Cracking the IR Code: Tips for Mastering

10/20/2021

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RadRx “YourPrescriptionforAccurateCoding&Reimbursement”


Cracking the IR Code: Tips for Mastering Lower Extremity Interventions

Presented by

Stacie L. Buck, RHIA, CCS‐P, RCC, RCCIR, CIRCC

President & Senior Consultant

RadRx


Speaker Stacie L. Buck, RHIA, CCS‐P, RCC, RCCIR, CIRCC

• Stacie L. Buck, RHIA, CCS‐P, RCC, RCCIR, CIRCC is President & Senior Consultant at RadRx in Stuart, FL. Stacie is a nationally sought out speaker who provides consulting services to providers of diagnostic and interventional radiology services. She is the author of the bookCracking the IR Code: Your Comprehensive Guide to Mastering Interventional Radiology Coding and creator of Mastering Interventional Radiology & Cardiology Online Education Program. Stacie has 29 years experience in healthcare, 21 of which she has spent working in radiology. She is a nationally sought out speaker who has presented well over 200 coding seminars.

ContactEmail: [email protected]

Website: www.radrx.com

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Disclaimer

• Every effort has been made to provide accurate and up‐to‐date information; however, the presenter is not responsible in any way for any form of information provided that may be in error, or outdated, or have any other adverse effect. Furthermore, individual private payer guidelines and individual MAC policy may differ from what is suggested in this presentation. The content contained herein, is based on official coding guidelines, advice published by ACR, and CMS National Policies. All attendees are strongly encouraged to verify that the information presented is accurate and correct. Additionally, all attendees are responsible for verifying the specific payer guidelines for their payers.

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DIAGNOSTIC ANGIOGRAPHY & THERAPEUTIC INTERVENTIONS

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Therapeutic Interventions & Diagnostic Angiography

• Diagnostic angiography codes should NOT be used to report services already captured through the reporting of a therapeutic transcatheter RS&I code, including:– contrast injections, angiography/venography and fluoroscopic

guidance

– vessel measurement

– roadmapping

– completion angiography/venography (except in those circumstances when code 75898 is applicable)

– Post‐angioplasty/stent angiography ‐ this work is captured in the interventional radiologic supervision and interpretation code(s)

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• Diagnostic angiography performed at the time of an interventional procedure is separately reportable if:

– No prior catheter‐based angiographic study* is available and a full diagnostic study is performed, and the decision to intervene is based on the diagnostic study, OR…


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• Diagnostic angiography performed at the time of an interventional procedure is separately reportable if:– A prior study is available, but as documented in the medical

record:

• The patient's condition with respect to the clinical indication has changed since the prior study, OR

• There is inadequate visualization of the anatomy and/or pathology, OR

• There is a clinical change during the procedure that requires new evaluation outside the target area of intervention




• Diagnostic angiography performed at the time of an interventional procedure is separately reportable if:

– Diagnostic angiography performed at a separate setting from an interventional procedure is separately reported.

– Diagnostic angiography performed at the time of an interventional procedure is NOT separately reportable if it is specifically included in the interventional code descriptor.


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Diagnostic Angiography with Therapeutic Interventions

• NCCI Chapter 5, D.13 & Chapter 9, D.4

– A diagnostic angiogram/venogram may be separately reportable with modifier 59 if it satisfies "CPT Manual" guidelines, national Medicare guidelines, and local Medicare Administrative Contractor guidelines.

– If the code descriptor for a vascular procedure specifically includes diagnostic angiography, the provider shall not separately report a diagnostic angiography code.

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• NCCI Chapter 5, D.13 & Chapter 9, D.4– A second diagnostic angiogram may not be reported unless medically reasonable and necessary to repeat the study to further define the anatomy and pathology.

– Prior fluoroscopic OR computed tomographic imaging


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• NCCI Chapter 5, D.13 & Chapter 9, D.4– Report the repeat angiogram with modifier 59 or XU. If it is medically reasonable and necessary to repeat only a portion of the diagnostic angiogram, append modifier 52 in addition to modifier 59 or XU to the angiogram CPT code.

– The provider shall not report a second angiogram for the dye injections necessary to perform the open or percutaneous intravascular interventional procedure.



Documentation Examples

• “Diagnostic abdominal aortogram with iliac angiogram with possible intervention and bilateral lower extremity angiogram are planned to confirm presence of hemodynamically significant stenosis and to further define anatomical location and morphology of iliac stenosis, as well as to evaluate for additional inflow or outflow disease.”

• “Recent CTA (no images available, only written report) shows right common iliac stenosis. Diagnostic abdominal aortogram with iliac angiogram with possible intervention and right lower extremity angiogram are planned to confirm presence of hemodynamically significant stenosis and to further define anatomical location and morphology of iliac stenosis, as well as to evaluate for additional inflow or outflow disease.”


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Source: Buck, Stacie L. Cracking the IR Code: Your Comprehensive Guide to Mastering Interventional Radiology Coding. RadRx, 2021 ed.



ANGIOPLASTY

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Arterial Angioplasty 37246 & +37247• 37246 Transluminal balloon angioplasty (except lower

extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), open or percutaneous, including all imaging and radiological supervision necessary to perform the angioplasty within the same artery; initial artery

• +37247 Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), open or percutaneous, including all imaging and radiological supervision necessary to perform the angioplasty within the same artery; each additional artery (List separately in addition to code for primary procedure)



Arterial Angioplasty37246 & +37247

• Assigned for angioplasty of upper extremity, visceral, and renal arteries; lower extremity used for clinical indications other than occlusive disease

• Angioplasty codes are assigned one time per vessel/lesion treated

– Multiple dilations of the same vessel

– Multiple lesions in the same vessel

– Bridging lesions


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Arterial Angioplasty37246 & +37247

• Code 37246 is reported for the initial vessel treated, +37247 reported for each additional vessel treated. – RS&I is bundled, there are no corresponding RS&I codes.

• Angioplasty is bundled with stent placement when performed in the same vessel unless angioplasty is performed in a separate and distinct vessel.

• Codes 37246 & +37247 bundled with 37220‐37235 when performed in the same vessel.



Angioplasty 37246 & +37247: Components Reported Separately• Catheterization Codes (36140, 36200, 36245‐36248, 36215‐36218)

• Diagnostic Angiography when criteria is met

• Ultrasound guidance for vascular access (+76937)

• Closure of arteriotomy (G0269 ‐ facility)

• Intravascular Ultrasound (+37252, +37253)

• Moderate Sedation (99151‐99157)

• Other Therapeutic Interventions


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STENT


Arterial Stent 37236 & +37237

• 37236 Transcatheter placement of an intravascular stent(s) (except lower extremity artery(ies) for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; initial artery

• +37237 Transcatheter placement of an intravascular stent(s) (except lower extremity artery(ies) for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; each additional artery (List separately in addition to code for primary procedure)


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• Assigned for arterial stent placement, EXCEPT for lower extremity arteries for occlusive disease, cervical carotids, extracranial vertebral, intrathoracic carotid, intracranial or coronary – In lower extremity, treatment of pseudoaneurysm, aneurysm

• Stent codes are assigned one time per vessel/lesion treated – Multiple stents (overlapping) same vessel

– Multiple lesions in the same vessel

– Bridging lesions




• Code 37236 is reported for the initial vessel treated, +37237 reported for each additional vessel treated.

– RS&I is bundled, there are no corresponding RS&I codes

• Angioplasty is bundled with stent placement when performed in the same vessel unless angioplasty is performed in a separate and distinct vessel

– Codes 37236 & +37237 bundled with 37220‐37235 when performed in the same vessel.

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Stent 37236 & +37237: Components Reported Separately• Catheterization Codes (36140, 36200, 36245‐36248, 36215‐36218)






– Angioplasty in separate and distinct vessel



LOWER EXTREMITY REVASCULARIZATION: PTA, STENT, ATHERECTOMY

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Lower Extremity Revascularization 37220‐37235• Assigned for angioplasty, stent and atherectomy of lower extremity arteries for treatment of occlusive disease – Lower extremity revascularization codes are broken down into three distinct vascular territories for coding purposes:

• Iliac: common iliac, internal iliac and external iliac

• Femoral/popliteal: common femoral, superficial femoral, deep femoral and popliteal

• Tibial/peroneal: anterior tibial, posterior tibial, peroneal and tibioperoneal trunk



Lower Extremity Revascularization 37220‐37235• Codes are reported one time per vessel treated with the exception of the femoral/popliteal territory.

• Codes are unilateral, therefore a primary code is reported for each side.


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Bundled Components: 37220‐37235• Access to vessel

• Catheterization codes for the vascular territory for which therapeutic intervention is being performed

• Traversing the lesion

• Radiological supervision & interpretation

• Guidance

• Embolic protection

• Completion angiography

• Closure of arteriotomy



Components Reported Separately: 37220‐37235







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Lower Extremity Interventions: Potential Coding Errors

• Not choosing the correct therapeutic code– 37220 – 37235 vs. 37236 ‐37239 for clinical indication

• Unbundling– 36245 ‐36248 w/ 37220 ‐37235

– Unbundling +37186 w/ 37220 ‐37235

• Not coding per vessel/per territory – Bridging lesions

– Multiple interventions in same vessel/territory



Lower Extremity Interventions:Choosing the Correct Codes

• Angioplasty & Stent

– 37220 – 37235

• Occlusive disease

• Catheter placement bundled

– 37236 – 37237

• Non‐occlusive disease

• Catheter placement not bundled


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Lower Extremity Revascularization: Choosing the Correct Code(s)• Determine the following for each vascular territory:

– Each vessel treated– Intervention(s) performed in each vessel– Most extensive procedure performed

• Determines the primary CPT® code for each territory

• The Society for Interventional Radiology (SIR) has established the following hierarchy to determine the most extensive procedure.– Angioplasty– Stent– Atherectomy– Stent with Atherectomy



Lower Extremity Revascularization: Iliac Territory• 37220 Revascularization, endovascular, open or percutaneous,

iliac artery, unilateral, initial vessel; with transluminal angioplasty

• 37221 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within same vessel, when performed.

• +37222 Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral Iliac vessel; with transluminal angioplasty (List separately in addition to code for primary procedure).

• +37223 Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure).


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Lower Extremity Revascularization: Iliac Territory

• Each artery is considered a separate vessel for coding purposes

– Common iliac

– Internal iliac

– External iliac



Lower Extremity Revascularization: Iliac Territory

• Up to 3 codes may be reported for this territory– 1 primary

– Up to 2 add‐on codes

• Atherectomy of the iliacs is not included in this code range– Report iliac atherectomy with 0238T in addition to lower extremity revascularization codes


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Atherectomy 0234T – 0238T

• 0234T Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; renal artery, each vessel

• 0235T Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; visceral artery, each vessel

• 0236T Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; aorta

• 0237T Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; brachiocephalic trunk and branches, each vessel

• 0238T Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; iliac artery, each vessel



Atherectomy 0238T

• Assigned for atherectomy of the iliac arteries

• Atherectomy of other lower extremity arteries is reported with 37225, 37227, 37229, 37231, 37233, 37235

• Code 0238T is reported for each vessel treated

– RS&I is bundled, there are no corresponding RS&I codes


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Components Reported Separately: Atherectomy 0238T

• Catheterization Codes

• Diagnostic Angiography when criteria met


• Closure of arteriotomy (G0269 ‐ facility)






Atherectomy: NCCI Manual Chapter 5, D.27• Thrombectomy of thrombus in the vascular territory of a diseased artery is inherent in the work for an atherectomy procedure. CPT code 37186 (Secondary percutaneous transluminal thrombectomy) shall not be reported for removal of such thrombus. For example, if a physician performs a lower extremity endovascular revascularization atherectomy, removal of any thrombus from the vascular territory of the vessel treated with atherectomy is not separately reportable.


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Coding Scenario #1

• Access is gained at the right common femoral artery and the catheter is advanced over the aortic bifurcation into the left common iliac artery for diagnostic imaging. Atherectomy is performed of the left external iliac artery. Clinical indication is occlusive disease.– Atherectomy code: 0238T

– Catheterization code: 36246

– Diagnostic imaging code: 75710(59)LT



Coding Scenario #2

• Access is gained at the right common femoral artery and the catheter is advanced into the abdominal aorta for an aortogram and bilateral runoff. Following diagnostic imaging, angioplasty of the left common iliac is performed, followed by atherectomy of the left external iliac artery. Clinical indication is occlusive disease.

– Atherectomy code: 0238T(LT)

– Revascularization code: 37220(LT)

– Catheterization code: Bundled

– Diagnostic imaging code: 75630(59)


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Coding Scenario #3

• Access is gained at the right common femoral artery and the catheter is placed at the origin of the left common iliac for diagnostic imaging of the left lower extremity. Following diagnostic imaging, angioplasty of the two separate lesions is performed – one in the left common iliac and another in the left external iliac. Following angioplasty, a stent is placed in the left external iliac artery. Clinical indication is occlusive disease.

– Revascularization codes: 37221, 37222

– Catheterization codes: Bundled

– Diagnostic imaging codes: 75710(59)LT



Coding Scenario #4

• Access is gained at both the right common femoral and left common femoral arteries. Catheter is placed into the aorta for an aortogram with runoff. A stenosis bridging the common iliac arteries and the aorta is noted. Kissing angioplasty and stent placement are performed. – Revascularization codes: 37221‐50


– Diagnostic imaging codes: 75630(59)


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Coding Scenario #5

• Access is gained at the left limb of an aorto‐bifemoral bypass graft. A stent is placed in both the right and left limbs of the bypass graft. Clinical indication is occlusive disease.– Revascularization codes: 37221(RT), 37221(LT)




Lower Extremity Revascularization: Femoral/Popliteal Territory• 37224 Revascularization, endovascular, open or percutaneous,

femoral/popliteal artery(s) unilateral; with transluminal angioplasty• 37225 Revascularization, endovascular, open or percutaneous,

femoral/popliteal artery(s) unilateral; with atherectomy, includes angioplasty within the same vessel, when performed

• 37226 Revascularization, endovascular, open or percutaneous, femoral/popliteal artery(s) unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed

• 37227 Revascularization, endovascular, open or percutaneous, femoral/popliteal artery(s) unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed


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Lower Extremity Revascularization: Femoral/Popliteal Territory

• Entire territory is designated as one vessel for coding purposes:

– Common femoral

– Superficial femoral

– Deep femoral

– Popliteal

• Only 1 code (most extensive procedure) will be reported for interventions in this territory



Coding Scenario #6

• Access is gained at the right common femoral artery and the catheter is advanced over the aortic bifurcation into the left common femoral artery for diagnostic imaging. An pseudoaneurysm is noted in the left superficial femoral artery. A stent is placed to treat the pseudoaneurysm.– Stent codes: 37236

– Catheterization codes: 36247



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Coding Scenario #7

• Access is gained at the left common femoral artery and the catheter is advanced into the right common femoral artery for diagnostic imaging. Following diagnostic imaging, angioplasty of the popliteal, followed by angioplasty and stent placement in the superficial femoral is performed. Clinical indication is occlusive disease. – Revascularization codes: 37226(RT)


– Diagnostic imaging codes: 75710(59)RT



Coding Scenario #8

• Access is gained at the left common femoral artery and the catheter is advanced to the aortic bifurcation for bilateral runoff. Following diagnostic imaging, angioplasty and stent placement in the right superficial femoral artery were performed for occlusive disease. Angioplasty is then performed of the left superficial femoral artery. Clinical indication is occlusive disease. – Revascularization codes: 37226(RT), 37224(59)LT


– Diagnostic imaging codes: 75716(59)


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Coding Scenario #9

• Access is gained at the right common femoral artery and the catheter is advanced into the left common femoral for angioplasty of the femoral‐peroneal bypass graft. Following angioplasty, a stent is placed in the bypass graft. Clinical indication is occlusive disease.– Revascularization codes: 37226(LT)




Lower Extremity Revascularization: Tibial/Peroneal Territory• 37228 Revascularization, endovascular, open or percutaneous,

tibial/ peroneal artery, unilateral, initial vessel; with transluminal angioplasty

• 37229 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the same vessel, when performed

• 37230 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed

• 37231 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, initial vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed


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Lower Extremity Revascularization: Tibial/Peroneal Territory• +37232 Revascularization, endovascular, open or percutaneous,

tibial/peroneal artery, unilateral, each additional vessel; with transluminal angioplasty

• +37233 Revascularization, endovascular, open or percutaneous, tibial/ peroneal artery, unilateral, each additional vessel; with atherectomy, includes angioplasty within the same vessel, when performed

• +37234 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed

• +37235 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed



Lower Extremity Revascularization: Tibial/Peroneal Territory

• Each artery is considered a separate vessel for coding purposes

– Anterior tibial

– Posterior tibial

– Peroneal

– Tibiperoneal trunk (part of posterior tibial or peroneal)


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Lower Extremity Revascularization: Tibial/Peroneal Territory

• Up to 3 codes may be reported for this territory– 1 primary

– Up to 2 add‐on codes

– When revascularization of TP trunk is performed with either posterior tibial or peroneal revascularization, the TP trunk is considered part of those vessels and should not be coded separately.

– When revascularization is performed in the anterior tibial and TP trunk only, each are considered separate vessels



Coding Scenario #10

• Access is gained at the right common femoral artery and the catheter is advanced into the left common femoral for diagnostic imaging. Following diagnostic imaging, angioplasty is performed of the left anterior tibial and posterior tibial. A stent is also placed in the left posterior tibial artery. Clinical indication is occlusive disease.– Revascularization codes: 37230(LT), 37232(LT)




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Coding Scenario #11

• Access is gained at the right common femoral artery and the catheter is advanced into the left common femoral for diagnostic imaging. Following diagnostic imaging, angioplasty is performed of the left anterior tibial, posterior tibial and TP trunk. A stent is also placed in the left posterior tibial artery. Clinical indication is occlusive disease. – Revascularization codes: 37230(LT), 37232(LT)





Lower Extremity Revascularization: Multiple Lesions/Bridging Lesions

• Multiple lesions in same vessel

– Codes are reported per vessel, not per lesion.

– Bridging lesion same territory

– Treated with a single therapy, reported once with a single code.

• Example: Stenosis extends from the common iliac artery into the proximal external iliac artery, and a single stent is placed to open the entire lesion, the procedure is coded as a single stent placement in the iliac artery.


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Lower Extremity Revascularization: Multiple Lesions/Bridging Lesions• Bridging lesion two territories

– Code selection based on the size of the lesion in each vessel and the vessel that has the most disease.

• Example: PTA of a lesion spanning the popliteal through to the tibioperoneal trunk is performed, and the majority of the lesion is in the popliteal, the appropriate code to assign is for a PTA of the femoral/popliteal territory.

• Example: When a single stent is placed to treat a single lesion across two territories, only one procedure code may be reported and is determined based on whether the proximal or distal end of the area treated has the most disease.



Exceptions to Bundling of Catheterization Codes

• Diagnostic angiography performed at the same time as the intervention requires a higher degree of selectivity than the one used for the lower extremity intervention. – Example: Contralateral extremity angiography in conjunction with a revascularization procedure. (Access at RT Common Femoral, revascularization of RT Internal Iliac, catheterization and imaging of LT leg.)


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Exceptions to Bundling of Catheterization Codes

• Diagnostic angiography for the revascularization is performed at the same time as revascularization from a separate access

– Example: Catheterization of the aorta for an aortogram may be performed via a left groin puncture, yet the revascularization is performed on the right iliac via a right groin puncture.



Exceptions to Bundling of Catheterization Codes• Another catheterization is performed through the same access for another diagnostic or therapeutic procedure requiring catheterization in a different vascular bed.– Example: Performing a renal PTA in conjunction with a revascularization

• A separate vessel punctured for an additional access that is not part of the revascularization procedure and another vessel is selectively catheterized for another purpose.

• Another procedure is performed on the same date of service at a different session.


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Coding Scenario #12

• Access is gained at the left common femoral artery and the catheter is placed into the suprarenal aorta for an abdominal aortogram and pelvic run off. Next the catheter is placed into the right common femoral for diagnostic imaging of the right lower extremity. Angioplasty is performed at the left common iliac. Clinical indication is occlusive disease.– Revascularization codes: 37220(LT)

– Catheterization codes: 36246(59)

– Diagnostic imaging codes: 75625, 75710(59)RT



Coding Scenario #13

• Access is gained at the left common femoral artery and the catheter is placed into the suprarenal aorta for an abdominal aortogram. The catheter is then pulled down to the aortic bifurcation for bilateral extremity imaging. Following diagnostic imaging, access is gained at the right common femoral for angioplasty of the right common iliac. Clinical indication is occlusive disease. – Revascularization codes: 37220(RT)

– Catheterization codes: 36200(59)

– Diagnostic imaging codes: 75716(59), 75625


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References

• Cracking the IR Code: Your Comprehensive Guide to Mastering Interventional Radiology Coding, 2021 Edition by Stacie L. Buck

• 2021 CPT Professional Edition

• NCCI Policy Manual


Connect & Contact

• Facebook Discussion Groups– Diagnostic Radiology:

• https://www.facebook.com/groups/RadRxDxRad/

– Interventional Radiology: • https://www.facebook.com/groups/RadRxIVR/

• Connect with Stacie on LinkedIn!

• Email: [email protected]

• Website: www.radrx.com– Sign up for SMS Messages (Flash Sales)

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Cracking the IR Code: Tips for Mastering