outpatient hospital use of modifiers

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1 Interventional Interventional Radiology Radiology Coding...What You Coding...What You Need To Know Need To Know April, 27 2007 Pat Maccariella-Hafey, RHIA, CCS, CCS-P Director of Education Health Information Associates [email protected] 843-602-6181

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Page 1: OUTPATIENT HOSPITAL USE OF MODIFIERS

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Interventional Interventional Radiology Radiology

Coding...What You Coding...What You Need To KnowNeed To Know

April, 27 2007

Pat Maccariella-Hafey, RHIA, CCS, CCS-PDirector of Education

Health Information [email protected]

843-602-6181

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ObjectivesObjectives Discuss resources Discuss resources Review common problem issues in IR Review common problem issues in IR

coding including documentationcoding including documentation Explain basic conventions/rules used in Explain basic conventions/rules used in

interventional radiology surgical codesinterventional radiology surgical codes Discuss importance of supervision and Discuss importance of supervision and

interpretation codes.interpretation codes. Discuss action plans to rectify coding and Discuss action plans to rectify coding and

charging issuescharging issues

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Interventional RadiologyInterventional RadiologyWhat is it?What is it?

Interventional radiology is the non-Interventional radiology is the non-surgical treatment of a growing number surgical treatment of a growing number of diseases using radiologic imaging to of diseases using radiologic imaging to guide guide catheterscatheters (hollow, flexible tubes), (hollow, flexible tubes), balloons, filters, and other tiny balloons, filters, and other tiny instruments through the body's blood instruments through the body's blood vessels and other organs.vessels and other organs.

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Official Guidance IssuesOfficial Guidance Issues

Check all Program Memorandums at Check all Program Memorandums at http://cms.hhs.gov/Transmittals/2007Tranhttp://cms.hhs.gov/Transmittals/2007Trans/list.asps/list.asp

Although CMS does not get specific, Although CMS does not get specific, industry standard is that SIR industry standard is that SIR conventions be used to assign codes. conventions be used to assign codes.

www.sirweb.orgwww.sirweb.org The Society of The Society of Interventional RadiologyInterventional Radiology Coding section Coding section

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Official Guidance IssuesOfficial Guidance Issues http://www.zhealthpublishing.com/http://www.zhealthpublishing.com/ David David

Zielske, MD. Website Q&A, books, Zielske, MD. Website Q&A, books, seminars. Many complicated cases.seminars. Many complicated cases.

www.medlearn.comwww.medlearn.com Books, seminars Books, seminars www.AHIMA.orgwww.AHIMA.org Communities of Practice, Communities of Practice,

Radiology Coding and ComplianceRadiology Coding and Compliance http://www.medicalassetmanagement.com/http://www.medicalassetmanagement.com/

Color illustrations, seminars, booksColor illustrations, seminars, books

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Official Guidance IssuesOfficial Guidance Issues CPT Assistant may have old information. CPT Assistant may have old information.

Coding Clinic for HCPCS is now the Coding Clinic for HCPCS is now the official source for HOPPS coding official source for HOPPS coding guidanceguidance

Relevant Coding Clinic for HCPCS Relevant Coding Clinic for HCPCS Issues:Issues: 33rdrd Quarter 2005 page 10 Quarter 2005 page 10 44thth Quarter 2004 pages 4-5 Quarter 2004 pages 4-5 33rdrd Quarter 2004 page 16 Quarter 2004 page 16 33rdrd Quarter 2002 pages 8-9 Quarter 2002 pages 8-9

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Official Guidance IssuesOfficial Guidance Issues Beware of the “pink sheets” or vendor info. Beware of the “pink sheets” or vendor info.

These have been found to contain erroneous These have been found to contain erroneous info. info.

For hospital billing, For hospital billing, angiographyangiography APCs are APCs are driven by the S&I codes, (7XXXX) and the driven by the S&I codes, (7XXXX) and the surgical codes (3XXXX) are packaged. (APC surgical codes (3XXXX) are packaged. (APC 19900) 19900)

Beware of Category III codes in the back and Beware of Category III codes in the back and also any HCPCS level II codes or G codes.also any HCPCS level II codes or G codes.

See Appendix L for ordered vessels.See Appendix L for ordered vessels.

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IR and Billing IssuesIR and Billing Issues Revenue Codes are used in hospitals, 0001-0999Revenue Codes are used in hospitals, 0001-0999 They act as “buckets” or cost centers for third They act as “buckets” or cost centers for third

party payers to allow tracking of services party payers to allow tracking of services provided.provided.

There must be agreement between the revenue There must be agreement between the revenue codes and CPT codes, or the line rejects. Most codes and CPT codes, or the line rejects. Most rejections initially are due to wrong revenue rejections initially are due to wrong revenue codes, not CPT codes.codes, not CPT codes.

Revenue codes differ by state. Ingenix has a Revenue codes differ by state. Ingenix has a book UB92/04 Editor with all revenue codes for book UB92/04 Editor with all revenue codes for each state. each state.

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IR and Billing IssuesIR and Billing Issues Not matching CPT codes with Not matching CPT codes with

correct device codes “C Codes”correct device codes “C Codes”http://http://

www.cms.hhs.gov/HospitalOutpatienwww.cms.hhs.gov/HospitalOutpatientPPS/01_overview.asp#TopOfPagetPPS/01_overview.asp#TopOfPage

i.e. 35473-LT for PTA of left iliac i.e. 35473-LT for PTA of left iliac can match with C1725, C1874, can match with C1725, C1874, C1876, C1885 or C2625.C1876, C1885 or C2625.

Chargemaster driven Chargemaster driven Audit recommendedAudit recommended

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IR Modifier UsageIR Modifier Usage

FOR PHYSICIAN BILLING ONLY:FOR PHYSICIAN BILLING ONLY:CMS may no longer support use of CMS may no longer support use of bilateral modifier "-50" or "-RT"/"-LT" bilateral modifier "-50" or "-RT"/"-LT" when reporting multiple selective when reporting multiple selective catheterization servicescatheterization services For Carriers (Physician billing) onlyFor Carriers (Physician billing) only

FACILITY modifiers, refer to state MAC FACILITY modifiers, refer to state MAC (FI/Carrier). Always verify with payor.(FI/Carrier). Always verify with payor.

Use of modifier -50 rare among MACs. Use of modifier -50 rare among MACs. See Transmittal 442 (PM A-00-73)See Transmittal 442 (PM A-00-73)

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IR Modifier UsageIR Modifier Usage

Modifiers typically used by the hospital for Modifiers typically used by the hospital for radiology:radiology:

-RT and -LT-RT and -LT -25 ( on ER cases or clinic cases)-25 ( on ER cases or clinic cases) -50 bilateral (if surgical in nature and MAC likes it)-50 bilateral (if surgical in nature and MAC likes it) -52 reduced services-52 reduced services -58 staged procedure (biliary mostly)-58 staged procedure (biliary mostly) -59 distinct procedure-59 distinct procedure -76 repeat procedure same MD-76 repeat procedure same MD -77 repeat procedure different MD-77 repeat procedure different MD -78 Return to OR, related procedure (tunneled -78 Return to OR, related procedure (tunneled

caths)caths) -79 Unrelated procedure by MD same day-79 Unrelated procedure by MD same day

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IR Modifier UsageIR Modifier Usage

When using modifier –59 with another When using modifier –59 with another modifier i.e.;modifier i.e.; 36216 RT36216 RT 36215-59-LT36215-59-LT

Be sure that the –59 is on the lower Be sure that the –59 is on the lower ordered vessel and that –59 is before any ordered vessel and that –59 is before any other modifiers. The modifier that most other modifiers. The modifier that most affects payment should be listed first baffects payment should be listed first b

Many FI s still only look at the first Many FI s still only look at the first modifier. Check with “MAC” to be sure.modifier. Check with “MAC” to be sure.

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IR Review of Coding IR Review of Coding RulesRulesSurgical codes (3XXXX) deal with actual Surgical codes (3XXXX) deal with actual

procedural work (such as needle positioning, procedural work (such as needle positioning, catheter placement or manipulation, catheter placement or manipulation, angioplasty or stent deployment). angioplasty or stent deployment). HOW YOU HOW YOU DID IT.DID IT.

Supervision and Interpretation (Imaging) (S&I) Supervision and Interpretation (Imaging) (S&I) codes (7XXXX) describe the imaging guidance codes (7XXXX) describe the imaging guidance and image interpretation portions. (Studying and image interpretation portions. (Studying the vessels) the vessels)

Some S&I codes are specifically paired with a Some S&I codes are specifically paired with a surgical code 35473 and 75962 surgical code 35473 and 75962

There are also S&I codes for image There are also S&I codes for image interpretation, without a similar one-to-one interpretation, without a similar one-to-one matched relationship. matched relationship. WHAT YOU DIDWHAT YOU DID

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IR Review of Coding IR Review of Coding RulesRules A vascular A vascular FAMILY FAMILY is a group of is a group of

vessels which is fed by a vessels which is fed by a primary primary branch off the aorta, vena cava, OR branch off the aorta, vena cava, OR the vessel punctured. the vessel punctured.

Smaller vessels need microcatheters. Smaller vessels need microcatheters. Cath to the aorta follows natural flow. Cath to the aorta follows natural flow.

No work to get there so this is non-No work to get there so this is non-selective.selective.

Other vessels off aorta or Other vessels off aorta or vessel punctured are vessel punctured are selected.selected.

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IR Review of Coding IR Review of Coding RulesRulesNon selectiveNon selective cath insertion is when it is cath insertion is when it is

placed directly into an artery or vein placed directly into an artery or vein with no further advancement of the with no further advancement of the catheter past the punctured vessel catheter past the punctured vessel OR the catheter is placed into any OR the catheter is placed into any portion of the aorta or superior/ portion of the aorta or superior/ inferior vena cava from any approach inferior vena cava from any approach (TLA, femoral, axillary, brachial) (TLA, femoral, axillary, brachial)

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IR Review of Coding IR Review of Coding RulesRules SelectiveSelective catheter is guided, catheter is guided,

negotiated or advanced into any negotiated or advanced into any arterial or venous vessel other than arterial or venous vessel other than the aorta or vena cavae, or the the aorta or vena cavae, or the original vessel punctured.original vessel punctured.

(The intent of reimbursement (The intent of reimbursement differences is that it takes more skill to differences is that it takes more skill to negotiate other than the main large negotiate other than the main large vessels. Each time a bifurcation is vessels. Each time a bifurcation is passed, the difficulty increases. Used passed, the difficulty increases. Used for MD billing RBRVS)for MD billing RBRVS)

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Pigtail Catheter

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IR Review of Coding IR Review of Coding RulesRules

Always code the highest ordered vessel first, Always code the highest ordered vessel first, and then any additional second or third order and then any additional second or third order vessels in the same family to 36218. (head/neck)vessels in the same family to 36218. (head/neck)

Contrast injections on the way up are included in Contrast injections on the way up are included in the highest ordered vessel code.the highest ordered vessel code.

For example, if cath placed in right subclavian For example, if cath placed in right subclavian (36216-RT), and then placed in right internal (36216-RT), and then placed in right internal carotid (36217-RT) code carotid (36217-RT) code 36217-RT and 36218-RT36217-RT and 36218-RT (for the right subclavian which is an additional (for the right subclavian which is an additional second or third order but lower than 36217.) second or third order but lower than 36217.) This assures the appropriate depiction of the This assures the appropriate depiction of the case.case.

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IR Review of Coding IR Review of Coding RulesRules Each entry into a Each entry into a vascular familyvascular family is is

coded separately; i.e., catheter to right coded separately; i.e., catheter to right common carotid then to left common common carotid then to left common carotid, code both of these 36215-59-LT, carotid, code both of these 36215-59-LT, 36216-RT. The 59 will be appended on 36216-RT. The 59 will be appended on the lower numbered vessel.the lower numbered vessel.

Add on code 36218 for head and neck Add on code 36218 for head and neck and 36248 for abdomen down are when and 36248 for abdomen down are when you are in same vascular family.you are in same vascular family.

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IR Review of Coding IR Review of Coding RulesRules Catheters inserted “at origin of” “at Catheters inserted “at origin of” “at

origins” for “road-mapping” “flush origins” for “road-mapping” “flush aortogram” “close to” “drive by” do aortogram” “close to” “drive by” do NOT constitute a selective catheter of NOT constitute a selective catheter of the structure. MD has to state that he the structure. MD has to state that he negotiated the catheter into the negotiated the catheter into the vessels.vessels.

Prevalent in renal angiograms. Prevalent in renal angiograms. Transmittal AB-03-119 8/8/03 Transmittal AB-03-119 8/8/03

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IR Review of Coding IR Review of Coding RulesRules36245-LT Renal angiogram (Cath in renal)36245-LT Renal angiogram (Cath in renal) APC 19900 packaged $0APC 19900 packaged $0

75722-LT Selective renal angiography75722-LT Selective renal angiography

S&I unilateralS&I unilateral APC 280 $1,211.03APC 280 $1,211.03

--------------------------------------------------------------------------------------

G0275 Renal Angiogram Flush (cath aorta)G0275 Renal Angiogram Flush (cath aorta) APC 19900 packaged $0APC 19900 packaged $0 Also code cardiac cath codesAlso code cardiac cath codes

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IR Review of Coding IR Review of Coding RulesRules Selective codes take precedence overSelective codes take precedence over

non-selective codes, if done from the same non-selective codes, if done from the same puncture site. Only code the selective.puncture site. Only code the selective. Guide wires are inserted as far as they Guide wires are inserted as far as they can get it to anchor. Do not confuse catheter can get it to anchor. Do not confuse catheter placement with guidewire placement.placement with guidewire placement. Post-angiography S&I or road-mapping Post-angiography S&I or road-mapping S&I, “quick injections” are not coded/ S&I, “quick injections” are not coded/ charged. These are part of the procedure.charged. These are part of the procedure.

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IR Review of Coding IR Review of Coding RulesRules

37205 Stent in common iliac37205 Stent in common iliac APC 081 $2,497.15APC 081 $2,497.15

36245-LT Catheter in common iliac36245-LT Catheter in common iliac APC 19900 Packaged $0APC 19900 Packaged $0

75962 S&I PTA peripheral artery unilateral 75962 S&I PTA peripheral artery unilateral APC 668 $363.29APC 668 $363.29

--------------------------------------------------------------------------------If trying to bill follow up angiographyIf trying to bill follow up angiography75710-59 Angiography unilateral lower extremity 75710-59 Angiography unilateral lower extremity

S&IS&I APC 280 $1,211.03APC 280 $1,211.03 THIS IS INCORRECT!THIS IS INCORRECT!

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IR Review of Coding IR Review of Coding RulesRules

Again, S&I codes describe the imaging. If Again, S&I codes describe the imaging. If

““selective” is not in the imaging code selective” is not in the imaging code

description, the cath does not need to be in the description, the cath does not need to be in the

vessel imaged to use the S&I code. If “selective” vessel imaged to use the S&I code. If “selective”

is in the description, then yes the cath has to be is in the description, then yes the cath has to be

in that vessel. See 75625 and 75662 for example.in that vessel. See 75625 and 75662 for example. Code Code 7577475774 is used to report additional is used to report additional

selective or supra-selective exams performed in selective or supra-selective exams performed in

the same area as the base exam. It has to be a the same area as the base exam. It has to be a

SELECTIVE cath (cath in vessel interpreted)SELECTIVE cath (cath in vessel interpreted)

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Example 1Example 1

““Abdominal aortogram and bilateral Abdominal aortogram and bilateral lower extremity arteriograms and lower extremity arteriograms and run off via high and low catheter run off via high and low catheter placement and injections from a placement and injections from a single, left groin stick.” (very single, left groin stick.” (very common)common)

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Example 1 AnswerExample 1 AnswerWhat you did:What you did:

75625 Abdominal Aortogram 75625 Abdominal Aortogram APC 280 $1,211.03APC 280 $1,211.03

75716 Bilateral Lower Extremity Arteriogram75716 Bilateral Lower Extremity Arteriogram APC 280 $1,211.03APC 280 $1,211.03 (Full lower ext exam does not need to go all the way to (Full lower ext exam does not need to go all the way to

the toes)the toes)How you did it:How you did it:

36200 Catheter placed high and low in 36200 Catheter placed high and low in aorta (it does not matter that two injections were aorta (it does not matter that two injections were done in the aorta, only code it once) done in the aorta, only code it once) APC 19900 packagedAPC 19900 packaged

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Example 1 AnswerExample 1 Answer

75630, Abdominal aortogram with 75630, Abdominal aortogram with

bilateral iliofemoral angiogram is only bilateral iliofemoral angiogram is only

used when the abdominal aorta and used when the abdominal aorta and

lower extremities are studied with a lower extremities are studied with a

single catheter position and as a single single catheter position and as a single

exam. 75630 can also be used when the exam. 75630 can also be used when the

catheter is repositioned and only the catheter is repositioned and only the

pelvis is imaged.pelvis is imaged. APC 280 $1,211.03APC 280 $1,211.03

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Example 2Example 2 Bilateral renal angiogram, selective, additional Bilateral renal angiogram, selective, additional

selective study of accessory left renal arteries selective study of accessory left renal arteries with 3 entranceswith 3 entrances 7572475724 S&I S&I APC 280 $1,211.03APC 280 $1,211.03 75774 x 275774 x 2 S&I for additional viewsS&I for additional views

APC 279 $552.87 Often missedAPC 279 $552.87 Often missed APC 279 $552.87 Often missedAPC 279 $552.87 Often missed

3624536245 -RT right side -RT right side APC 19900 packaged $0APC 19900 packaged $0 36245-59-LT36245-59-LT left side (or 36245-50 plus)left side (or 36245-50 plus) 36245-59-LT36245-59-LT first accessory leftfirst accessory left 36245-59-LT36245-59-LT second accessory leftsecond accessory left

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AV Fistula/Graft APC 88AV Fistula/Graft APC 88 Creation of AV fistula by other than direct AV Creation of AV fistula by other than direct AV

anastomosis, autogenous graft (CPT code anastomosis, autogenous graft (CPT code 36825) describes a procedure in which a donor's 36825) describes a procedure in which a donor's vein is used to connect an artery and vein.vein is used to connect an artery and vein.

Creation of AV fistula by other than direct AV Creation of AV fistula by other than direct AV anastomosis, non-autogenous graft (e.g., anastomosis, non-autogenous graft (e.g., biological collagen, thermoplastic graft, Gortex) biological collagen, thermoplastic graft, Gortex) (CPT code 36830) is used to report placement of (CPT code 36830) is used to report placement of a synthetic subcutaneous tube graft with one a synthetic subcutaneous tube graft with one end anastomosed to the brachial artery and the end anastomosed to the brachial artery and the other to a large vein.other to a large vein. This method is the most commonly performed This method is the most commonly performed

hemodialysis access procedure performed hemodialysis access procedure performed today (50,000/yr).today (50,000/yr).

36818 and 36819 are arm vein transpositions36818 and 36819 are arm vein transpositions

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AV Fistula/GraftAV Fistula/Graft Be sure to code the catheterization of the Be sure to code the catheterization of the

limbs in addition to therapeutic procedures. limbs in addition to therapeutic procedures. If both the arterial and venous sides are If both the arterial and venous sides are both punctured, 36145 would be reported both punctured, 36145 would be reported twice. You may need modifier –59 with this. twice. You may need modifier –59 with this. It is also called “fistulogram.”It is also called “fistulogram.”

Report S&I code 75790 for imaging Report S&I code 75790 for imaging APC 279 $552.97APC 279 $552.97

Code S&I 75790 includes imaging of outflow Code S&I 75790 includes imaging of outflow to the level of the right atrium. Do not report to the level of the right atrium. Do not report the vena cavagram S&I with this. It is the vena cavagram S&I with this. It is included. included. Additional 75790-59 APC 279 Additional 75790-59 APC 279 $552.97 is incorrect$552.97 is incorrect

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AV Fistula/GraftAV Fistula/Graft

Thrombus is not the same as stenosis.Thrombus is not the same as stenosis. ThrombusThrombus is a clot within the blood vessel, is a clot within the blood vessel,

blocking blood flow. It is the final result of blocking blood flow. It is the final result of blood coagulation thru aggregate of platelets. blood coagulation thru aggregate of platelets. Thrombectomy is the choice to alleviate Thrombectomy is the choice to alleviate thrombus.thrombus.

Stenosis Stenosis is plaque (arteriosclerosis) or is plaque (arteriosclerosis) or hyperplasia of the intimal layer of the arterial hyperplasia of the intimal layer of the arterial wall, causing narrowing of the vessel, also wall, causing narrowing of the vessel, also blocking blood flow. blocking blood flow.

PTA is the choice to alleviate stenosis.PTA is the choice to alleviate stenosis.

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AV Fistula/GraftAV Fistula/Graft Declotting (most thrombus occurs on Declotting (most thrombus occurs on

venous side)venous side) 36870 describes percutaneous removal of 36870 describes percutaneous removal of

clot from an AV fistula/graft by any method.clot from an AV fistula/graft by any method. There is no S&I code for this procedure.There is no S&I code for this procedure. 36145 is used for puncture, code twice if 36145 is used for puncture, code twice if

both artery and venous limbs puncturedboth artery and venous limbs punctured 75790 is used for fistulogram and only 75790 is used for fistulogram and only

reported once despite 2 punctures.reported once despite 2 punctures. APC 279 $ 552.87APC 279 $ 552.87

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AV Fistula/GraftAV Fistula/Graft

Q: If our radiologist performs thrombolytic Q: If our radiologist performs thrombolytic infusion on a dialysis graft for more than one infusion on a dialysis graft for more than one hour (i.e. 4 hours) should we assign 37201 hour (i.e. 4 hours) should we assign 37201 and 75896 instead of 36870?and 75896 instead of 36870?

A: Duration does not affect coding. If A: Duration does not affect coding. If thrombolysis is done thrombolysis is done withinwithin a graft, it is a graft, it is considered part of the procedure and considered part of the procedure and reported with 36870. If the infusion is done reported with 36870. If the infusion is done outsideoutside the graft, (with the outflow veins or the graft, (with the outflow veins or distal artery) 37201 and 75896 would be used. distal artery) 37201 and 75896 would be used.

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AV Fistula/GraftAV Fistula/Graft 36870 AV thrombectomy 36870 AV thrombectomy APC 653 $1,883.31APC 653 $1,883.31 36145 x 2 36145 x 2 (APC 19900 packaged)(APC 19900 packaged) 75790 S&I for fistulogram 75790 S&I for fistulogram APC 279 $552.87APC 279 $552.87Do not report the below if thrombolysis in graftDo not report the below if thrombolysis in graft 37201-59 Infusion 37201-59 Infusion APC 676 $60.29 at 50%APC 676 $60.29 at 50% 75898 S&I for infusion 75898 S&I for infusion APC 263 $98.62APC 263 $98.62If documented as outside graft this is coded If documented as outside graft this is coded

see CPT Assistant May 2001 page 3-4. see CPT Assistant May 2001 page 3-4. Normally a vessel is selected and cath Normally a vessel is selected and cath advanced to outflow thrombus.advanced to outflow thrombus.

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AV Fistula/GraftAV Fistula/Graft Angioplasty of AV fistula use 35476 + 75978 Angioplasty of AV fistula use 35476 + 75978

or G0393 + 75978 for Venous PTA of AV graft or G0393 + 75978 for Venous PTA of AV graft Medicare or G0392 + 75962 for Arterial only Medicare or G0392 + 75962 for Arterial only PTA for of AV graft MedicarePTA for of AV graft Medicare Venous Includes treatment of one or more Venous Includes treatment of one or more

stenoses at the arterial anastomosis, within the stenoses at the arterial anastomosis, within the graft, at the venous anastomosis, or in the outflow graft, at the venous anastomosis, or in the outflow vessels to the level of the axillary vein.vessels to the level of the axillary vein.

****if arterial and venous PTA done, only code the ****if arterial and venous PTA done, only code the venous side. Code arterial PTA if ONLY that is venous side. Code arterial PTA if ONLY that is done. The graft vessel that is PTA’d is considered done. The graft vessel that is PTA’d is considered a vein.a vein.

Code 36870 for thrombectomy if this is also Code 36870 for thrombectomy if this is also performed.performed.

Code puncture 36145 (x2 if done) and 75790.Code puncture 36145 (x2 if done) and 75790.

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AV Fistula/Graft Example AV Fistula/Graft Example

Two catheters are used to puncture Two catheters are used to puncture the arterial and venous limbs of the the arterial and venous limbs of the AV fistula. Fistulogram and vena AV fistula. Fistulogram and vena cavagram are performed, revealing cavagram are performed, revealing strictures at both the arterial and strictures at both the arterial and venous anastomosis. PTA done of venous anastomosis. PTA done of artery and venous limbs. Medicare.artery and venous limbs. Medicare.

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AV Fistula/Graft Example AV Fistula/Graft Example G0393 AV venous PTA G0393 AV venous PTA APC 081 $2,491.15APC 081 $2,491.15

35476 Non-Medicare same APC35476 Non-Medicare same APC 75978, S&I PTA 75978, S&I PTA APC 668 $363.29APC 668 $363.29 36870 Thrombectomy 36870 Thrombectomy APC 653 $941.66APC 653 $941.66 36145 X 2, for both limbs 36145 X 2, for both limbs APC 19900 APC 19900

packaged packaged 75790 for fistulogram 75790 for fistulogram APC 279 $552.87APC 279 $552.87

Do not code G0392, 75962 for arterial side of Do not code G0392, 75962 for arterial side of graft graft APC 81 $1,248.57 at 50%APC 81 $1,248.57 at 50%

APC 668 $363.29APC 668 $363.29

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Zones for AV Graft/UpperZones for AV Graft/UpperUpper ExtremityUpper Extremity Zone 1Zone 1: Arterial anastomosis, intra-graft, : Arterial anastomosis, intra-graft,

venous anastomosis and outflow veins to venous anastomosis and outflow veins to axillary veinaxillary vein

Zone 2Zone 2: Subclavian and brachiocephalic : Subclavian and brachiocephalic veins (central extremity veins)veins (central extremity veins)

Zone 3Zone 3: Superior Vena Cava: Superior Vena CavaOnly one venoplasty per zone Only one venoplasty per zone can be reported in this can be reported in this Interpretation.Interpretation.

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Zones for Lower Zones for Lower ExtremityExtremityLower ExtremityLower Extremity Zone 1Zone 1: Arterial anastomosis, intra-graft : Arterial anastomosis, intra-graft

to venous anastomosis (common femoral to venous anastomosis (common femoral vein)vein)

Zone 2Zone 2: External iliac and common iliac : External iliac and common iliac veins (central extremity veins)veins (central extremity veins)

Zone 3Zone 3: Inferior Vena Cava: Inferior Vena CavaOnly one venoplasty per zone can be Only one venoplasty per zone can be

reportedreported

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PTA Non AV GraftPTA Non AV Graft PTA surgical codes are 35470-35476PTA surgical codes are 35470-35476 Code one PTA for each VESSEL treatedCode one PTA for each VESSEL treated

PTA of three lesions in the SFA = one PTA of three lesions in the SFA = one PTA, 35474, 75962PTA, 35474, 75962

PTA of one lesion in the SFA and two in PTA of one lesion in the SFA and two in the iliac = two PTA’s 35474 + 35473, the iliac = two PTA’s 35474 + 35473, 75962, 7596475962, 75964

Code any catheter placements (i.e., 36245, Code any catheter placements (i.e., 36245, 36246, etc)36246, etc)

Per CPT Asst Aug 2006 page 10 the SFA Per CPT Asst Aug 2006 page 10 the SFA and popliteal are 2 separate vessels so both and popliteal are 2 separate vessels so both can be coded. can be coded.

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PTA Non AV GraftPTA Non AV Graft If PTA and atherectomy of same vessel, code only If PTA and atherectomy of same vessel, code only

atherectomy of that vessel, CMS policy atherectomy of that vessel, CMS policy If PTA and atherectomy both done at separate vessels, If PTA and atherectomy both done at separate vessels,

report both codes (35470-35476, 35490-35495) Check report both codes (35470-35476, 35490-35495) Check with MAC as some only allow 1.with MAC as some only allow 1.

Code the S&I codes (75962-75968, 75978, 75992-75996)Code the S&I codes (75962-75968, 75978, 75992-75996) Code diagnostic angiogram S&I if performed (75710, Code diagnostic angiogram S&I if performed (75710,

etc)etc) Do not code the “completion” or follow up angiogram Do not code the “completion” or follow up angiogram

which is done to check after the procedure is done. Do which is done to check after the procedure is done. Do not report a surgical or S&I code for this at all.not report a surgical or S&I code for this at all.

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Transcatheter StentTranscatheter Stent Transcatheter placement of intravascular stent Transcatheter placement of intravascular stent

is coded to 37205-37206 (75960 each stent)is coded to 37205-37206 (75960 each stent) Assign one code for each vessel stentedAssign one code for each vessel stented

If multiple stents in same vessel, only one If multiple stents in same vessel, only one stent placement code is assignedstent placement code is assigned

Multiple vessels stented = 37205 for the first Multiple vessels stented = 37205 for the first vessel and 37206 for each additionalvessel and 37206 for each additional

Be careful, this is different than ICD-9-CM Be careful, this is different than ICD-9-CM procedure coding.procedure coding.

Code diagnostic angiogram if performed (75710)Code diagnostic angiogram if performed (75710) Code any catheter placements (36245, 36246, Code any catheter placements (36245, 36246,

etc.etc.

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Angioplasty with StentAngioplasty with Stent Angioplasty performed as the means of stent Angioplasty performed as the means of stent

deployment to expand the stent) is NOT deployment to expand the stent) is NOT separately coded. For example, with 30% separately coded. For example, with 30% lesion, they pre-dilate and then insert stent. lesion, they pre-dilate and then insert stent. (or balloon mounted)(or balloon mounted)

TherapeuticTherapeutic angioplasty performed before or angioplasty performed before or after the stent placement should be separately after the stent placement should be separately coded. coded. Failed angioplastyFailed angioplasty Angioplasty of a separate lesionAngioplasty of a separate lesion Another example is a lesion of 70%, treated with Another example is a lesion of 70%, treated with

PTA, which still shows 30% lesion so stent is now PTA, which still shows 30% lesion so stent is now inserted. Code both in this situation.inserted. Code both in this situation.

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VAD and Line PlacementsVAD and Line Placements See 36555 thru 36597See 36555 thru 36597 Codes grouped by Codes grouped by

Central, Non –tunneledCentral, Non –tunneled Insert/Repair/ReplaceInsert/Repair/Replace

Central TunneledCentral Tunneled W/O Sub Q port or pump/With Sub Q port/With W/O Sub Q port or pump/With Sub Q port/With

Sub Q PumpSub Q Pump All above, insert, Repair, Replace, RemoveAll above, insert, Repair, Replace, Remove

Peripherally inserted/PICC Peripherally inserted/PICC W/O Sub Q port or Pump/With Sub Q portW/O Sub Q port or Pump/With Sub Q port Insert/Repair/Replace/Remove (sub Q port)Insert/Repair/Replace/Remove (sub Q port)

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Central TunneledCentral Tunneled CentralCentral = Cath or device tip must terminate in = Cath or device tip must terminate in

the subclavian, brachio cephalic (innominate) the subclavian, brachio cephalic (innominate) or iliac veins, the superior OR inferior vena or iliac veins, the superior OR inferior vena cava or the right atriumcava or the right atrium 3655636556 APC 621 $510.91 77001 packaged APC 621 $510.91 77001 packaged

CentralCentral = jugular, subclavian, femoral vein or = jugular, subclavian, femoral vein or inferior vena cava catheter entry site)inferior vena cava catheter entry site)

TunneledTunneled means that a portion of the cath is means that a portion of the cath is tunneled underneath the skin and then the tunneled underneath the skin and then the end comes out of vessel/skin and is exposed end comes out of vessel/skin and is exposed to outside (W/O port or pump)to outside (W/O port or pump) 36558 36558 APC 623 $1,318.27 77001 packagedAPC 623 $1,318.27 77001 packaged

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Peripherally Inserted Peripherally Inserted (PICC) (PICC) PeripherallyPeripherally inserted includes cath entry site inserted includes cath entry site

from basilic (inner side of forearm to elbow) from basilic (inner side of forearm to elbow) or cephalic veins (upper arm).or cephalic veins (upper arm).

W/O Sub Q port or pump W/O Sub Q port or pump Insert, < 5 yrs 36568; >5 yrs, 36569 Insert, < 5 yrs 36568; >5 yrs, 36569 APC 621 $510.91APC 621 $510.91 Repair, 36575; Replace, 36584; remove, E/MRepair, 36575; Replace, 36584; remove, E/M

With Sub Q PortWith Sub Q Port Insert, ,5 yrs 36570; >5 yrs, 36571 Insert, ,5 yrs 36570; >5 yrs, 36571 APC 622 $1,218.27APC 622 $1,218.27 Repair 36576; Replace cath only, 36578; complete Repair 36576; Replace cath only, 36578; complete

replace, 36585, replace, 36585, Remove, 36590Remove, 36590

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Cardiac CathsCardiac Caths Cardiac catheterization is the insertion Cardiac catheterization is the insertion

and passage of small plastic tubes and passage of small plastic tubes (catheters) into arteries and veins up to the (catheters) into arteries and veins up to the heart to obtain x-ray pictures of coronary heart to obtain x-ray pictures of coronary arteries and cardiac chambers as well a to arteries and cardiac chambers as well a to measure pressures in the heart (intracardiac measure pressures in the heart (intracardiac hemodynamics). Diagnostic angiography is hemodynamics). Diagnostic angiography is also performed to obtain images and also performed to obtain images and determine the function of the cardiovascular determine the function of the cardiovascular system for diseases of the aorta, pulmonary system for diseases of the aorta, pulmonary and peripheral vessels.and peripheral vessels.

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Cardiac CathsCardiac CathsCheck to see if a true left heart cath is being done.Check to see if a true left heart cath is being done. If you look at the pressures or pressure result If you look at the pressures or pressure result

(mmhg), and see “LV”, then you know that the (mmhg), and see “LV”, then you know that the physician did a left heart catheterization. He has to physician did a left heart catheterization. He has to cross the aortic valve to get these pressures.cross the aortic valve to get these pressures.

93510 for left heart cath, 93508 if only coronary 93510 for left heart cath, 93508 if only coronary artery angiogram and no left heart cath. Same APC.artery angiogram and no left heart cath. Same APC.

If you see “RV” pressure measurements, then you If you see “RV” pressure measurements, then you know that the physician did a right heart know that the physician did a right heart catheterization. To do a right cath, the entrance way catheterization. To do a right cath, the entrance way is through the vena cava. Usually there is a venous is through the vena cava. Usually there is a venous puncture to thread the catheterpuncture to thread the catheter

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Cardiac CathsCardiac Caths• Two other codes, 93561 and 93562 cannot be Two other codes, 93561 and 93562 cannot be

assigned for cardiac outputs during cardiac assigned for cardiac outputs during cardiac cath as NCCI edit 20 is elicited.cath as NCCI edit 20 is elicited.

• Define arterial and venous bypass injections Define arterial and venous bypass injections individually.individually.

• For right and left heart catheterizations, the For right and left heart catheterizations, the patients usually have a diagnosis of COPD, patients usually have a diagnosis of COPD, CHF, Valve stenosis. In some cases they CHF, Valve stenosis. In some cases they complete RT cath because the left coronary complete RT cath because the left coronary artery does not come off in the normal artery does not come off in the normal fashion and is closer to the right. They need fashion and is closer to the right. They need to do a right heart cath in order assess the to do a right heart cath in order assess the pulmonary artery which is in between.pulmonary artery which is in between.

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Cardiac CathsCardiac Caths• An IVUS (intravascular ultrasound) is an An IVUS (intravascular ultrasound) is an

ultrasound catheter, which they are using ultrasound catheter, which they are using more and more. It saves the patient from being more and more. It saves the patient from being exposed to more dye.exposed to more dye.• 92978 IVUS 92978 IVUS APC 670 $1,877.71APC 670 $1,877.71

  • If the iliacs are injected to see if the closure If the iliacs are injected to see if the closure

device (angio seal or plugs) can be inserted, it device (angio seal or plugs) can be inserted, it is not coded separately.is not coded separately.

• AngioSeal, Perclose, etc used to close access AngioSeal, Perclose, etc used to close access assigned assigned G0269G0269 packaged APC 19900 packaged APC 19900

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IR G CodesIR G Codes

See PM A-02-129See PM A-02-129 G0275 Renal artery angiography with G0275 Renal artery angiography with

Cardiac Cath (non selective, drive by only)Cardiac Cath (non selective, drive by only) G0278 Iliac artery angiography with G0278 Iliac artery angiography with

Cardiac Cath (non selective, drive by only)Cardiac Cath (non selective, drive by only) Both include cath insertion, dye, S&I. APC Both include cath insertion, dye, S&I. APC

19900 Packaged19900 Packaged Effective January 1, 2003 for hospitalsEffective January 1, 2003 for hospitals If diagnostic selective, use 3634X and S&IIf diagnostic selective, use 3634X and S&I

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Thank You!Thank You!