2018 CPT Code Update: Interventional & Diagnostic Radiology

11/30/2017

2018 CPT Code Update: Interventional & Diagnostic Radiology Stacie L. Buck, RHIA, CCS‐P, RCC, CIRCC, AAPC Fellow President & Senior Consultant RadRx

December 5, 2017

RadRx “Your Prescription for Accurate Coding & Reimbursement”

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

• Stacie L. Buck, RHIA, CCS‐P, RCC, CIRCC, RCC 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 book Cracking the IR Code: Your Comprehensive Guide to Mastering Interventional Radiology Coding and creator of Mastering Interventional Radiology & Cardiology Online Education Program. Stac ie has 25 years experience in healthcare, 17 of which she has spent working in radiology. She is a nationally Contact sought out speaker who has presented Email: [email protected] well over 200 coding seminars. Website: www.radrx.com RadRx “Your Prescription for Accurate Coding & Reimbursement” 2

1 11/30/2017

DIAGNOSTIC RADIOLOGY

RadRx “Your Prescription for Accurate Coding & Reimbursement”

Chest X‐Rays

• 71045 Radiologic examination chest; single view – 71010 (frontal), 71015(stereo frontal), 71035 (special views) • 71046 Radiologic examination chest; two views – 71020 (AP & Lat), 71035 (special views) • 71047 Radiologic examination chest; three views – 71021 (2 v w/ apical lordotic), 71022 (2v w/ oblique), 71035 ((pspecial views) • 71048 Radiologic examination chest; 4 or more views – 71030 (min 4 v), 71034 (min 4 v w/ fluoro), 71035 (special views) RadRx “Your Prescription for Accurate Coding & Reimbursement” Copyright 2017. RadRx all rights reserved. Unauthorized distribution is prohibited.

2 11/30/2017

Abdominal X‐Rays • 74018 Radiologic examination abdomen; 1 view – 74000 (AP) • 74019 Radiologic examination abdomen; 2 views – 74010 (AP & addl oblique/cone) • 74021 Radiologic examination abdomen; 3 or more views – 74020 (complete inc. decubitus and/or erect) RadRx “Your Prescription for Accurate Coding & Reimbursement” Copyright 2017. RadRx all rights reserved. Unauthorized distribution is prohibited.

Revised: 76881 & 76882

• 76881 Ultrasound, complete joint (ie, joint space and peri‐articular soft tissue structures) real‐time with image documentation – Old “extremity, nonvascular” • 76882 Ultrasound, limited, joint or other nonvascular extremity structure(s) (eg, joint space peri‐articular tendon[s], muscle[s], nerve[s], other soft tissue structure[s], or soft tissue mass[es]), real‐ time with image documentation – Old “extremity, nonvascular…limited, anatomic specific” RadRx “Your Prescription for Accurate Coding & Reimbursement” Copyright 2017. RadRx all rights reserved. Unauthorized distribution is prohibited.

3 11/30/2017

Revised: 76881 & 76882

• 76881 requires US exam of all of the following: – Joint space (eg, effusion) – Peri‐articular soft‐tissue structures that surround the joint (ie, muscles, tendons, other soft tissue structures), and any identifiable abnormality. – Includes dynamic imaging or stress maneuvers when performed – Permanently recorded images required with a written report containing a description of each of the element(s) or reason for non‐visualization

Revised: 76881 & 76882

• 76882 represents a limited exam of a joint or an evaluation of a structure(s) in an extremity other than a joint: – Soft tissue, fluid collection, or nerve(s) – Assessment of specific anatomic structure – Joint space only (effusion), tendon, muscle, and/or other soft tissue structure(s) that surround the joint – Permanently recorded images required with a written report containing a description of each of the element(s)

4 11/30/2017

Appropriate Use Criteria (AUC)

• Applies to “advanced” imaging: CT/MR/PET/Nuclear Medicine • Delayed until January 1, 2020 – Allow ordering physicians time to select a Clinical Decision Support Mechanism (CDSM) – Voluntary reporting currently allowed – MIPS Improvement Activity for 2018 (high weight activity) – 2020 will be a “testing” year not affecting payment of Medicare claims. • Ordering professionals will be required to consult AUC and furnishing providers will report AUC consultation information on the claim • Imaging facility and interpreting provider required to report: – Qualified CDSM consulted by the ordering physician – Whether the service ordered would adhere to specified applicable AUC – NPI of the ordering physician • Required for both the TC & PC claims for applicable advanced diagnostic imaging services in all three applicabl e payment systems (PFS, HOPPS and ASC). • Qualified CDSMs: https://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐ Assessment‐Instruments/Appropriate‐Use‐Criteria‐Program/CDSM.html

Appropriate Use Criteria (AUC)

• G codes will be created for CDSM – Line‐item on both practitioner and facility claims. – CMS would expect that one AUC consultation G‐code would be reported for every advanced diagnostic imaging service on the claim with a HCPCS modifier. • HCPCS modifiers will be appended to indicate whether the ordered exam adheres to AUC and whether any exceptions apply. – Whether the imaging service would adhere to the applicable AUC – Whether the imaging service would not adhere to the applicable AUC – Whether such criteria were not applicable to the imaging service ordered – Whether the imaging service was ordered for a patient with an emergency medical condition – Whether the ordering professional has a hardship exception.

5 11/30/2017

‐FY Modifier

• Reported on claims including codes that describe X‐ rays taken using computed radiography. – 7% reduction on payments for services between CY 2018 and CY 2022 – 10 % reduction in subsequent years • Required for the technical component, global billing. • When payment for X‐ray or computed radiography services are packaged into those for another item or service under the OPPS, there is no payment attributable to X‐ray or computed radiography, and therefore, there would be no corresponding payment reduction to either service. RadRx “Your Prescription for Accurate Coding & Reimbursement” 11 Copyright 2017. RadRx all rights reserved. Unauthorized distribution is prohibited.

‐CT Modifier

• Modifier –CT “Computed tomography services furnished using equipment that does not meet each of the attributes of the National Electrical Manufacturers Association (()NEMA) XE‐29‐2013 standard” • Beginning January 1, 2016 hospitals and suppliers were required to report the modifier ‐CT on claims for CT scans described by codes 70450‐70498, 71250‐ 71275, 72125‐72133, 72191‐72194, 73200‐73206, 73700‐73706, 74150‐74178, 74261‐74263, 75571‐75574 that are furnished on non‐NEMA Standard XR‐29‐ 2013‐compliant CT scanners. – The use of this modifier will result in the applicable payment reduction for the technical component of the CT service under MPFS and OPPS. In 2016, there was a 5% reduction and for 2017 and in subsequent years, it has increased to a 15% reduction. • The NEMA standards identify four key features of CT scanners which contribute to or help perform optimization and or management of doses of ionizing radiation while still enabling the system to ddlieliver the diagnost ic image quality needdded by the physician. • Standards at https://www.nema.org/Standards/Pages/Standard‐Attributes‐on‐CT‐ Equipment‐Related‐to‐Dose‐Optimization‐and‐Management.aspx

6 11/30/2017

‐FX Modifier

• Appended to the CPT® code when film is used instead of digitally capturing the image – Used on Medicare claims – Hospital outpatient billing and physician technical/ global billing • Technical payment will be discounted 20% for 2017 and subsequent years

NCCI POLICY MANUAL CHANGES: DIAGNOSTIC RADIOLOGY

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7 11/30/2017

Chapter 9, Section C

Revised • 15. CPT code 77063 is an add‐on code describing screening digital tomosynthesis for mammography. This procedure requires performance of a screening mammography producing direct digital images. For calendar year 2017 Medicare allowed CPT code 77063 to be reported with HCPCS code G0202, not CPT code 77067. Beginning calendar year 2018 CPT code 77063 may be reported with CPT code 77067. (HCPCS code G0202 was deleted January 1, 2018. RadRx “Your Prescription for Accurate Coding & Reimbursement” 15 Copyright 2017. RadRx all rights reserved. Unauthorized distribution is prohibited.

Chapter 9, Section E Chapter 12, Section C • 13. NCCI contains procedure to procedure (PTP) edits that bundle some radiopharmaceutical codes into nuclear medicine procedure codes. These code pairs represent radiopharmaceuticals that should not be reported with the nuclear medicine procedure since it is inappropriate to utilize that radiopharmaceutical for that procedure. In some situations where a patient has two nuclear medicine procedures performed on the same date of service, the radiopharmaceutical utilized for one procedure may be incompatible with the second nuclear medicine procedure. In this circumstance, it may be appropriate to report the radiopharmaceutical with modifier 59. RadRx “Your Prescription for Accurate Coding & Reimbursement” 16 Copyright 2017. RadRx all rights reserved. Unauthorized distribution is prohibited.

8 11/30/2017

Added Chapter 9, Section E Revised Chapter 9, Section H • 14. Tumor imaging by positron emission tomography (PET) may be reported with CPT codes 78811‐78816. If a concurrent computed tomography (CT) scan is performed for attenuation correction and anatiltomical lllitiocalization, CPT codes 78814‐78816 shhllall be reporttded rather than CPT codes 78811‐78813. A CT scan for localization shall not be reported separately with CPT codes 78811‐78816. A medically reasonable and necessary diagnostic CT scan may be separately reportable with an NCCI‐associated modifier. If the data set for the diagnostic CT is obtained concurrently on the same PET/CT integrated system where the CT portion of the study is co‐registered with the PET images for the purpose of attenuation correction and anatomic localization, the diagnostic CT CPT code may be reported with PET CPT codes 78811‐78813 utilizing an NCCI‐ associated modifier. Under these circumstances the diagnostic CT CPT code shall not be reported with PET/CT CPT codes 78814‐78816. However, if a data set for the PET/CT for attenuation correction and anatomic localization and a separate data set for the diagnostic CT are obtained on separate pieces of equipment, the diagnostic CT CPT code may be reported with CPT codes 78811‐78816 utilizing an NCCI‐associated modifier. RadRx “Your Prescription for Accurate Coding & Reimbursement” 17 Copyright 2017. RadRx all rights reserved. Unauthorized distribution is prohibited.

INTERVENTIONAL RADIOLOGY

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9 11/30/2017

Deleted: 36120, 75658

• 36120 Introduction of needle or intracatheter; retdtrograde bhilbrachial artery • 75658 Angiography, brachial, retrograde, radiological supervision and interpretation – Use 36140 and 75710, 75716 – Note: 36140 revised from “extremity artery” to “upper or lower extremity artery”

Foam Sclerotherapy Vein

• 36465 Injection of non‐compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of injectate, inclusive of all imaging guidance and monitoring; single incompetent extremity truncal vein (eg, great saphenous vein, accessory saphenous vein) • 36466 Injection of non‐compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of injectate, inclusive of all imaging guidance and monitoring; multiple incompetent extremity truncal veins (eg, great saphenous vein, accessory saphenous vein), same leg RadRx “Your Prescription for Accurate Coding & Reimbursement” Copyright 2017. RadRx all rights reserved. Unauthorized distribution is prohibited.

10 11/30/2017

Foam Sclerotherapy Vein

• Codes 36465 and 36466 use ultrasound guided compression maneuvers of the junction of the central vein to limit dispersion of the foam sclerosant. – For injection of a sclerosant into an incompetent vein without compression maneuvers to guide dispersion of the injectate, see codes 36470 and 36471. – Codes 36465 and 36466 may be reported once for each leg. – Do not report 36465, 36466 for injection of compounded foam sclerosant. • Compounding is a practice in which ingredients of a drug are combined, mixed or altered by the physician or qualified health care professional to create a medication tailored to specific patient needs. • When a compounded sclerosant foam is utilized, see codes 36470 and 36471. – Do not report 36465 and 36466 in conjunction with 37241 in the same surgilical fie ld. – Ultrasound guidance and monitoring are inherent to codes 36465 and 36466. – When performed in the office setting, all required supplies and equipment are inherent to the procedure and not separately reportable.

Vein Ablation Chemical Adhesive

• 36482 Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (g(eg, cyyyanoacrylate) remote from the access site, inclusive of all image guidance and monitoring, percutaneous; first vein treated • +36483 Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all image guidance and monitoring, percutaneous; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in additional to code for primary procedure)

11 11/30/2017

Vein Ablation Chemical Adhesive

• Codes 36482 and +36483 are assigned for transcatheter delivery of a chemical adhesive into ittincompetent veins. – The add on codes for subsequent vein(s) treated in the same extremity may only be reported once per extremity – If bilateral extremities are treated, append modifier ‐50 – Codes 36478 and +36479 include imaging guidance necessary to perform the procedure. – See codes 36468, 36470, 36471 for treatment of spider veins or varicose veins by sclerotherapy. – When performed in the office setting, all required supplies and equipment are inherent to the procedure and not separately reportable. RadRx “Your Prescription for Accurate Coding & Reimbursement” 23 Copyright 2017. RadRx all rights reserved. Unauthorized distribution is prohibited.

Revised: 36468, 36470, 36471

• 36468 Injection(s) of sclerosant for spider veins (telangiectasia), limb or trunk – Old “Single or multiple injections of sclerosing solutions, spider veins (telangiectasia), limb or trunk” • 36470 Injection of sclerosant; single incompetent vein (other than telangiectasia) – Old “Injection of sclerosing solution; single vein” • 36471 Injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg – Old “Injection of sclerosing solution; multiple veins, same leg” RadRx “Your Prescription for Accurate Coding & Reimbursement” Copyright 2017. RadRx all rights reserved. Unauthorized distribution is prohibited.

12 11/30/2017

Vein Sclerotherapy

• Code 36468 describes the injection of a sclerosing agent such as Asclera® for the treatment of spider veins (telangiectasia) and/or ittincompetent veins. – Code 36468 may be reported once for each leg. – Do not report 36468 in conjunction with 37241 in the same surgical field. • Ultrasound guidance (76942), when performed, is not included and may be reported separately. – Documentation requirements for code 76942 must be met for reporting USG ‐ permanently recorded images of the site to be localized, as well as a documented description of the localization process. – When performed in the office setting, all required supplies and equipment are inherent to the procedure and not separately reportable. RadRx “Your Prescription for Accurate Coding & Reimbursement” 25 Copyright 2017. RadRx all rights reserved. Unauthorized distribution is prohibited.

Vein Sclerotherapy

• Codes 36470 and 36471 describe the injection of a sclerosing agent to treat varicose veins. – Code 36471 may be reported once for each leg. – When “foam” agents are utilized to treat varicose veins this is not considered venous embolization as described by code 37241. – Do not report 36470 and 36471 in conjunction with 37241 in the same surgical field. – Echosclerotherapy is the use of ultrasound guidance during sclerotherapy for the treatment of varicose veins. • Ultrasound guidance, when performed, is not included and may be reported separately. Documentation requirements for code 76942 must be met for reppgorting – ppyermanently recorded images of the site to be localized, as well as a documented description of the localization process. – When performed in the office setting, all required supplies and equipment are inherent to the procedure and not separately reportable. RadRx “Your Prescription for Accurate Coding & Reimbursement” 26 Copyright 2017. RadRx all rights reserved. Unauthorized distribution is prohibited.

13 11/30/2017

Bone Marrow Aspiration & Biopsy

• Revised – 38220 Diagnostic bone marrow; aspiration(s) • Old Bone marrow; aspiiiration only – 38221 Diagnostic bone marrow; biopsy(ies) • Old Bone marrow; biopsy, needle or trocar • Deleted – G0364 Bone marrow aspiration performed with bone marrow biopsy through the same incision on the same date of service • New – 38222 Diagnostic bone marrow; b()biopsy(ies) and aspiration(s • Append ‐50 modifier for bilateral, 38220‐38222

Ablation Pulmonary Tumors

• New – 32994 Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, including imaging guidance when performed, unilateral; cryoablation • Deleted – 0340T Ablation, pulmonary tumor(s), including pleura or chest wall when involved by tumor extension, percutaneous, cryoablation, unilateral, includes imaging guidance • Revised – 32998 Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, including imaging guidance when performed, unilateral; radiofrequency – Old “…percutaneous, radiofrequency, unilateral” RadRx “Your Prescription for Accurate Coding & Reimbursement” 28 Copyright 2017. RadRx all rights reserved. Unauthorized distribution is prohibited.

14 11/30/2017

ENDOVASCULAR PROCEDURES

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Deleted: Endovascular Repair

• 34800 Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using aorto‐aortic tube prosthesis • 34802 Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using modular bifurcated prosthesis (1 docking limb) • 34803 Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using modular bifurcated prosthesis (2 docking limbs) • 34804 Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using unibody bifurcated prosthesis • 34805 Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using aorto‐uni‐iliac or aorto‐unifemoral prosthesis – 75952 Endovascular repair of infrarenal abdominal aortic aneurysm or dissection, RS&I • 34900 Endovascular repair of iliac artery (eg, aneurysm, pseudoaneurysm, arteriovenous malformation, trauma) using ilio‐iliac tube endoprosthesis – 75954 Endovascular repair of iliac artery aneurysm, pseudoaneurysm, arteriovenous malformation, or trauma, using ilio‐iliac tube endoprosthesis, RS&I RadRx “Your Prescription for Accurate Coding & Reimbursement” 30 Copyright 2017. RadRx all rights reserved. Unauthorized distribution is prohibited.

15 11/30/2017

Deleted: Endovascular Repair

• 34825 Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, or dissection; initial vessel • +34826 Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, or dissection; each additional vessel (List separately in addition to code for primary procedure) • 0255T Endovascular repair of iliac artery bifurcation (e.g., aneurysm, pseudoaneurysm, arteriovenous malformation, trauma) using bifurcated endoprosthesis from the common iliac artery into both the external and internal iliac artery, unilateral; RS&I • 75953 Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal aortic or iliac artery aneurysm, pseudoaneurysm, or dissection, RS&I • +34806 Transcatheter placement of wireless physiologic sensor in aneurysmal sac during endovascular repair, including radiological supervision and interpretation, instrument calibration, and collection of pressure data (List separately in addition to code for primary procedure)

Endovascular Repair

• Endovascular graft, endoprosthesis, endograft, and stent graft • Clinical indications – Aneurysm – Pseudoaneurysm – Dissection – Penetrating ulcer – Traumatic disruption

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Endovascular Repair of Abdominal Aorta and/or Iliac Arteries • Bundled Components – Pre‐procedure sizing and device selection – Device posiiition ing, maniliipulation and dldeployment – Non‐selective catheterizations (36140, 36200) – Diagnostic angiography of aorta and branches – All RS&I: Intraprocedural imaging (angiography, rotational CT), fluoroscopic guidance, roadmapping, completion angiography – Placement of extensions in the aorta from the renal arteries to the iliac bifurcation • Placement of a docking limb is inherent to a modular endograft – PTA/stent of treatment zone – Closure of arteriotomy RadRx “Your Prescription for Accurate Coding & Reimbursement” 33 Copyright 2017. RadRx all rights reserved. Unauthorized distribution is prohibited.

Endovascular Repair of Abdominal Aorta and/or Iliac Arteries • Separate Components – Exposure of access vessels – Selective catheterizations outside treatment zone (36245‐ 36248) – Extensive repair of an artery (35226, 35286, 35371)* – Other interventions outside of target zone (PTA, stent, embolization, etc.) – IVUS (322(+37252, +323)37253) – Moderate sedation (99151‐99157)

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Endovascular Repair of Abdominal Aorta and/or Iliac Arteries • Treatment Zone – Vessels that contain an endograft(s) (main body, docking limb[s] and/or extension[s]) deployed during the same operative session. – PTA/stent/embolization outside of zone may be coded separately. • Example: When an endograft terminates in the common iliac artery, any additional treatment of the common iliac artery is not reported separately. Only additional treatment in the external and/or internal iliac artery is reported when performed. RadRx “Your Prescription for Accurate Coding & Reimbursement” 35 Copyright 2017. RadRx all rights reserved. Unauthorized distribution is prohibited.

Endovascular Repair of Abdominal Aorta and/or Iliac Arteries • Code Structure – Device type • Aorto‐aortic tube (34701‐34702) • Aorto‐uni‐iliac tube (34703‐34704) • Aorto‐bi‐iliac tube (34705‐34706) • Ilio‐iliac tube (34707‐34708), Bifurcated endograft for iliac (0254T) – Rupture vs. non‐rupture • Codes 34702, 34704, 34706, 34708 used for aorta or iliac artery rupture • Rupture definition: Clinical and/or radiographic evidence of acute hemorrhage – Chronic, contained rupture (pseudoaneurysm) = non‐rupture codes • If a decompressive laparotomy is performed at the same time as repair of a rupture, assign code 49000. RadRx “Your Prescription for Accurate Coding & Reimbursement” 36 Copyright 2017. RadRx all rights reserved. Unauthorized distribution is prohibited.

18 11/30/2017

34701‐34706

• Endograft for treatment of aneurysm, pseudoaneurysm, dissection, penetrating ulcer, traumatic disruption in the infrarenal abdominal aorta with or without extension into the iliac arteries. • For covered stent placement for atherosclerotic occlusive disease isolated to the aorta assign codes 37236/+37237 as applicable.

Endovascular Repair

• 34701 Endovascular repair of infrarenal aorta by deployment of an aorto‐aortic tube endograft including pre‐procedure sizing and device selection, all non‐ selective catheterization(s), all associated RS&I, all endograft extensions(s) placed in the aorta from the level of the renal arteries to the aortic bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the aortic bifurcation; for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer) – Replaces 34800,75952 • 34702 Endovascular repair of infrarenal aorta by deployment of an aorto‐aortic tube endograft including pre‐procedure sizing and device selection, all non‐ selective catheterization(s), all associated RS&I, all endograft extensions(s) placed in the aorta from the level of the renal arteries to the aortic bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the aortic bifurcation; for rupture including temporary aortic and/or iliac balloon occlusion, when performed (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer, traumatic disruption) – Replaces 34800,75952 • Treatment zone is defined as the infrarenal aorta

19 11/30/2017

Endovascular Repair

• 34703 Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto‐uni‐iliac endograft including pre‐procedure sizing and device selection, all non‐selective catheterization(s), all associated RS&I, all endograft extensions(s) placed in the aorta from the level of the renal arteries to the iliac bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the iliac bifurcation; for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer) – Replaces 34802, 34805, 75952 • 34704 Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto‐uni‐iliac endograft including pre‐procedure sizing and device selection, all non‐selective catheterization(s), all associated RS&I, all endograft extensions(s) placed in the aorta from the level of the renal arteries to the iliac bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the iliac bifurcation; for rupture including temporary aortic and/or iliac balloon occlusion, when performed (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer, traumatic disruption) • Treatment zone = infrarenal aorta and ipsilateral common iliac

Endovascular Repair

• 34705 Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto‐bi‐iliac endograft including pre‐procedure sizing and device selection, all non‐selective catheterization(s), all associated RS&I, all endograft extensions(s) placed in the aorta from the level of the renal arteries to the iliac bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the iliac bifurcation; for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer) – Replaces 34803 & 34804,75952 – For isolated bilateral iliac repair assign 34707 or 34708 with modifier ‐50. • 34706 Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto‐bi‐iliac endograft including pre‐procedure sizing and device selection, all non‐selective catheterization(s), all associated RS&I, all endograft extensions(()s) placed in the aorta from the level of the renal arteries to the iliac bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the iliac bifurcation; for rupture including temporary aortic and/or iliac balloon occlusion, when performed (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer, traumatic disruption) • Treatment zone: infrarenal aorta and both common iliac arteries RadRx “Your Prescription for Accurate Coding & Reimbursement” 40 Copyright 2017. RadRx all rights reserved. Unauthorized distribution is prohibited.

20 11/30/2017

Endovascular Repair: Iliac

• 34707 Endovascular repair of iliac artery by deployment of an ilio‐iliac tube endograft including pre‐procedure sizing and device selection, all non‐selective catheterization(()s), all associated RS&I, all endogfgraft extensions(()s) pyproximally to the aortic bifurcation and distally to the iliac bifurcation, and treatment zone angioplasty/stenting, when performed, unilateral; for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation) – Replaces 34900,75954 • 34708 Endovascular repair of iliac artery by deployment of an ilio‐iliac tube endograft including pre‐procedure sizing and device selection, all non‐selective catheterization(s), all associated RS&I, all endograft extensions(s) proximally to the aortic bifurcation and distally to the iliac bifurcation, and treatment zone angioplasty/stenting, when performed, unilateral; for rupture including temporary aortic and/or iliac balloon occlusion when performed (eg, for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation, traumatic disruption) – Replaces 34900, 75954 • Treatment zone = portion of the iliac (common, external , internal) arteries that contain the endograft

Endovascular Repair: Iliac

• Codes 34707 and 34708 are not used when an abdominal aortic stent graft is placed with treatment of the iliac artery at the same time. • For an isolated bilateral iliac artery repair, report code 34707 or 34808 with modifier ‐50. • For covered stent placement to treat atherosclerotic occlusive disease only isolated to the aorta assign codes 37236/+37237 as applicable. • For covered stent placement to treat atherosclerotic occlusive disease only of the iliac artery assign codes 37221/+37223 as applicable. RadRx “Your Prescription for Accurate Coding & Reimbursement” 42 Copyright 2017. RadRx all rights reserved. Unauthorized distribution is prohibited.

21 11/30/2017

0254T Revised/0255T Deleted

• 0254T Endovascular repair of iliac artery bifurcation (eg, aneurysm, pseudoaneurysm, arteriovenous malformation, trauma, dissection) using bifurcated endograft from the common iliac artery into both the external and internal iliac artery, including all selective and non‐selective catheterization(s) required for device placement and all associated radiological supervision and interpretation, unilateral • Note that code 0254T includes BOTH non‐selective and selective catheterizations required for endoprosthesis placement. • Code 0254T (unilateral) describes placement of a bifurcated iliac stent graft (Cook Zenith® Branch Iliac Endovascular Graft) for treatment of the bifurcation. This involves placement of a stent graft device from the common iliac into both the internal and external iliac arteries. RadRx “Your Prescription for Accurate Coding & Reimbursement” 43 Copyright 2017. RadRx all rights reserved. Unauthorized distribution is prohibited.

Endovascular Repair

• +34709 Placement of extension prosthesis(es) distal to the common iliac artery(ies) or proximal to the renal artery(ies) for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, penetrating ulcer, including pre‐procedure sizing and device selection, all nonselective catheterization(s), all associated RS&I, and treatment zone angioplasty/stenting, when performed, per vessel treated (List separately in addition to code for primary procedure) – Describes placement of an extension prosthesis distal to (below) the common iliac arteries or proximal to (above) the renal arteries. • Extensions must terminate either in the internal iliac, external iliac or common femoral arteries or be placed in the abdominal aorta above the renal arteries. • Endograft extensions that terminate in the common iliac arteries are inherent to 34701‐34708. • Proximal infrarenal abdominal aortic extension prosthesis that terminate in aorta below the renal arteries are bundled w/ 34701‐34706. • Placement of a docking limb is inherent to a modular endograft; 34709 may not be reported separately if the docking limb extends into the external iliac artery • For an endograft placed into a renal artery that is being covered by a proximal extension, see codes 37236‐37237. – Reported 1x per vessel – Replaces 34825, 34826, 75953 RadRx “Your Prescription for Accurate Coding & Reimbursement” 44 Copyright 2017. RadRx all rights reserved. Unauthorized distribution is prohibited.

22 11/30/2017

Endovascular Repair

• 34710 Delayed placement of distal or proximal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, endoleak, or endoggfraft migration, including pre‐procedure sizing and device selection, all nonselective catheterization(s), all associated RS&I, and treatment zone angioplasty/stenting, when performed; initial vessel treated • +34711 Delayed placement of distal or proximal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, endoleak, or endograft migration, including pre‐procedure sizing and device selection, all nonselective catheterization(s), all associated RS&I, and treatment zone angioplasty/stenting, when performed; each additional vessel treated – 34710 & 34711 replace 34825, 34826, 75953 • Report 34710 and 34711 per vessel treated, but each is reported one time per session – If a decompressive laparotomy is performed at the same time, assign 49000 with 34710. • If a delayed revision is placement of a transcatheter enhanced fixation device, assign code 34712.

Revised: Open Arterial Exposure

• The codes used to describe open exposure of access vessels, i.e., femoral or iliac artery(s), include both the work of exposing the vessel and closing of the exposure site(s). • Open exposure add‐on codes are reported twice for bilateral open exposure. Do not utilize modifier ‐50 to report a bilateral procedure. • +34812 Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral (List separately in addition to code for primary procedure) • +34820 Open iliac artery exposure for delivery of endovascular prosthesis or iliac occlusion during endovascular therapy, by abdominal or retroperitoneal incision, unilateral (List separately in addition to code for primary procedure) • +34833 Open iliac artery exposure with creation of conduit for delivery endovascular prosthesis or for establishment of cardiopulmonary bypass, by abdominal or retroperitoneal incision, unilateral (List separately in addition to code for primary procedure) • +34834 Open brachial artery exposure for delivery of endovascular prosthesis, unilateral (List separately in addition to code for primary procedure) – Removed from description “to assist in the deployment of aortic or iliac endovascular prosthesis by arm incision” RadRx “Your Prescription for Accurate Coding & Reimbursement” 46 Copyright 2017. RadRx all rights reserved. Unauthorized distribution is prohibited.

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New: Open Arterial Exposure • +34714 Open femoral artery exposure with creation of conduit for delivery of endovascular prosthesis or for establishment of cardiopulmonary bypass, by groin incision, unilateral (List separately in addition to code for primary procedure) • +34715 Open axillary/subclavian artery exposure for delivery of endovascular prosthesis by infraclavicular or supraclavicular incision, unilateral (List separately in addition to code for primary procedure) • +34716 Open axillary/subclavian artery exposure with creation of conduit for delivery of endovascular prosthesis or for establishment of cardiopulmonary bypass, by infraclavicular or supraclavicular incision, unilateral (List separately in addition to code for primary procedure) RadRx “Your Prescription for Accurate Coding & Reimbursement” 47 Copyright 2017. RadRx all rights reserved. Unauthorized distribution is prohibited.

Percutaneous Access, Large Sheath • +34713 Percutaneous access and closure of femoral artery for delivery of endograft through a large sheath (12 French or l)larger), ildiincluding uldltrasound guidance, when perfdformed, unilateral (List separately in addition to code for primary procedure) – Code +34713 may be reported with codes 33880‐33886, 34701‐ 34708 and 34841‐34848 when a 12 French or larger sheath is used. • – It includes ultrasound guided vascular access (+76937) for the same access site and placement of dual closure devices. • – Code +34713 may be reported once per side. • – Do not report +34713 for access and closure of the femoral artery associated with procedures 37221, 37223, 37236, 37237 RadRx “Your Prescription for Accurate Coding & Reimbursement” 48 Copyright 2017. RadRx all rights reserved. Unauthorized distribution is prohibited.

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Endograft Fixation Device

• 34712 Transcatheter delivery of enhanced fixa tion didevices ()(s) to the enddftograft (eg, anchor, screw, tack) and all associated RS&I – Report once per operative session

Revised: Iliac Aneurysm Repair

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Endovascular Repair Coding Checklist

• Open surgical exposure – Percutaneous large sheath (12 Fr) • Selective catheterizations outside treatment zone • Endograft placement • Extensions (distal to common iliac arteries or proximal to renal arteries) • Interventions outside target treatment zone

TEVAR & FEVAR

• New codes applicable to TEVAR & FEVAR procedures: – TEVAR • Access: +34713, +34714, +34715, +34716 – FEVAR • Access: +34713, +34714, +34715, +34716 • Extensions: +34709, 34710, +34711

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NCCI POLICY MANUAL CHANGES: INTERVENTIONAL RADIOLOGY

RadRx “Your Prescription for Accurate Coding & Reimbursement”

Chapter 9, Section H Revised • 9. Evaluation of an anatomic region and guidance for a needle placement procedure by the same radiologic modlidality on the same date of service may be reported separately if the two procedures are performed in different anatomic regions. For example, a physician may report a diagnostic ultrasound CPT code and CPT code 76942 (ultrasonic guidance for needle placement...) when performed in different anatomic regions on the same date of service. Physicians should not avoid edits based on this principle by requiring patients to have the procedures performed on different dates of service if historically the evaluation of the anatomic region and guidance for needle biopsy procedures were performed on the same date of service. RadRx “Your Prescription for Accurate Coding & Reimbursement” 54 Copyright 2017. RadRx all rights reserved. Unauthorized distribution is prohibited.

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Chapter 5, Section E Revised

• 1. When diagnostic bone marrow aspiration(s) is performed alone, the appropriate code to report is CPT code 38220. When diagnostic bone marrow biopsy(ies) is performed alone, the appropriate code to report is CPT code 38221. This code shall not be reported with CPT code 20220 (bone biopsy). When diagnostic bone marrow aspiration(s) and biopsy(ies) are performed on the ipsilateral iliac bone, the appropriate code to report is CPT code 38222. CPT codes 38220 and 38221 may only be reported together if the two procedures are performed without accompanying biopsy(ies) or aspiration(s) respectively on different iliac bones or sternum or at separate patient encounters. If a diagnostic bone marrow biopypsy (CPT code 38221) and diagnostic bone marrow aspiration (CPT code 38220) are performed on the same bone, do not report the bone marrow aspiration, CPT code 38220, in addition to the bone marrow biopsy (CPT code 38221).

Chapter 5, Section D

• 28. Thrombectomy of thrombus in the vascular territory of a diseased artery is inherent in the work of 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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Chapter 7, Section E

• 11. Radiofrequency ablation of uterine fibroid(s) (e.g., CPT codes 58674, 0404T) and myomectomy of leiomyoma(ta) (e.g., CPT codes 58140‐58146, 58545, 58546, 58561) shllhall not be reported for a procedure on the same leiomyoma. For example if a physician initiates a laparoscopic radiofrequency ablation of a uterine fibroid but must complete the procedure by laparoscopic myomectomy, only the completed procedure, laparoscopic myomectomy, may be reported. In the unusual circumstance where a physician performs radiofrequency ablation on one or more leiomyoma(ta) and it is medically reasonable and necessary to perform a myomectomy on a different leiomyoma, the physician may report both procedures.

Chapter 3, Section L

• 20. CPT code 36591 describes “collection of blood specimen from a completely implantable venous access device”. CPT code 36592 dibdescribes “lli“collection of bloo d specimen using an established central or peripheral venous catheter, not otherwise specified”. These codes shall not be reported with any service other than a laboratory service. That is, these codes may be reported if the only non‐laboratory service performed is the collection of a blood specimen by one of these methods. • 21. CPT code 96523 describes “irrigation of implanted venous access device for drug delivery system”. This code may be reported only if no other service is reported for the patient encounter. RadRx “Your Prescription for Accurate Coding & Reimbursement” 58 Copyright 2017. RadRx all rights reserved. Unauthorized distribution is prohibited.

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Chapter 11, Section I Revised

• 15. Cardiac catheterization, percutaneous coronary artery interventional procedures (angioplasty, atherectomy, or stenting), and internal cardioversion include insertion of a needle and/or catheter, infusion, fluoroscopy and ECG rhythm strips (e.g., CPT codes 36000, 36140, 36160, 36200‐36248, 36410, 96360‐96376, 76000‐76001, 93040‐93042). All these services are components of a cardiac catheterization, percutaneous coronary artery interventional procedure, or internal cardioversion and are not separately reportable. Additionally, ultrasound guidance is not separately reportable with these procedures. Physicians shall not report CPT codes 76942, 76998, 93318, or other ultrasound procedural codes if the ultrasound procedure is performed for guidance during one of these procedures.

References

• Cracking the IR Code: Your Comprehensive GidGuide to MMtiastering IItnterventi ona l RRdiladiology Coding, 2018 Edition by Stacie L. Buck • Mastering Interventional Radiology & Cardiology Coding Comprehensive Online Education Program by Stacie L. Buck • 2018 CPT Insider’s View • 2018 CPT Professional Edition RadRx “Your Prescription for Accurate Coding & Reimbursement” Copyright 2017. RadRx all rights reserved. Unauthorized distribution is prohibited.

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Get Ready for 2018!

• Grab your copy of Cracking the IR Code: Your Comprehensive Guide to Mastering Interventional Radiology Coding by Stacie L. Buck, RHIA, CCS-P, RCC, CIRCC, AAPC Fellow • Wheth er you are searchi ng f or a compreh ensi ve i nt erventi onal radi o logy co ding re ference boo k or you are searching for an easy to understand reference so you can learn interventional radiology coding this book is for you! The majority of users rate Cracking the IR Code a “10” on a scale of 1- 10. Also 90% of customer survey respondents stated they consider Cracking the IR Code “above average” when compared to radiology coding references published by our competitors. This guide features over 800 pages of content including: *Explanation of the coding rules for interventional radiology procedures *Short coding scenarios with written explanation of code selection *Actual case studies with written explanation of code selection *Quick Reference Guides *Vascular Illustrations shop.radrx.com PROMO CODE: SAVE50 Expires December 8th RadRx “Your Prescription for Accurate Coding & Reimbursement”

Get Ready for 2018!

• Cracking the IR Code: Mastering Interventional Radiology & Cardiology Coding Online (LIMTED SEATING – WE HAVE A FEW SEATS LEFT FOR JANUARY 2018 START DATE) • Our comprehensive Interventional Radiology & Cardiology Coding online training program offers the f ollowing advantages over other programs: – Save time and money! No travel expenses and no time away from work and home. – Access to content for 1 year, allowing you ongoing access as you study for your exam. – Q & A support available during your 1 year enrollment period. – Incremental instruction supports maximized learning and retention. – Practice your skills with hundreds of coding scenarios and actual operative reports. • Modules include the following: – Module 1 – IR Coding Basics & Diagnostic Angiography – Module 2 – Venography, Pulmonary Angiography, CVADs, IVC Filters – Module 3 – Anggpioplast y, Stent & Atherectom y – Module 4 – Embolization, Thrombolysis/Thrombectomy & Dialysis Circuit – Module 5 – Biopsy, Aspiration, Drainage, Sclerotherapy, Spinal Procedures – Module 6 – Urinary, Biliary & GI Procedures – Module 7 – Cardiac Catheterization & Coronary Revascularization – Module 8 – Endovascular Procedures RadRx “Your Prescription for Accurate Coding & Reimbursement” 62

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Connect & Contact

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RadRx “Your Prescription for Accurate Coding & Reimbursement”

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