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2019 Coding Updates for Interventional Radiology and Cardiology

Presented by:

David Zielske, MD

CIRCC, COC, CCVTC, CCC, CCS, RCC

CPT Coding for 2019

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§ FNA-Biopsy§ New and revised PICC lines procedures § G-tube replacements w or w/o gastrostomy tract revision§ Tract dilation for endourologic intervention§ Percutaneous creation of AV fistula for dialysis§ Knee arthrography injection§ Endovenous arterial revascularization of fem/pop artery§ Balloon assisted lower extremity varicose vein treatment§ Intraosseous basivertebral nerve destruction§ Iliac AV fistula creation (effective 7/1/2019)

2019 IR Coding Changes Overview

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§ Pulmonary Wireless Pressure Sensor placement (also called an Implantable Hemodynamic Monitor) and remote monitoring

§ Subcutaneous Cardiac Rhythm Monitor (SCRM) procedures§ Cardiac Ischemic Monitoring System (AngelMed) procedures§ Leadless Pacemaker procedures§ Leadless LVL for resynchronization therapy procedures§ FFR with 3D functional mapping§ Mitral and Tricuspid Valve Repairs (effective 7/1/2019)§ TAVR NCD update

2019 Cardiology Coding Overview

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Percutaneous Image-Guided

BiopsiesFNA BX and Core BX

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10021 FNA biopsy, initial lesion, without imaging guidance10004 FNA biopsy, each additional lesion, without imaging guidance10005 FNA biopsy, initial lesion, including US guidance10006 FNA biopsy, each additional lesion, including US guidance10007 FNA biopsy, initial lesion, including fluoroscopic guidance10008 FNA biopsy, each additional lesion, including fluoroscopic guidance10009 FNA biopsy, initial lesion, including CT guidance10010 FNA biopsy, each additional lesion, including CT guidance10011 FNA biopsy, initial lesion, including MRI guidance10012 FNA biopsy, each additional lesion, including MRI guidance

Fine Needle Aspiration “Biopsy” 2019

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§ 10022 is deleted§ Added word “Biopsy” to FNA. Bundles imaging guidance.§ Dependent on pathologic evaluation by Cytology (not Histology).– For FNA Biopsy, do not report imaging guidance codes as

bundled– For FNA without Biopsy, report puncture aspiration code 10160

along with imaging guidance (76942, 77002, 77012, 77021) – For intervertebral disc/paravertebral soft tissue FNA, report 62267

Fine Needle Aspiration “Biopsy” 2019

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§ 10160– Needle (or non-indwelling catheter) drainage of fluid

collection for therapeutic or diagnostic purposes (change in FNA Biopsy code descriptions in 2019)

– Guidance is additionally reported as appropriate• 76942 (US), 77002 (fluoroscopy), 77012 (CT), 77021 (MR) • Do not report code 75989

Puncture/Aspiration without Indwelling Catheter

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§ FNA biopsy codes are based on imaging guidance (none, US, Fluoro, CT, MR)§ FNA biopsy specimen are evaluated with cytology§ Core biopsy specimen are evaluated with histology

§ If FNA and Core biopsies are performed of the same lesion, same imaging guidance, same session, do NOT report imaging guidance for core bx

§ If FNA and Core biopsies are performed of the same lesion, different imaging guidance, same session, do report separate imaging guidance for core bx

§ If FNA and Core biopsies are performed of the different lesions, same imaging guidance, same session, do report separate imaging guidance for core bx

§ If FNA and Core biopsies are performed of the different lesions, different imaging guidance, same session, do report separate imaging guidance for core bx

Fine Needle Aspiration “Biopsy” 2019: CPT Rules

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§ Per CPT: If both FNA biopsy and a Core biopsy are performed of the same lesion, report both FNA biopsy and Core biopsy and use rules on prior page for imaging guidance

HOWEVER

Fine Needle Aspiration “Biopsy” 2019: CPT Rules

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§ Per CMS: If both FNA biopsy and a Core biopsy are performed, DO NOT report both the FNA biopsy and the Core biopsy, even if suboptimal FNA biopsy requires Core biopsy of the same lesion.

§ NCCI Provider Policy Manual 25.0 specifically states do NOT report both FNA BX and Core BX at same session of same lesion. Zhealth follows CMS guidelines and do NOT recommend reporting per CPT rules in this case. We recommend reporting the more comprehensive core biopsy code with imaging guidance. Hopefully, CMS and AMA can address this mismatch.

Fine Needle Aspiration “Biopsy” 2019: CMS Rules

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§ Imaging guidance: 76942, 77002, 77012, 77021 for US, Fluoro, CT, MR

§ Non-Imaging guidance: Radar, Magnetic, Electromechanical (ECG) signals for guided tracking or localization systems (Sherlock). Use of these devices is considered part of the procedure it is used for and is NOT considered imaging.

Imaging vs Non-Imaging Guidance

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– 36568 – PICC without port or pump, under 5, without imaging– 36569 – PICC without port or pump, age 5+, without imaging– 36572 – PICC, under age 5, bundles imaging guidance– 36573 – PICC , age 5+, bundles imaging guidance– 36584 – PICC, replacement via same access site, bundles

imaging guidance

Peripheral Insertion Central Catheter (PICC)

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• Do NOT report imaging guidance codes with PICC line procedures.• Do NOT report 76937 or 77001 with PICC line procedures. • Sherlock 3CG Tip Confirmation System is NOT imaging guidance (often

used by “PICC line teams”). Magnetic tracking and ECG based.• PICC replacement w/o imaging guidance is reported with code 37799• A midline catheter is described as a catheter that does not reach the

central veins. Central veins are the subclavian and brachiocephalic veins and the superior vena cava. Consider code 36410.

• If PICC line doesn’t reach central veins it is a midline. US guidance 76937 may be reported with 36410 if documented appropriately

Peripheral Insertion Central Catheter (PICC)

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§ 43760 deleted in 2019§ 43762 – Replacement of gastrostomy tube without

imaging or endoscopic guidance, without revision of the tract. Includes routine balloon dilation or use of dilators to enlarge the tract

§ 43763 – Replacement of gastrostomy tube withoutimaging or endoscopic guidance, with revision of the tract. Revision refers to surgical incision or debridement.

§ KUB is separately reported if done

GI Tube Replacements

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Large Renal Calculus

Antegrade Pyelogramwith Needle

Balloon Dilation for Creation of Tract Through Kidney

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§ Code 50395 is deleted and 74485 is NOT used with tract dilation in 2019§ Report 50432 or 50433 when an access and drainage catheter are

placed at a session prior to tract dilation for endourologic intervention§ Report 53899 if a “wire only” is placed for access at separate session§ Code 50436 describes dilation of a pre-existing tract between the skin

and kidney with a large (8-10 mm) balloon or sequential 12-30Fr dilators. This includes placing a post-procedure drainage catheter

§ Code 50437 includes access and dilation of a new tract between the skin and kidney with a large (8-10 mm) balloon on the same DOS. This includes placing a post-procedure drainage catheter

§ Do not report 50432 or 50433 with codes 50436 or 50437

Dilation of Percutaneous Tract for Endourologic Stone Extraction

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§ Ellipsys Vascular Access System creates an anastomosis between an artery and a vein after an initial venous access. The specialty catheter applies RF energy to fuse the artery to the vein. Only requires a transvenous access so bandaid at end of procedure.

§ WavelinQ Vascular Access System utilizes arterial and venous catheters with magnets to guide the catheters for AV fistula creation. RF energy is applied to create the fistula. Arterial access needs pressure device.

§ Ellipsys and WavelinQ devices were both FDA approved June 26, 2018§ BD (Becton, Dickinson and Company) acquired BARD, which acquired

WavelinQ (previously called everlinQ) now FDA approved 4FR system

Percutaneous Dialysis Fistula Creation

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Dialysis Fistula Creation: Ellipsys Procedure

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Dialysis Fistula Creation: WavelinQ Procedure

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§ C9754: Creation of AV fistula, percutaneous, direct, any site, includes imaging guidance and all procedures to redirect blood flow (e.g., embolization of branches, venoplasty)

§ C9755: Creation of AV fistula, using magnetic guided arterial and venous catheters with RF energy, includes any procedure to redirect blood flow (e.g., embolization of branches, venoplasty)

§ Involves creation of a dialysis fistula using percutaneous techniques§ HCPCS II codes can be reported effective January 1, 2019.§ Initial 2019 CMS payment is $4,056 for ASC and $9,669 for Hospital OPPS§ If MD performs in hospital setting, report 37799 for physician billing.

Percutaneous Dialysis Fistula Creation

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§ 27369, 73580 – Knee injection for MRI,CT, or contrast arthrogram

§ 27370 was deleted and replaced with 27369 due to misuse of the code (reported ¼ of the 150,000 times billed to CMS by Family Practice Physicians who don’t perform arthrography!)

Conventional Arthrography

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• 0505T: Endovenous “extraluminal” arterial revascularization of femoral/popliteal artery with endograft (effective 7/1/2018) • Bundles percutaneous or open accesses (requires both

antegrade femoral arterial and retrograde pedal venous accesses), access closure, catheter placements, radiologic supervision and interpretation, US guidance, balloon dilation, other revascularization techniques with eventual endograft(s) placement(s).

• IVUS may be separately reported

Femoral/Popliteal “Endovenous” Revascularization

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§ 0524T – Endovenous catheter directed chemical ablation with balloon isolation of incompetent extremity vein, open or percutaneous– Includes open or percutaneous vascular access, diagnostic

imaging, imaging guidance and monitoring during the procedure – Done with NTNT local anesthesia– Catheter with a distal occlusion balloon placed with the balloon

inflated near the saphenofemoral junction for treatment of truncal veins. The sclerosing agent or chemical is administered through sideports of the catheter while the balloon prevents the chemical from reaching the normal veins

Chemical Ablation of Incompetent Leg Veins with Balloon Occlusion

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§ C9752 – Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance, lumbar/sacral

§ C9753– each additional

Intraosseous Basivertebral Nerve Destruction

The Basivertebral Nerve has been shown to innervate endplate nociceptors which are thought to be a source of chronic low back pain. Relievant’s “Intracept System”

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Pulmonary Artery Wireless Pressure Sensor Implantation

• 33289 Transcatheter implantation of a pulmonary artery wireless pressure sensor. This bundles associated pulmonary angiography, pressure measurements, RHC, placement of the device and calibration of the sensor (see 93264 for remote monitoring).

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• 33285 Placement (including programming)• 33286 Removal • Remove and replace same pocket: use 33285• Remove from one pocket and place in separate pocket:

33285 & 33286• Reveal is a small SCRM (loop recorder). Use 33285.• Linq is a really small (injectable) SCRM. Use 33285. • 33282 and 33284 are deleted in 2019

Subcutaneous Cardiac Rhythm Monitor (Loop Recorder) Procedures

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Interventional Cardiology: FFR • Intravascular Doppler/Pressure (FFR, CFR, Wavewire) and

Instantaneous wave-free ratio (Instant Flow Reserve), iFR• +93571 Initial vessel (once per heart)• +93572 Each additional vessel (up to 4)• Recommend -52 modifier for iFR at this time as no adenosine• FFR <=to .80 or iFR<=to .90 is considered a significant stenosis

• 0501T-0504T FFR CT • +0523T FFR with 3D functional mapping of color-coded FFR

values for the coronary tree derived from coronary angiogram data for real-time review and interpretation during intervention

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Interventional Cardiology: FFR

• +0523T Utilizes concurrent coronary angiograms in two projections to create a 3D color map of FFR values

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Interventional Cardiology: FFR

• +0523T is reported once per session, as all vessels in the coronary tree are evaluated with this procedure

• +0523T is and add on code with 93454-93461• Do NOT report 93571 or 93572, 0501T-0504T, or

76376-73677

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• Micra by Medtronic is first FDA approved leadless pacemaker (2016)• Nanostim by St. Jude’s Medical remains an Investigational device • Do not report heart catheterization, right sided chamber injection,

extremity venography, venous US, or interrogation and programming of the device

• 33274 Transcatheter insertion or replacement of permanent leadless pacemaker in the right ventricle

• 33275 Transcatheter removal of permanent leadless pacemaker from RV• Codes 0387T-0391T deleted in 2019

Leadless Pacemaker (“Micra”)

Wireless Cardiac Stimulator for LV

Pacing

The WiSE™ CRT System (by ebr

Systems)

Wireless Cardiac Stimulator for LV Pacing• 0515T: Insertion complete system

• 0516T: Insertion electrode only

• 0517T: Insertion pulse generator component(s) (battery and/or transmitter) only

• 0518T: Removal of pulse generator components (battery and/or transmitter) only

• 0519T: Removal and replacement of pulse generator components (battery and/or transmitter)

• 0520T: Removal and replacement of pulse generator components (battery and/or transmitter) including placement of a new electrode

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Wireless Cardiac Stimulator for LV Pacing• 0521T: Interrogation device evaluation (in person) with

analysis, review, and report, includes connection, recording, and disconnection per patient encounter

• 0522T: Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report

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AngelMed Guardian System

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1/1/2013-12/31/2017: Category III codes 0302T-0306T1/1/2018-9/30/2018: No code 10/1/2018-12/31/2018: HCPCS C9750 payment of $9,747.991/1/2019: Category III codes 0525T-0532T

AngelMed Guardian SystemIntracardiac Ischemia Monitoring System

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0525T: Insertion or replacement of complete system0526T: Insertion or replacement of electrode only0527T: Insertion or replacement of implantable monitor only0528T: Programming device evaluation (in person) with iterative

adjustment of values, with analysis, review and report0529T: Interrogation device evaluation (in person) with analysis,

review, and report0530T: Removal of complete system0531T: Removal of electrode only0532T: Removal of implantable monitor only

AngelMed Guardian System: Intracardiac Ischemia Monitoring System

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• Do NOT report 76937 with diagnostic cardiac catheterization procedures, coronary and cardiac interventions, electrophysiology procedures and pacemaker/ICD procedures per NCCI Provider Policy Manual 25.0

• Closure device angiography and device placement are bundled with all cardiac catheterization procedures. Do NOT bill closure device placement code G0269, or imaging codes 75710, 75736, 75774, G0278 when the intent of the access site imaging is to evaluate for possible closure device placement

Ultrasound Guidance 76937 Bundling• Do not report ICE guidance code 93662, or atrial septostomy codes 92992

or 92993 when performed during TMVI. • Do not report septal closure (93580) of a large, persistent opening

created during device deployment (iatrogenic). This is included with TMVI and other transseptal procedures if performed.

• Do not report MitraClip codes 33418 or 33419 when a MitraClipprocedure is performed on a Tricuspid Valve. Report unlisted code 33999-GZ as investigational.

• Do not report 0483T for Tricuspid Valve Implantation. Report unlisted code 33999-GZ as investigational.

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Tricuspid and Mitral Valve Procedures

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§ Valvular Repair: MitraClip, MitraClipNT, Pascal§ Chordal Repair; NeoChord DS1000, Harpoon TSD-5, V-Chordal § Annular Repair: Cardioband, Carillion, Arto, Mitralign, Mitral

Loop Cerclage

2019: Types of Mitral Valve Repairs

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§ 0543T: Transapical mitral repair, including TTE, when performed, with placement of artificial chordae tendineae: Chordal Repair

§ 0544T: Transcatheter mitral valve annulus reconstruction with implantation of adjustable annulus reconstruction device: percutaneous approach including transseptalpuncture: Annular Repair

§ 0545T: Transcatheter tricuspid valve annulus reconstruction with implantation of adjustable annulus reconstruction device: percutaneous approach: Annular Repair

2019 Category III codes effective 7/1/2019

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§ 0543T: Bundles TTE (not TEE which is separately reported with 93355) guidance. Bundles transapical access.

§ 0544T-0545T: Bundles heart catheterization and coronary angiography (93451-93461, 93530-93533) related to the intervention. If for other indication, change in clinical, etc. OK

§ Separately reportable:§ TEE (93355)§ CP Bypass (33967-33969)§ IABP (33967, 33970, 33973)§ Percutaneous LVAD (33990-33993)

2019 Category III codes effective 7/1/2019• Do not report 93580 when PFO closure is performed w/o device placement. • Report unlisted code 93799 when RF ablation used to close a small PFO.

HIS Leads• HIS leads are now placed for resynchronization therapy. The lead is

placed at the Bundle of HIS above or below the tricuspid valve (in the RA or RV respectively).• Current guidance is to code the procedure to the location of the HIS

lead (e.g., if HIS lead placed below valve in the RV, code to the RV)• New codes for resynchronization via HIS lead are anticipated for 2020?

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PFO Closure with RF Alblation

• AHA states to report 33999 for placement of a dual chamber pacemaker with one of the leads being a His lead

We code to the chamber the lead is placed (33206/7/8). • AHA states to report 61635 for cerebral venous stent

AMA, CMS and NCD state for cerebral arterial only. We recommend 37238 for venous stent placement in the cerebral

veins• AHA states to report 76937 with endomyocardial biopsy code 93505. Our

concern is that since a RHC is a component of a biopsy (per OIG), and 76937 is bundled by 93451 (per CMS NCCI PPM 25.0), if a RHC and Bx are performed, it should be bundled. If Bx ONLY, then should consider 76937

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Recent (6/19) AHA Recommendations

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§ Report 37191 twice when 2 filters are placed in duplicated vena cava systems

§ Report 37191 twice when 2 filters are placed in common iliac veins (large cava)

§ Report 37799 for smashing a filter with balloons and stents when the filter is not retrievable.

§ Report 37197 for removal of cap of convertible filter (and 36010, 75825)§ The Angel Catheter is a self centering temporary device that is placed in ICU

setting usually. It is a temporary IVC filter on a CVC. No imaging is necessary. § Report 37799 for placement of an Angel Catheter§ Report 37193-52 for removal of an Angel Catheter.

Vena Cava Filter Procedure Updates

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§ 99151 – Under age 5, initial 15 minutes by MD performing intervention§ 99152 – Age 5 or older, initial 15 minutes by MD performing intervention§ 99153 – Age 5 or older, additional 15 minutes by MD performing

intervention– Billed by hospital (or by MD in non-facility setting)– MUE is 12 for hospital billing (3.25 hours total)– Based on MD face-to-face (intraservice) time, patient age (< 5 or 5 and older), and

presence of “trained independent observer”– Work with physicians on their documentation (and consistency of reporting)

Don’t forget to report codes for conscious sedation

Moderate Conscious Sedation

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§ CPT codes:– 37799 or 38999 – Fibrin Sheath-o-plasty. Do not report 36595-52 or

75901 for balloon disruption of a fibrin sheath (as previously recommended).

– Do not report venous thrombolysis (37212) when related to a dialysis circuit. The circuit includes arterial inflow to right atrium and all vessels along the way. Use 36904 for removal of thrombus by any method in the peripheral segment, central segment or in both segments. If it is necessary to place an infusion catheter, start thrombolytic infusion and continue overnight, there is NO additional code. This overnight infusion is considered part of the code set 36904-36906.

Miscellaneous

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§ CPT codes:– 37799 or 38999 – Fibrin Sheath-o-plasty. Do not report 36595-52 or

75901 for balloon disruption of a fibrin sheath (as previously recommended).

– Do not report venous thrombolysis (37212) when related to a dialysis circuit. The circuit includes arterial inflow to right atrium and all vessels along the way. Use 36904 for removal of thrombus by any method in the peripheral segment, central segment or in both segments. If it is necessary to place an infusion catheter, start thrombolytic infusion and continue overnight, there is NO additional code. This overnight infusion is considered part of the code set 36904-36906.

Miscellaneous

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§ National Coverage Determinations (NCD)– Created by CMS– Binding on all Medicare Administrative Contractors (MACs), including

Medicare+ Choice organizations– Change infrequently– Often the basis for an OIG or DOJ review

§ Local Coverage Determinations (LCD)– Created by an individual MAC– Binding on the MACs’ jurisdictions only– Change frequently (updated at least annually)– CPT and ICD-10 codes no longer listed in LCD (will refer to articles)

Coverage Determinations

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§ 20.4 – Implantable Automatic Defibrillators (DOJ audits)§ 20.8 – Pacemakers§ 20.8.4 – Leadless Pacemakers (1/2017)§ 20.7 – Carotid Stents (and Other Vessel Angioplasty/Stent) § 20.32 – Transcatheter Aortic Valve Replacement (TAVR) § 20.33 – Transcatheter Mitral Valve Repair§ 20.34 – Left Atrial Appendage Closure (implemented 10/16)§ 240.6 – Transvenous (Catheter) Pulmonary Embolectomy

Key NCDs for Cardiolgy/IR

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§ 20.4 – Implantable Automatic Defibrillators (Primary Prevention required)

§ 20.7 – Carotid Stents (and other vessels: PCI, PVI registry) § 20.32 – Transcatheter Aortic Valve Replacement (TAVR) § 20.33 – Transcatheter Mitral Valve Repair (MitraClip)§ 20.34 – Left Atrial Appendage Closure (Watchman Device)

Note: NCDR registries may be audited by DOJ.

NCDR Registry Requirements

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§ ICD: CMS Decision Memo CAG00157R4:§ ICD allowed instead of pacemaker during waiting period if qualifies

for an ICD but needs a pacemaker now§ EF can be determined by MRI (most accurate way)§ No requirement for Registry for primary prevention

§ TAVR: Only requires 1cardiothoracic surgeon and 1 interventional cardiologist (not 2 CT surgeons) to examine patient and document indicated procedure prior to the procedure. Updates to volume requirements for SAVR, TAVR, PCI for new and existing facilities.

NCD Updates

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Iliac Arterial-Venous Creation with Device

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§ 0553T: Effective 7/1/2019Percutaneous transcatheter placement of iliac arteriovenous anastomosis implant, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention

ROX Medical arteriovenous coupler. Stent-like device for creation of AV fistula. ~4mm size just above the common femoral artery and vein. May help with resistant hypertension.

Iliac Arterial-Venous Creation with Device

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