 4 French sheath was placed in the right commonfemoral limb of the aortobifemoral graft. The patient was sedated with a total of 2 mgVersed and 100 mcg of Fentanyl during the procedure.

A 4 French pigtail catheter was placed just above the celiac axis and a lateralaortogram was performed. The sheath was then exchanged for a 5 French sheath through which a 5 French St. Francis catheter was placed selectively in the celiacaxis. A celiac axis study was performed in a left anterior oblique projection. This wasfollowed by a celiac axis study in an anterior projection. A glide catheter was placedacross the celiac axis and pressures were measured. There is a 130 mm peak systolic gradient measured with the catheter across the stenosis.

Case Study #3


EXHIBIT B

9

1717

Given the findings of the diagnostic angiogram, a decision was made to intervenewith angioplasty. Using a combination of catheters and guidewires, ultimately, a 7mm, 2 cm long balloon was placed at the celiac axis and inflated twice by hand.Moderately highgrade stenosis resolved partially. There was still a modest wasteremaining. A glide catheter was then replaced in the distal common hepatic artery,contrast was injected and pressures were measured. The peak systolic pressure in the artery was now 119 mm of mercury over 60 mm of mercury with biphasic flow.Prior to the angioplasty, only monophasic flow is demonstrated. Test injectiondemonstrated brisk flow in the common hepatic artery improved from predilatation.

Findings:There is a moderate to high grade stenosis of the stented segment of the celiac axis which is across the origin. A peak systolic gradient of approximately 130 mm ofmercury was demonstrated as mentioned above. The celiac axis is patent, however,and there is flow through the gastroduodenal arcades into the occluded superior mesenteric artery. No branches of the inferior mesenteric artery were outlined on this injection.


1818


recent CT scan of the abdomen and his tenuous circumstance with obvious ischemiaof the bowel and portal gas. Postprocedure, hemostasis was achieved. The patienttolerated the procedure well.

Conclusion:High grade stenosis of stented segment of the celiac axis with occluded superiormesenteric artery with partially successful celiac axis angioplasty reducing a 130mm Hg peak systolic gradient to 5060mm Hg with improved flow visually.

EXHIBIT B


1919

Combos

Code if:1. One fails and the other is used to treat2. Different treatment for different sites

(okay if adjacent as long as different lesion)3. Stent complication repaired via balloon

Brief History:This is a 68-year old man underwent peripheral lower extremity angiogram on 02/01/07. That study revealed occluded right superficial femoral artery, 90% stenosis in the proximal SFA and 80 and 90% stenosis on other areas in the SFA. He underwent successful stenting of those lesions at that time. Angioplasty result was suboptimal. Some of the mild to moderate lesions were left alone in the SFA. The patient became symptom free on the right side; however, he continued to have significant claudication symptoms on the left lower extremity. Angiogram in February 2007 reveals 70% stenosis in the distal SFA. After detailed discussion, we decided to bring him back for angioplasty of that stenosis.

Procedure:Both groins were prepped and draped in the sterile fashion. Right groin was infiltrated with 1% Lidocaine. Right femoral artery was accessed using a 6 French sheath. Following that, a LIMA catheter was tried; however, the right iliac artery appears very tortuous. Wholeywire was used to negotiate that curve. The LIMA catheter was placed at the ostium of the left common iliac artery and iliofemoral angiogram obtained. After that, a magic torque wire was tried to get down to the left SFA without success. After that, a Glidewire was successfully placed into the distal SFA. To provide a complete detailed view of the lower extremity, the LIMA catheter was brought down into the proximal part of the superficial femoral artery and superficial femoral artery angiogram with a distal run off obtained.

Case Study #4


EXHIBIT B

1

2121

After that, a T4 was placed in the distal SFA and the LIMA catheter changed. A Glide catheter was placed, and the wire was exchanged to the magic torque wire. Over that wire, a 45 cm long arrow sheath was placed. The proximal end of the sheath was in the proximal SFA. The steel coil wire was placed back in the popliteal artery. The patient was started on intravenous Angiomax.

A 5.0 x 40 mm Agiltrack balloon was placed across the mid SFA stenosis and dilated at46 atmospheres of pressures. The same balloon was used to dilate the two long stenosis in the distal SFA, in the adductor canal. Those lesions were calcified. The fourth angioplasty result reveals dissection to all areas with a suboptimal result. Intra arterialnitroglycerin was administered. After that, the decision was made to proceed with stenting of those stenoses secondary to suboptimal results. A 6.0 x 100 mm Absolute self-expanding stent was placed across the distal SFA stenosis and deployed. Following that a 6.0 x 80 mm Absolute stent was placed across the mid/distal SFA stenosis and deployed. Both stents were postdilated using the 5.0 Agile tract balloon at 1214 atmospheres of pressure. Intracoronary nitroglycerin was administered to relieve the distal vasospasm.


2222

Final angiogram revealed a very good result without any residual stenosis or dissection. Following that, the long sheath was exchanged back to the short sheath. The LIMA catheter was placed in the external iliac artery and iliofemoral angiogram with the distal runoff was obtained. The patient tolerated the procedure without complications.

Findings:Left Iliofemoral Angiogram: Fifty (50%) percent focal stenosis in the external iliacartery just after the bifurcation of the common iliac artery. There was a 10 mm pressuregradient across that stenosis. Mild disease in the common femoral artery; however, thatvessel is very tortuous. The mid/distal left SFA has 85% ulcerated plaque. There is a 70% long calcified stenosis in the distal SFA. There is another 70% long stenosis in the distal SFA in the adductor canal. The angiotibial runoff is very good. There is mild disease inthe tibioperoneal trunk. There is moderate severe disease in the posterior tibial vessels.

Right Iliofemoral Angiogram: Mild disease in the iliac and common femoral artery. Theproximal SFA stent has a 40% instent restenosis. At the mid SFA stent has a 50% instentrestenosis. There is an 80% focal eccentric stenosis at the distal edge of the mid SFA stent. There is another focal stenosis, which is about 70% in severity in the mid SFA.Distal SFA stent is widely patent.


EXHIBIT B


2323

Case Study #4 (cont’d)Final Impression:1. Severe stenosis in the left superficial femoral artery.2. Suboptimal angioplasty of left superficial femoral artery stenosis.3. Successful stenting of mid/distal left superficial femoral artery stenosis with reduction

in severity from 85 – 0%.4. Successful stenting of distal superficial femoral artery stenosis with reduction in

severity of lesion from 70 – 0%.5. Moderate instent restenosis in the proximal and mid right superficial femoral artery

stents.6. Severe stenosis in the right mid superficial femoral artery (at the prior PTA site).

Recommendation:1. Aspirin.2. Plavix 75 mg once a day for at least one year.3. Adjunctive medical treatment.4. Angioplasty of right mid superficial femoral artery stenosis in one month.

2424

35490 Transluminal peripheral atherectomy, percutaneous;renal or other visceral artery

35491 aortic35492 iliac35493 femoralpopliteal35494 brachiocephalic trunk or branches, each vessel35495 tibioperoneal trunk and branches

75992 Transluminal atherectomy, peripheral artery, radiological supervision and interpretation

75993 each additional peripheral artery75994 Transluminal atherectomy, renal, radiological

supervision and interpretation75995 Transluminal atherectomy, visceral, radiological

supervision and interpretation75996 each additional visceral artery

Atherectomies


EXHIBIT B

13

2525

� Catheter placement should be coded in addition to the therapies

� Multiple treatments should be coded for eachvessel separately treated

� Multiple lesions in a single vessel treated by different therapies would be coded by therapy


2626

� Angiography for guidance and documentation isincluded in therapies


� Follow-up angiography is not coded separately


EXHIBIT B


2727

Description of Procedure:The patient was taken to the peripheral vascular lab in the fasting state after givinginformed consent. A 6French sheath was introduced into the right femoral artery. A6 French Omni Flush catheter was then introduced into the distal abdominal aortaand aortogram with runoff was performed.

Preliminary findings revealed no significant disease of the distal abdominal aorta orthe iliac arteries bilaterally. The left superficial femoral artery had a 75% midstenosis which was focal. There is a patent stent in the distal left superficial femoralartery but this has approximately 50% instent restenosis. There is at least twovessel runoff to the left foot. On the right side, there is mild instent restenosis of thedistal superficial femoral artery. The right popliteal artery is free of significantdisease as is the right profunda. There is good one vessel runoff to the right footthrough the posterior tibial artery. The anterior tibial artery is occluded proximallyand the peroneal artery has sluggish flow.

Case Study #5

2828

The decision was made to proceed with atherectomy of the left superficial femoral

contralateral sheath was placed across the iliac bifurcation with its distal tip in theleft common femoral artery. A 300 cm wire was then advanced through a strelcuttapered glide catheter and the superficial femoral artery lesion was crossed withoutdifficulty. The wire was placed below the knee.

A L5 atherectomy Foxhollow catheter was then advanced and numerous passes atthe mid and distal lesions were performed. A large amount of atheromatousmaterial was removed from these two stenoses. Final angiography revealed lessthan 10% residual stenosis in the mid and distal SFA. There was no evidence of dissection or perforation, and there was good distal runoff.



EXHIBIT B

15

2929

Case Study #5 (cont’d)Summary of Findings:Aortogram with runoff revealed no significant disease of the distal abdominalaorta. Both iliac arteries were patent with no significant disease. The bilateralprofunda femoral arteries are free of significant disease. The right superficialfemoral artery has mild distal instent restenosis. The right popliteal artery is free ofsignificant disease. Below the right knee, the right posterior tibial artery is widelypatent but there is sluggish flow in the peroneal artery and the anterior tibial arteryappears to be occluded proximally. On the left side, the left profunda is widelypatent. The left superficial femoral artery has a focal mid 75% stenosis. There isdistal 60% instent restenosis. There is at least two vessel runoff to the left foot.Successful atherectomy of the left superficial femoral artery with an L5atherectomy catheter. There is less than 10% residual stenosis in the mid and distalSFA and there is good distal runoff.

3030

37204 Transcatheter occlusion or embolization (e.g., for tumor destruction, toachieve hemostasis, to occlude a vascular malformation), percutaneous,any method, noncentral nervous system, non-head or neck

37210 Uterine fibroid embolization, 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

61624 Transcatheter permanent occlusion or embolization (e.g., for tumordestruction, to achieve hemostasis, to occlude a vascular malformation),percutaneous, any method; central nervous system (intracranial, spinal cord)

61626 noncentral nervous system, head or neck (extracranial, brachiocephalicbranch)

75894 Transcatheter therapy, embolization, any method, radiologicalsupervision and interpretation

75898 Angiography through existing catheter for followup study fortranscatheter therapy, embolization or infusion

Embolization

EXHIBIT B


3131

� Embolization may be coded only once peroperative field

� Catheter placement should be coded in addition to the therapies


3232

� Angiography for guidance and documentation is included in therapies


� Follow-up angiography may be codedseparately



EXHIBIT B

17

3333

Clinical History:The patient is a 70-year old white female with refractory bilateral epistaxis.

Technique:Utilizing sterile technique and local anesthesia, direct percutaneous puncture of theright femoral artery was performed and a 6 French sheath was placed subselectively into the right femoral artery. Through this 6 French sheath a 6French diagnostic Base catheter was utilized to subselectively catheterize the rightand left common carotid arteries. Diagnostic angiography was performed in each of these 2 separate catheter positions focused on the neck and intracranial vasculaturein multiple projections. No definite angiographic abnormalities are identified.Specifically no definite etiology for

Following diagnostic angiography and the with Base catheter initially in the rightcommon carotid artery a microcatheter was inserted into the patient in coaxialfashion through the indwelling Base catheter and utilized to subselectivelycatheterize the distal aspect of the right internal maxillary artery.

Case Study #6

3434

Diagnostic microcatheter angiography was performed to confirm catheter positionand the absence of intracranial collateral vessels prior to subsequent embolization.Embolization was then performed by instilling polyvinyl alcohol or PVA particlesmeasuring 300 500 microns in diameter through the microcatheter into the rightinternal maxillary artery and its distal branches.

Following particulate embolization, diagnostic microcatheter angiography wasperformed which demonstrated or suggested near occlusion of the distal branches of the right internal maxillary artery. At this point embolization of this vessel wascompleted by instilling a single Gelfoam pledget into the internal maxillary arteryon the right again through the microcatheter. Final diagnostic microcatheterangiography suggested occlusion of the right internal maxillary artery. At thispoint embolization of this vessel was completed. The microcatheter wastemporarily withdrawn from the patient as the Base catheter was placed into theopposite left common carotid artery.


EXHIBIT B


3535

The microcatheter was again inserted into the patient in coaxial fashion through the indwelling Base catheter and utilized to subselectively catheterize the distalaspect of the left internal maxillary artery. Again diagnostic microcatheterangiography was performed through the indwelling microcatheter to confirmcatheter position and the absence of intracranial collateral vessels prior tosubsequent embolization. Embolization was then performed by instilling PVA orpolyvinyl alcohol particles measuring 300 500 microns in diameter through themicrocatheter into the left internal maxillary artery and its distal branches.Following particulate embolization, diagnostic microcatheter angiography wasperformed which demonstrated or suggested near occlusion of the left internalmaxillary artery and its branches.

Embolization of this vessel was completed by instilling a single Gelfoam pledgetinto the left internal maxillary artery through the microcatheter. Final diagnosticmicrocatheter angiography was then performed demonstrating or suggestingocclusion or near occlusion of the left internal maxillary artery and its branches.Embolization of this vessel and the procedure was then completed.


3636


Diagnostic microcatheter and Base catheter were removed from the patient. Theright femoral arterial sheath was also removed and pressure was held over the rightgroin for a period of 15 minutes to obtain adequate hemostasis. There were noapparent complications to the procedure which were identified at the time of theprocedure or shortly thereafter.

Conclusion:Technically successful subselective embolization of the right and left internalmaxillary arteries as therapy for patient with chronic refractory epistaxis asdescribed above.


EXHIBIT B

19

3737

Modifiers

� Anatomical modifiers� LT, RT

� Other modifiers� 50� 59

3838

Points to Remember

� Read the operative reports carefully� Note radiology guidance and intent of

guidance� Note the intent of the intervention performed

and any subsequent intervention� Modifiers� Utilize resources

Exhibit C

A set of anatomical drawings

Source: Yvonne Hoiland, CCS-P, CPC-H, RCC, CPC, PMCCI and Coding Continuum, Inc.


EXHIBIT C

Current Procedural Terminology© 2007 American Medical Association. All Rights Reserved. ©2007 CODING CONTINUUM, INCwww.codingcontinuum.com

Head and Neck Femoral Approach

EXHIBIT C

38 Interventional Radiology: Accurate Coding for Appropriate Reimbursement

Contralateral Lower Extremity

Current Procedural Terminology© 2007American Medical Association. All Rights Reserved. ©2007CODING CONTINUUM, INC. www.codingcontinuum.com


EXHIBIT C

Ipsilateral Lower Extremity

. ©2007CODING CONTINUUM, INC.

Current Procedural Terminology© 2007American Medical Association. All Rights Reserved. www.codingcontinuum.com

EXHIBIT C


Visceral

Current Procedural Terminology© 2007American Medical Association. All Rights Reserved. ©2007CODING CONTINUUM, INC. www.codingcontinuum.com

Exhibit D

Billing guides for arterial placement and sequential interventions

Source: The Cardiology Coalition

EXHIBIT D


Page 1

FFeebbrruuaarryy,, 22000077 VVoolluummee 33,, IIssssuuee 22

Inside This Issue

x Renal Angiography

x“Incident To” Billing

Renal AngiographyTwenty million Americans (11% of the adult population) have chronic

kidney disease. If left untreated, this disease frequently leads to kidney failure. Patients with kidney failure require dialysis or a kidney transplant in order to avoid death. Despite the availability of 3,600 dialysis facilities, 255 organ transplant facilities, and annual expenditures of approximately $18 billion dollars, over 67,000 Americans will die this year because of kidney failure.

One of the front lines against the war on chronic kidney disease is in the catheterization laboratory where cardiologists spend much of their time. Prompt detection of renal artery stenosis in its early stages allows physicians to implement therapies that slow the progression of the disease and prevent patients from reaching end stage renal failure. For this reason, manycardiologists have begun imaging the renal arteries at the time of coronary procedures.

Renal artery disease consists of either atherosclerotic build up in the renal arteries or the existence of fibromuscular dysplasia (FMD), a fibrous roadblock in the renal arteries that can facilitate the formation of clots. When the renal arteries are diseased the kidneys receive a reduced amount of blood flow. Thisdeprives the kidneys of the oxygen they need to survive and decreases their ability to do their job: remove waste from the body, regulate body water,

Incident To Billing for Medicare PatientsThe services of Non-Physician

Practitioners (including physician assistants, nurse practitioners, and clinical nurse specialists) continue to be a focal point of government auditors. While the rules specific toNon-Physician Practitioner (NPP) billing have not been modified much during recent years, the government has issued several "clarifications" specific to NPP billing that illustrate its continued focus on these services.

The most common way to bill for NPP services is known as "Incident To" billing. The termIncident To indicates that the services provided by the NPP are "incidental to" the physician's ongoing management of the patient. In order for NPP services to be incidental to the physician's management of the patient, the physician must perform an initial evaluation, establish a care-plan for the patient's condition, and remain actively involved in the patient's care.

Because of this, the NPP can only see established patients with established problems if the servicesare to be billed under the incident to provision.

Another requirement of the Incident To provision is that services can only be provided in the physician office when the supervising provider is physically present. The supervising provider's

www.cardiologycoalition.com

Illustration Copyright © Nucleus Medical Art, All rights reserved. CPT codes, descriptions and material only are copyright 2006 American Medical Associ-ation. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the datacontained herein. The online proficiency test has prior approval of the American Academy of Professional Coders for 2.5 continuing education units. Granting of this approval in no way constitutes endorsement by the Academy of the program, content or the program sponsor.

Continued on Pg. 4

Continued on Next Page


EXHIBIT D

Page 2

regulate blood pressure, etc. Over time, kidneys that receive reduced blood flow will shrink and die.

The most definitive way to identify and assess renal artery disease is with renal angiography. When coding for renal angiography it is necessary to nail down several pieces of information. Without this data you will most likely trigger avoidable denials and attract unwanted regulatory attention. As you’ll see, many of these issues overlap and influence each other:

Selective vs. Non-Selective

Non-selective renal angiography consists of an injection of radio-opaque contrast into the abdominal aorta just above the point where the renal arteries originate. The contrast is visualized by serial radiographic imaging as it flows downstream. This is commonly referenced as a “flush aortogram.” While most of the contrast agent flows down the aorta, some of it trickles into the renal arteries. The radiological images created while the contrast agent is flowing through the renal arteries provide a rough indication of the extent of renal artery stenosis.

Selective renal angiography involves the injection of a contrast agent directly into the renal artery. Doctors frequently perform flush aortography prior to attempting selective catheterization of the renal

arteries. Flush aortography images provide the doctor with a point of reference which tells him where the catheter is located in relation to the origin of the renal arteries. Using this point of reference, the doctor can shape and position the catheter so that its tip actually enters the renal artery. The contrast agent is then injected into the renal artery and radiological images of the renal artery are obtained.

Selective angiography provides the doctor with more accurate and diagnostic images than non-selective angiography. This is because the concentration of the contrast agent flowing through the renal arteries is much richer if it is selectively injectedinto the target vessel rather than into the aorta. As previously mentioned, most of the contrast agent injected into the aorta will flow downstream in the aorta, not into the renal artery.

Non-selective renal angiography, performed as a stand-alone procedure, is properly reported with code 36200 (Introduction of catheter,aorta) and 75625-26 (Aortography, abdominal, by serialography,radiological supervision andinterpretation).

Selective renal angiography, performed as a stand-alone procedure, is reported with the appropriate “selective” catheter placement code(s) and the

appropriate “selective” radiological supervision and interpretation code. Doctors typically position the catheter just inside the renal artery. This is a first order selective catheter position, 36245 (Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family). As discussed later, this code needs to be listed twice on the claim form or “modified” if your doctor performs bilateral selective renal angiography.

The radiological supervision and interpretation codes available to report selective renal artery imaging are:

x 75722-26 (Angiography, renal,unilateral, selective (including flush aortogram), radiological supervision and interpretation)

x 75724-26 (Angiography, renal, bilateral, selective (including flush aortogram), radiological supervision and interpretation)

Both of these codes require “selective” catheterization of the target vessel(s). The first codedescribes unilateral imaging, the second code describes bilateral imaging. Make sure not to report the flush aortogram performed to assist with the selective catheterization of the renal arteries. The parenthetical note in the definitions of code 75722 and 75724 establish that each of these services includes flush aortography.

Uilateral vs. Bilateral

The appropriate code for selective renal artery catheterization is typically 36245 (Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family). As illustrated by this code definition, it is specific to “each first order” selective catheterization.

This image was obtained by non-selective contrast injection. The majority of

contrast flows down the aorta.

Renal Arteries

This image was obtained by selective contrast injection. The majority of

contrast flows into the renal artery.

EXHIBIT D


Page 3

When one renal artery is selectively catheterized it is appropriate to report this code one time. When both renal arteries are selectively catheterized, it is appropriate to report this code two times or one time with the bilateral procedure modifier (50) attached.

The appropriate way to report bilateral, selective renal catheterization fluctuates based on payer preference. If you can’t identify the appropriate coding methodology from claim payment history, it may be necessary to contact each of your payers to identify their preferences. Following are four of the most common payer preferences for reporting bilateral selective renal artery catheterization:

The one liner:

36245-50

The generic two-liner:

36245

36245-59

The anatomic two-liner:

36245-LT

36245-RT

The hybrid two-liner:

36245-LT

36245-RT-59

While each of these coding combinations may accurately reflect selective catheterization of two renal arteries, payment rates and coverage may be impacted based on which option you choose. It is appropriate to confirm payer preference before submitting claims. The appropriate radiological supervision andinterpretation code (75722 vs. 75724) should be reported in addition to the catheter placement code(s).

First Order vs. Second Order

While most selective renal artery catheterizations are first order procedures (36245), there are cases where the doctor will selectively image from second order selective catheter positions. This will be described as selective catheterization of the superior and/or inferior branch of the renal artery. The initial second order selective position in each renal arterial vascular family should be reported with code 36246 (Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family). If both the superior and inferior renal arterial branches are selectively catheterized, the second branch catheterization should be reported with code 36248 (Selective catheter placement, arterial system; additional second order, third order,and beyond, abdominal, pelvic, orlower extremity artery branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriate)).

When imaging is conducted from both the superior and inferior branches of a renal arterial vascular family, the initial imaging should be reported with the appropriate selective renal imaging code (75722-26 vs. 75724-26). Each subsequent renal arterial branch study should be reported with code 75774-26 (Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation (List separately in addition to code for primary procedure)).

Accessory Renal Arteries

Most patients have one renal artery supplying each of their kidneys with blood. A little more than 20% of patients have accessory renal arteries. These patients have two separate vascular families supplying either of the kidneys with blood.

Doctors commonly reference accessory renal arteries as superiorand inferior poles. Since each renal pole is a unique vascular family (they each branch off of the aorta) selective catheterization of each pole should be reported as a first order selective catheterization (36245).

The appropriate selective renal angiography code (75722 vs. 75724) should be reported for the initial renal artery imaged on either side of the patient’s body. The “additional vessel” code (75774) should bereported for each accessory renal artery pole.

Make sure not to confuse the terms “pole” and “branch.” Selectivecatheterization of a superior renal artery branch increases the level of selectivity within that vascular family. Selective catheterization of the superior renal pole indicates that a separate vascular family is being catheterized. Each vascular family catheterized should have the appropriate first, second, or third order catheterization code assigned(36245 – 36247).

Stand-Alone vs. Concomitant with a Heart Catheterization

When renal angiography is performed as a stand-alone procedure the coding rules specific to peripheral vascular procedures prevail. You will

An accessory renal artery.


EXHIBIT D

Page 4

need to accurately assign codes for catheter placement and radiological imaging. When renal angiography is performed at the time of a heart catheterization it is frequently necessary to adjust your approach to coding.

If a non-selective study is conducted at the time of a heart catheterization it is necessary to omit the catheter placement code (36200) from your claim form. This is because the code used to report the heart catheterization, 93510 (Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous) includes navigation of the catheter from the access site into the heart and coronary arteries. The non-selective,suprarenal catheter position in the abdominal aorta is along the route that the catheter naturally travels to reach the heart. As such, it is not appropriate to report code 36200 inaddition to 93510. This prohibition is enforced by the Correct Coding Initiative Edit that bundles code36200 into code 93510 and does not permit payment regardless of modifier application.

Correct Coding Initiative Edits must also be considered when reporting renal angiography at the time of a heart catheterization. Thefollowing codes are each bundled into code 93510. Unlike code 36200, these codes should be separately reimbursed from code 93510 when reported with the appropriate Correct Coding Initiative related modifier (59, LT, or RT):

x 36245 Selective catheterplacement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family

x 75625 Aortography, abdominal, by serialography,radiological supervision andinterpretation

x 75722 Angiography, renal, unilateral, selective (including flush aortogram), radiologicalsupervision and interpretation

x 75724 Angiography, renal, bilateral, selective (including flush aortogram), radiological supervision and interpretation

x 75774 Angiography,selective, each additional vessel studied after basic examination, radiological supervision andinterpretation (List separately in addition to code for primary procedure)

As mentioned below, non-selective imaging of the renal arteries at the time of a heart catheterization for a Medicare patient must be reported with a Medicare specific code.

Medicare vs. Non-Medicare

In spite of the Standardized Transactions and Code Set requirement of the Health Insurance Portability and Accountability Act (HIPAA), it is necessary to report some renal angiograms performed on Medicare patients with a different coding methodology than if the sameprocedure was performed on a non-Medicare patient.

For non-Medicare patients it is appropriate to report a non-selective renal angiogram performed at the time of a heart catheterization as a flush abdominal aortogram with code 75625 (Aortography, abdominal, by serialography, radiological supervision and interpretation). Under the same circumstances, non-selective renal angiography performed on a Medicare patient should be reportedwith code G0275 (Renal angiography non-selective, one or both kidneys, performed at the same time as cardiac catheterization and/or coronary angiography, includes positioning or placement of any catheter in the abdominal aorta at or near the origins

(ostia) of the renal arteries, injection of dye, flush aortogram, production of permanent images, and radiologic supervision and interpretation (list separately in addition to primary procedure).

By requiring the substitution of code G0275 for code 75625,Medicare is securing a substantial discount. With a current Relative Value of just .37, code G0275 brings in only $14.02 (unadjusted national payment rate). This reflects a 77%discount from the $60.26 payment rate assigned to code 75625-26.

Indications for Renal Angiography

Keep in mind that renal angiography, as a stand-alone procedure or as an add-on to a heart catheterization, is not currently covered for screening purposes. It is important to familiarize yourself with applicable coverage criteria and to confirm that you only report diagnosis codes that are clearly documented in the patient’s record.

Incident To Billing(Continued from Pg. 1)

... presence must meet Medicare's "direct supervision" requirements. This requires the supervisor to be in the suite of offices maintained by the practice and available to renderassistance. However, the supervising provider does not needto be in the same room as the NPP when the service is rendered.

If the Incident To requirements are not met it is necessary for the service to be billed under the NPP's name and number. This will result in a 15% payment reduction. However, this is much smaller than the potential penalty that could be assessed for inappropriate billing of services.

EXHIBIT D


Page 5

Keep the following pointers in mind to avoid common Incident To billing errors:

x Incident To billing is a Medicare specific requirement. Non-Medicare payers have the freedom to create their own policies specific to NPPs. While it is necessary to check with individual payers to confirm their policies, you should find that most are not nearly as restrictive as Medicare.

x Physicians can delegate direct supervision of NPPs to other members of a group practice. The Incident To services should be billed under the provider's name that personally provided the direct supervision.

x Services cannot be billed Incident To if they are rendered in a hospital.

x New patient visits and consultations cannot be billed Incident To since the "established patient" and "established problem" requirements of the Incident To provision will not be met.

x NPPs can provide direct supervision for services rendered Incident To their management of patients. While the 15% reduction would still be applied to the service, this provision allows NPPs to superviseother NPPs and Registered Nurses who may be seeing patients when no physician is in the office.

x In order to bill for the work of an NPP under the Incident To provision, the NPP must represent a directfinancial expense to the practice. This requirement is met when the supervised NPP is a "W-2" employee, a leased employee, or an independent contractor. This requirement is not met if the NPP is an employee of another institution or a sales representative of a supplier. ¦

Online Proficiency Test AvailableYou can now enjoy online coder proficiency testing! An advanced level

test has been set up online which thoroughly assesses reader understanding of the topics presented in this publication. Successful completion of the test generates 2.5 AAPC pre-approved continuing education units for each reader. CEU certificates will be available online after completion of the test.

The designated administrator for your practice has been provided a user name and password to access the online publication and proficiency test. Additional users can be set up for online proficiency testing for just $50 each for your entire membership year. Each registered user will receive individual report cards, CEU certificates, and have access to the online publication and test. The designated administrator for each practice will be able to view the report cards for each enrolled employee and maintain documentation ofeffective training – an important element of every effective compliance program.

Visit www.cardiologycoalition.com today for a free test drive as a guest user. Plus, enrolled members can now access the February, 2007 publication and proficiency test after logging into the system.

Exhibit E

Coding and audit tool for interventional radiology procedures

Source: The Cardiology Coalition

EXHIBIT E


Exhibit F

Pair of recent articles from JustCoding.com

Source: HCPro, Inc.

EXHIBIT F


Clear mental coding blockages for IR proceduresfrom JustCoding.com

Interventional radiology (IR) is oftentimes a land of coding confusion consisting ofcomplicated operative reports, detailed anatomical references, and head-spinningprocedures.

And when a physician performs an intervention-such as a stent placement—inconjunction with another IR procedure—such as a percutaneous transluminal angioplasty(PTA)-there is confusion galore, says Yvonne Hoiland, CCS-P, CPC, CPC-H, RCC, senior consultant for Coding Continuum, Inc. in Tucson, AZ.

“What becomes confusing is whether the physician intended to place the stent or whetherhe or she decided to place it because of poor results,” Hoiland says.

On the outpatient side, the intent of the procedure determines whether the intervention isinherent to the IR procedure and thus not separately billable.

For example, a physician prepares a patient for an intended stent placement procedure.Before placing the stent, the physician must first open the vessel using a balloon angioplasty. In some cases, the physician may even place the stent on the balloon, inflatethe balloon, and then place the stent.

Do not report the angioplasty separately because it was only a means to prepare thevessel and a delivery method by which the physician could place the stent, Hoiland says.

However, when a physician performs a balloon angioplasty that has poor results-such aswhen a vessel collapses back on itself during the procedure—and the physician mustplace a stent to keep it open, report one code for the angioplasty and one code for thestent placement.

You may also code both the stent placement and angioplasty when a physician usesdifferent treatments for different sites and when the physician uses a balloon to repair astent complication.

Hoiland says that there are two important phrases that a physician can document thatwould help a coder identify the actual intent of the procedure:

% “Patient experienced residual stenosis.”% “An unacceptable result was obtained.”

“There has to be something to tell you that the decision was made at that time and notprior to the patient entering the surgical suite,” Hoiland points out.


EXHIBIT F

Both of these phrases clue the coder in to the fact that the stent was most likely notplanned and was placed because of poor results, she adds.

Identify the number, type of vessels intervenedWhen reporting stent placement, the number of vessels helps determine code selection.Report 37205 (transcatheter placement of an intravascular stent(s), percutaneous) for theinitial vessel, but 37206 for each additional vessel.

When reporting PTA, the type of vessel helps determine code selection. For example,code 35471 represents PTA of the renal or visceral artery, while code 35473 representsPTA of the iliac artery.

When coding stent placement and PTAs, also keep the following points in mind:

% Remember that stent placement includes angiography for guidance anddocumentation.

% Code the catheter placement in addition to the stent.% Code the additional access if the physician performs the stent placement through

an existing access.% Do not code follow-up angiography separately. The only exception to this is when

the provider clearly documents that he or she has made the decision to intervenebased on the angiography.

% Code stent placement separately for each vessel treated-not per stent.% Only code multiple lesions in single vessel once.% Do not code it as balloon angioplasty when a physician inflates a positioning

balloon during stenting.% Do not separately code angioplasty performed as a method of stent deployment.

Brushing up on visceral anatomy is a good way to easily identify which vessels aphysician might reference in his or her operative report. Click here to view an anatomicaldiagram from Coding Continuum. Please note that Coding Continuum owns the copyright to this diagram and that distribution of it is prohibited.

Remember to report radiological codes, too

coding, Hoiland says, meaning there should be one code for the surgical procedure (i.e.,the intervention, such as a stent placement) and one code for the associated radiologicalservice (i.e., the visualization, interpretation, guidance, and identification of the diseasedvessel).

Both the physician and the hospital should report a surgical code and a radiological code,Hoiland says.

When a physician places a stent, report 75960 (transcatheter introduction of intravascularstent(s) (except coronary, carotid, and vertebral vessel), percutaneous and/or open,

EXHIBIT F


radiological supervision and interpretation, each vessel) as the associated radiologicalcode.

When performing angioplasty, report 75962 (transluminal balloon angioplasty, peripheralartery, radiological supervision and interpretation) as the associated radiological code.

Carotid artery stent placements are the most commonly seen exception to this, Hoilandpoints out. When a physician performs stent placement in the carotid artery, report either37215 or 37216. Note that these codes include the following:

% All ipsilateral selective carotid catheterization% All diagnostic imaging for ipsilateral, cervical, and cerebral carotid arteriorgraphy% All related radiological supervision and interpretation

When the ipsilateral carotid arteriogram confirms the need for carotid stenting, 37215 and37216 include these services. If the carotid stenting is not indicated, report theappropriate codes for carotid catheterization and imaging in lieu of 37215 and 37216.

Note that, like carotid artery stent placements, CPT codes 61635 (transcatheter placementof intravascular stent(s), intracranial (e.g., atherosclerotic stenosis), including balloon angioplasty, if performed), 0075T (transcatheter placement of extracranial vertebral orintrathoracic carotid artery stent(s), including radiologic supervision and interpretation,percutaneous; initial vessel), and 0076T (each additional vessel) are also an exception tothe rule. The CPT Manual provides more information on these codes.

Ensure communication between HIM and IR departmentsThe reason why coders sometimes run into trouble is because of a disconnect between thecodes that coders assign and those that are chargemaster-driven.

For example, although coders are responsible for assigning surgical codes, theradiological codes are often chargemaster-driven and assigned in the department in whichthe procedure is performed, such as the radiology suite or the catheter lab.

This means that an individual in the IR lab or cardiac cath lab enters a radiological chargebased on what a physician may have marked off on a charge sheet or after havingwitnessed a certain intervention during the procedure.

If, however, the physician does not document the encounter properly, the coder couldpotentially enter an entirely different code based on improper documentation. “Then the

billing denials,” Hoiland says.

How can you alleviate this? Hoiland says to consider the following:

1. Hire a coder to specifically code IR procedures, including the surgical andradiological code. Depending on the amount of procedures performed, yourfacility may want to hire more than one full-time person to perform this duty. This


EXHIBIT F

individual would be responsible for not only assigning the surgical code, but also ensuring the correct radiological code.

2. Give coders access to add or remove charges as necessary to the radiologydepartment chargemaster.

3. Create an outpatient coding team that can meet with providers or technicians to provide documentation improvement education.

Note guideline changes for diagnostic radiology codesAs of 2005, keep the following radiology guideline changes in mind:

% Do not report a diagnostic angiography code with interventional proceduresperformed for roadmapping, fluoroscopic guidance, vessel measurements, or post-angioplasty/stent angiography because this work is inherent to the interventional procedure code.

% Append modifier -59 to the diagnostic code to show that the decision to intervenewas based on the diagnostic study. Otherwise payers will bundle the two codestogether and will pay for diagnostic-and not the therapeutic-code.

% Only separately report diagnostic angiography that providers perform at the time of an interventional procedure when

� no prior catheter-based angiographic study is available, a fulldiagnostic study is performed, and the decision to intervene is basedon the diagnostic study

�

changed, there is inadequate visualization of the anatomy/pathology,or there is a clinical change during the procedure that requires newevaluation.

% You can separately report diagnostic angiography from an interventional procedure when a physician performs the angiography at a separate setting.

[email protected].

EXHIBIT F


Specify lower extremity artery when coding thromboendarterectomyfrom JustCoding.com

Coding thromboendarterectomy has become more complicated due to new codes for2007 that further specify arteries in the lower extremity.

Instead of reporting code 35381—which had grouped thromboendarterectomy of thesuperficial femoral, popliteal, tibioperoneal trunk, and tibial or peroneal artery together—coders will now report one of the following new codes that took effect January 1:

% 35302—superficial femoral artery % 35303—popliteal artery % 35304—tibioperoneal trunk artery % 35305—tibial or peroneal artery, initial vessel % +35306—each additional tibial or peroneal artery (List separately in addition to

the code for the primary procedure)

Patch graft includedThe CPT Manual contains several important parenthetical notes regarding these newcodes, says Yvonne Hoiland, CCS-P, CPC, CPC-H, RCC, senior consultant for Coding Continuum, Inc. in Tucson, AZ. In particular, codes in the 35301–35306 range—in addition to codes in the 35311–35372 range (for upper extremity artery)—include theharvesting of a patch graft/vein segment [see the revised description for code 35301,which states “including patch graft, if any.”]

Physicians use a patch graft to enlarge the diameter of the vessel to enable it to heal. They

the procedure,” Hoiland says. “Now CPT has just incorporated it into the code.”

a coronary artery bypass graft (CABG) procedure, Hoiland points out. The harvesting ofthe graft is simply included in the procedure itself.

“But even though the patch graft is included,document it,” she says.

Specificity is importantBecause the new codes specify the lower extremity artery, physicians must be sure to

procedure on several lower extremity vessels during one session. This means that thecoder might report several codes for one encounter.


EXHIBIT F

For example, when a physician performs a thromboendarterectomy of the superficialfemoral artery, popliteal artery, and the initial vessel of the tibial artery, report codes35302, 35303, and 35305.

Thromoendarterectomy versus atherectomyCPT parenthetical guidelines state that coders should not report codes 35302 and 35303 in conjunction with code 35483 (transluminal atherectomy, open; femoral-popliteal), norshould they report codes 35304–35306 in conjunction with code 35485 (transluminal atherectomy, open; tibioperoneal trunk and branches).

The guidelines point out that coders should not confuse a thromboendarterectomy with atransluminal atherectomy, Hoiland says.

A thromboendarterectomy is an open surgical procedure during which a physicianremoves plaque from the lining of an artery. Click here to view a diagram thatMedlinePlus provides.

An atherectomy is a procedure during which a physician uses a catheter to clear aclogged artery by cutting, shaving, or vaporizing the plaque that blocks a blood vessel.

Although both procedures involve removing plaque from a vessel, there are twoimportant distinctions:

1. Physicians can opt to perform an atherectomy either using an open incision orusing a catheter (it is more common to use the catheter). This means that duringan atherectomy, a coder might potentially also need to code for a catheterinsertion. During a thromboendarterectomy, physicians do not place catheters.They isolate a particular artery and obtain direct access to that artery through anopen incision.

Physicians perform a thromboendarterectomy when a patient is not a goodcandidate for a catheter-based procedure, Hoiland says.

Some diagnoses that might warrant a thromboendarterectomy include thefollowing:

% Occlusion and stenosis% Atherosclerosis% Steal syndrome (subclavian, basilar, or vertebral artery)% Transient ischemia% Embolism% Thrombosis% Atheroembolism

Some diagnoses that might warrant an atherectomy include the following:

EXHIBIT F


% Atherosclerosis% Vascular insufficiency% Arterial stricture% Aneurysm of the artery

However, many of the reasons why a patient might undergo athromboendarterectomy are the same for a patient who might undergo anatherectomy.

2. During a thromboendarterectomy, physicians remove part of the vessel lining in addition to the plaque. During an atherectomy, physicians only remove theplaque.

Exercises to tryUse your CPT Manual to code the scenarios below and see the following page for theanswers:

1. A physician performs a thromboendarterectomy of the tibial (initial vessel) and three additional tibial vessels (all with patch graft). How should you report this?

2. A physician performs a thromboendarterectomy without a patch graft; carotid artery,by neck incision. How should you report this?

3. A physician performs a thromboendarterectomy of the popliteal artery, including patchgraft. How should you report this?

[email protected].


EXHIBIT F

Answers to exercises

1. A physician performs a thromboendarterectomy of the tibial (initial vessel) and three additional tibial vessels (all with patch graft). How should you report this?

Answer: Report codes 35305 and 35306 (x3).

2. A physician performs a thromboendarterectomy without a patch graft; carotid artery,by neck incision. How should you report this?

Answer: Report code 35301.

3. A physician performs a thromboendarterectomy of the popliteal artery, including patchgraft. How should you report this?

Answer: Report code 35303.

Exhibit G

List of useful industry acronyms

Source: HCPro, Inc.


EXHIBIT G

- 1 -

HIM Acronyms to Know

AAPCAHAAHICAHIMAAHRQAMIAOAAPCsAPR DRGASCASPAWP

BBA

CAHCARTCBSAsCCCCHITCCRCDACCDMCPICMICMSCMSACOBRACPICPTCRNACTCY

DEDDRADRGDSH

ECIEDEHREMR

American Academy of Professional CodersAmerican Hospital AssociationAmerican Health Information CommunityAmerican Health Information Management AssociationAgency for Health Care Research and QualityAcute myocardial infarctionAmerican Osteopathic AssociationAmbulatory payment classificationsAll Patient Refined Diagnosis Related Group System Ambulatory surgical centerAverage sales priceAverage wholesale price

Balanced Budget Act of 1997, Pub. L. 105-33BLS Bureau of Labor Statistics

Critical access hospitalCMS Abstraction & Reporting ToolCore-based statistical areasComplication or comorbidityCertification Commission for Health Information TechnologyContinuity of care record/Cost to charge ratioClinical Data Abstraction CenterCharge description masterConsumer price indexCase-mix index Centers for Medicare & Medicaid ServicesConsolidated Metropolitan Statistical AreaConsolidated Omnibus Reconciliation Act of 1985, Pub. L. 99-272 Consumer price indexCurrent Procedural TerminologyCertified registered nurse anesthetistComputed tomographyCalendar year

Dedicated emergency departmentDeficit Reduction Act of 2005, Pub. L. 109-171 Diagnosis-related group Disproportionate share hospital

Employment cost index Emergency departmentElectronic health recordElectronic medical record

EXHIBIT G

60 Interventional Radiology: Accurate Coding for Appropriate Reimbursement- 2 -

EMTALAEOB

FDAFFYFIFQHCFY

GAAPGAFGME

HCFAHCPCSHCRISHHAHHSHICHIMSSHIPAA HISHITHMOHSAHSRVccHQAHQIHwH

ICD-9-CMICD-10-PCSICUIHSIMEIOMIPFIPPSIRFIT

JCAHO

LCDLTC-DRGLTCH

Emergency Medical Treatment and Labor Act of 1986, Pub. L. 99-272Explanation of benefits

Food and Drug Administration Federal fiscal yearFiscal intermediaryFederally qualified health centerFiscal year

Generally Accepted Accounting PrinciplesGeographic Adjustment FactorGraduate medical education

Health Care Financing AdministrationHealthcare Common Procedure Coding SystemHospital Cost Report Information SystemHome health agencyDepartment of Health and Human ServicesHealth insurance cardHealth Information Management Systems SocietyHealth Insurance Portability and Accountability Act of 1996 Health information system/servicesHealth information technology Health maintenance organizationHealth savings accountHospital-specific relative value cost centerHospital Quality AllianceHospital Quality InitiativeHospital-within-a-hospital

International Classification of Diseases, Ninth Revision, Clinical Modification International Classification of Diseases, Tenth Edition Procedure Coding System Intensive care unitIndian Health ServiceIndirect medical educationInstitute of MedicineInpatient psychiatric facilityAcute care hospital inpatient prospective payment systemInpatient rehabilitation facilityInformation technology

Joint Commission on Accreditation of Healthcare Organizations

Local coverage determinationLong-term care diagnosis-related groupLong-term care hospital


EXHIBIT G

- 3 -

MACMCEMCOMCVMDCMDHMedPACMedPARMMA

MRHFP

NAHITNCCINCDNCHSNCQANCVHSNHINNICUNPINQFNVHRI

OCEOCROESOIGOMBOPPSOROSCAR

PPIPPSPRAProPACPRMPRRBPS&R

QIGQIO

RA

Medicare administrative contractorMedicare Code EditorManaged care organizationMajor cardiovascular conditionMajor diagnostic category Medicare-dependent, small rural hospitalMedicare Payment Advisory Commission Medicare Provider Analysis and Review File Medicare Prescription Drug, Improvement, and Modernization Act of 2003,

Pub. L. 108-173 Medicare Rural Hospital Flexibility Program

National Alliance for Health Information TechnologyNational Correct Coding InitiativeNational coverage determinationNational Center for Health StatisticsNational Committee for Quality AssuranceNational Committee on Vital and Health StatisticsNational health information networkNeonatal intensive care unitNational provider identifierNational Quality ForumNational Voluntary Hospital Reporting Initiative

Outpatient code editorOffice for Civil RightsOccupational employment statisticsOffice of the Inspector GeneralExecutive Office of Management and BudgetOutpatient prospective payment systemOperating roomOnline Survey Certification and Reporting (System)

Producer price indexProspective payment systemPer resident amount Prospective Payment Assessment CommissionProvider Reimbursement ManualProvider Reimbursement Review Board Provider Statistical and Reimbursement (System)

Quality Improvement Group, CMS Quality Improvement Organization

Remittance advice

EXHIBIT G

62 Interventional Radiology: Accurate Coding for Appropriate Reimbursement- 4 -

RCRHCRHIORHQDAPURRCRY

SAFSCHSNFSOCsSSASSIST

TAGTEFRA

UHDDS

Revenue codeRural health clinicRegional health information organizationReporting hospital quality data for annual payment updateRural referral centerRate year

Standard Analytic FileSole community hospitalSkilled nursing facilityStandard occupational classificationsSocial Security AdministrationSupplemental Security Income Status indicator

Technical Advisory GroupTax Equity and Fiscal Responsibility Act of 1982, Pub. L. 97-248

Uniform hospital discharge data set

Exhibit H

Answers to case studies

Source: Yvonne Hoiland, CCS-P, CPC-H, RCC, CPC, PMCCI

EXHIBIT H


Case Study Answers

Case Study #1 - UFE37210

Case Study #2 - Stent36245-5075722-59-RT37205-LT75960-LT

Case Study #3 - PTA3624675726-593547175966

Case Study #4 - Combo36247-LT35474-LT37205-LT75962-LT75960-LT75710-59-RT

Case Study #5 - Atherectomy36247-LT75716-5935493-LT75992-LT

Case Study #6 - Embolization36217-LT36217-RT616267589475898

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