Master the Significant Revisions to 2011 Vascular Codes
Changes make it quicker and easier to code these complex procedures.
By David Zielske, MD, CPC-H, CCIRC, CCC, CCS, RCC
Dramatic coding changes for lower extremity endovascular revascularization have been implemented for 2011:
- Sixteen new Category I CPT® codes (37220-37235) apply to combinations of angioplasty, atherectomy, and stent placement (interventions) performed in lower extremity arteries. The codes describe interventions performed for treatment of stenotic/occlusive disease, and report either open or percutaneous approaches.
- Five new Category III CPT® codes (0234T-0238T) replace the previous percutaneous and open atherectomy codes.
To report the new codes correctly, you’ll need to review the guidelines and bundling issues that apply.
Three Territories Divide Lower Extremity Arteries
The arteries of the lower extremities have been divided into three “territories,” each with separate guidelines and codes describing interventional procedures.
Like the coronary artery intervention codes, the lower extremity revascularization codes follow a hierarchy in which stent placement with atherectomy is considered the highest level of intervention, followed by stent placement, atherectomy, and then angioplasty. Subsequently, angioplasty is bundled to each of the new lower extremity revascularization codes.
1. Iliac Territory
The iliac territory, with three separately billable vessels (the internal iliac, external iliac, and common iliac arteries) allows separate billing of atherectomy, in addition to an angioplasty or stent placement. This is because atherectomy in the supra-inguinal vessels (iliacs, visceral, aorta, renal, and brachiocephalic) utilize Category III CPT® codes 0234T-0238T, which do not have the same bundling issues as infra-inguinal lower extremity revascularization codes.
CPT® codes 37220 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty and 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) describe initial and additional iliac angioplasty. Meaning, if angioplasty is the only intervention performed in the iliac arteries on one extremity, use these codes (one for the initial vessel, and up to two additional codes if two additional vessel—not lesion—angioplasties were performed).
If iliac stent placement was performed additionally in one vessel, replace 37220 (initial angioplasty) with 37221 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed, which bundles angioplasty in the same vessel. Code any additional iliac angioplasty procedures in additional iliac arteries with add-on code 37222.
If atherectomy is performed instead of stent placement, use 0238T Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; iliac artery, each vessel in addition to code 37220 for the initial angioplasty. If atherectomy and stent placement are performed in the common iliac artery, use codes 0238T and 37221 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed.
The new supra-inguinal atherectomy codes are coded in addition to any other intervention in the same vessel at the same lesion site. You may bill angioplasty, atherectomy, and stent placement in the aorta or a renal, visceral, brachiocephalic artery, depending on documentation.
2. Femoral/Popliteal Territory
The femoral/popliteal territory is unusual compared to the other two territories because all four vessels in this territory are considered a single vessel for coding purposes. All interventions performed in the common femoral, profunda femoral, superficial femoral, and popliteal arteries are described by a single code. The hierarchy still applies: Stent placement supersedes atherectomy, which supersedes angioplasty.
There are two choices for stent placement in the femoral/popliteal territory: Code 37226 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed describes stent placement alone (with or without angioplasty), while 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 describes stent placement with atherectomy (with or without angioplasty).
For one femoral/popliteal territory, consider all treatments in all vessels as treatment in a single vessel. For all interventions performed in this territory, only one code between 37224 and 37227 should be submitted, regardless of the number of interventions performed in these four vessels. There are no initial or additional revascularization codes for the femoral/popliteal territory; so if an angioplasty is performed in the profunda femoral, an atherectomy is performed in the superficial femoral, and a stent is placed in the popliteal artery, report stent placement with atherectomy, with or without angioplasty (37227).
3. Tibial/Peroneal Territory
The tibial/peroneal codes allow for more than one vessel to be described and coded. Three separately-billable vessels are recognized: the anterior tibial, posterior tibial, and peroneal arteries. The tibial/peroneal trunk is considered part of any distal intervention performed in the posterior tibial or peroneal arteries, while the dorsalis pedis artery is considered continuation of the anterior tibial artery, and the medial malleolar artery is considered continuation of the posterior tibial artery.
Here again, the hierarchy applies: Stent placement with atherectomy supersedes stent placement without atherectomy, which supersedes atherectomy, which supersedes angioplasty alone. Remember: Angioplasty is included in all interventions, if performed.) Code the highest vessel intervention as the initial intervention in this territory, and any other vessel interventions as additional tibial/peroneal interventions. Codes 37228-37231 describe initial interventions while add-on codes 37232-37235 describe additional interventions in the other two tibial/peroneal arteries.
Remember to code each territory separately (except bridging lesions) with initial and additional revascularizations in each territory, as appropriate (the femoral/popliteal territory does not use initial/additional designations). For instance, you can have an initial iliac revascularization and an initial tibial/peroneal revascularization. If you perform a bilateral procedure in the lower extremities, start the coding all over again for the opposite leg with initial revascularization codes for both sides (e.g., 37220, 37220-59; or 37220-50 for bilateral iliac angioplasty).
Include Angioplasty and More in Lower Extremity Revascularization
As already noted, all 16 lower extremity revascularization codes (37220-37235) include angioplasty, if performed.
- Angioplasty (balloon dilation of a stenosis or occlusion) can be performed with a compliant, non-compliant, cutting, or cryoballoon.
- Atherectomy (removal of atheroma) devices include rotational, front-cutting, side-cutting, and photoablation (laser) devices.
- Stent placement utilizes self-deploying, balloon expandable, covered (stent grafts), and drug-eluting stents.
- New codes 37220-37235 also bundle:
- Conscious sedation
- Vascular access
- Catheter placement
- Traversing the lesion
- Imaging related to the intervention (previously billed as the supervision and interpretation code for the specific intervention)
- Use of an embolic protection device (EPD)
- Imaging for closure device placement
- Closure of the access site (which could be by suture for an open approach, or by placement of a closure device for percutaneous approach)
Diagnostic imaging remains separately billable. The imaging must be truly diagnostic, however, and not performed just for confirmation of a lesion or guidance for an intervention. Imaging is bundled when done to measure vessel size, localize a lesion, follow up an intervention, or guide the procedure.
Other interventions in these lower extremity vessels treated with angioplasty, atherectomy, and/or stent placement are separately billable. These include: Intravascular ultrasound (IVUS) (37250, 75945), thrombolysis (37201, 75896, 75898), thrombectomy (37184-37186), and embolization (37204, 75894).
Bill Initial Vessel at Highest Intervention Level
Always bill the initial vessel intervention as the highest intervention level performed within a single territory. If a separate intervention is performed within a different territory, start coding all over again with an initial intervention for that territory, based on hierarchy guidelines (stent placement with atherectomy, followed by stent placement, atherectomy, and then angioplasty).
These guidelines are for treatment of one extremity. If performing intervention on both legs, start coding all over again on the new leg. You may need modifier 59 Distinct procedural service (per CPT® instruction), or modifier 50 Bilateral procedure (per the Physician Fee Schedule Relative Value File), as appropriate, to alert the payer that intervention occurred in both extremities.
Bridging lesions still are considered a single vessel intervention, even if the bridging lesion extends from one territory into another. You still need to have a hemodynamically-significant vessel stenosis to meet medical necessity and code for these interventions.
Example Shows How Codes Have Been Condensed
Compare coding between 2010 and 2011 guidelines and codes, with this example.
Patient with known left external iliac 80 percent stenosis, left SFA 90 percent proximal stenosis, 90 percent mid popliteal stenosis and posterior tibial and peroneal artery occlusions. The iliac lesion is treated with balloon angioplasty alone and the SFA is treated with an appropriately sized balloon however a flow limiting dissection occurred requiring a self-deploying stent. The popliteal artery is treated with a stent graft alone while atherectomy with a laser is performed in both the posterior tibial and peroneal arteries with 70 percent residual stenosis in both requiring 3 mm drug-eluting stents. Closure device is placed.
In 2010, the appropriate codes from a contralateral approach would have been: 36247, 36248, 35473, 75962, 35474, 75964, 37205, 75960, 37206, 75960-59, 35495, 75992, 35495-59, 75993, 37206, 75960-59, 37206, 75960-59, and G0269.
In 2011, the appropriate codes are:
- 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
- 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 (List separately in addition to code for primary procedure)
We’ve gone from 19 codes in 2010 to four codes in 2011. Once you master the new codes, you will be able to code these complex procedures with improved accuracy and decreased compliance risk.
David Zielske, MD, CPC-H, CIRCC, CCC, CCS, RCC, is an interventional radiologist and president of ZHealth and ZHealth Publishing in Brentwood, Tenn.