2012 Brings All-inclusive Codes for Interventional Radiology
New, more concise codes facilitate spot-on coding for all components of vascular and nonvascular procedures.
By David Zielske, MD, CPC-H, CIRCC, CCC, CCS, RCC
Many interventional radiology code changes over the past several years have resulted in the creation of a single code to describe what was previously described with multiple codes. This trend continues in CPT® 2012 with new bundled codes describing renal angiography, vena cava filter intervention, paracentesis, and other nonvascular interventions.
Last year, renal angiography was described by catheter placement(s) (e.g., 36245, 36246), radiological supervision and interpretation (e.g., 75722, 75724), and imaging for accessory renal artery evaluation (e.g., 36245-59, 75774). In 2012, codes 75722 and 75724 are deleted. New codes 36251-36254 include main renal artery catheter placement(s), radiological supervision and interpretation, and accessory or superselective branch renal arterial catheter placement and imaging:
36251 Selective catheter placement (first-order), main renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; unilateral
36253 Superselective catheter placement (one or more second order or higher renal artery branches) renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture, catheterization, fluoroscopy, contrast injection(s), image post processing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; unilateral
Codes 36251 and 36252 describe selective (first-order catheter placement only) of unilateral or bilateral renal arteries (including accessory renals off the aorta and iliac artery). Codes 36253 and 36254 describe superselective (second order or higher) catheter selection(s). Superselective renal angiography includes accessory renals off the aorta and iliac artery, but also includes selection and imaging of multiple additional intrarenal branches.
Just one of these four codes should be billed per session, with a single exception (see below). All codes include nonselective imaging of the abdominal aorta (do not report 75625 Aortography, abdominal, by serialography, radiological supervision and interpretation with 36251-36254), closure device imaging and placement, conscious sedation, and pull-back pressure determinations (with wire or catheter) across the renal arteries to evaluate the hemodynamic significance of identified arterial abnormalities—3D reconstructions are also included. Basically, one code describes the entire procedure from puncture to closure, when the procedure is for diagnostic imaging related to the renal arteries (and other imaging or intervention is not performed).
Here are a few things not to do when reporting 36251-36254:
- Do not report a unilateral and a bilateral renal code together.
- Do not report two bilateral codes together.
- Do not report two unilateral codes when selective and superselective imaging is performed on one side of the body.
- Do not code preliminary nonselective abdominal aortography.
- Do not separately code catheter placements, imaging, closure device placement, or conscious sedation.
The exception for submitting just one of codes 36251-36254 is if unilateral selective renal imaging is performed along with contralateral superselective renal imaging. In this case (which may occur in patients with suspected renal trauma), both kidneys are evaluated by selective imaging. A bleeding site is identified on one side, evaluated further with superselective imaging, and then treated with embolization therapy. Codes 36251 (unilateral, selective) and 36253 (unilateral, superselective) are both submitted with modifier 59 applied to code 36251 to demonstrate that the procedures are performed on different sides of the body. The American College of Radiology (ACR), Society of Interventional Radiology (SIR), and Society for Vascular Surgery (SVS) have made this recommendation.
Procedure: The patient is a 48-year-old male with hypertension and abnormal renal Doppler. A 5-French sheath is placed in the right common femoral artery, followed by placement of a pigtail catheter into the aorta. Abdominal aortography shows two right and three left renal arteries. All five vessels are selected with an SOS catheter and imaging is performed. Superselective imaging of both the right and left main renal arteries is performed followed by advancing the catheter into the upper-pole, mid-pole, and lower-pole third-order renal artery branches with additional imaging. Pressure wire is placed across the two questionable stenoses in right intrarenal branches. The catheter and sheath are removed and the closure device placed.
Findings: Fibromuscular dyplastic changes are seen in the intrarenal branches, bilaterally. No hemodynamically significant stenosis is identified.
Coding: 36254 (describes the entire procedure)
Vena Cava Filters
Vena cava filters are placed as temporary or permanent devices in the vena cava (inferior vena cava (IVC) and, rarely, the superior vena cava (SVC)) to trap blood clots traveling from the extremities and prevent them from reaching the pulmonary arterial circulation, causing pulmonary embolism and its sequelae. When a permanent filter is placed, it cannot be manipulated. Temporary filters, which are quite common today, can be repositioned if they migrate and become ineffective, and they can be removed when the risk of thromboembolism has passed. If the risk remains or clot is seen in the filter, the temporary filter can stay as a permanent filter.
Three new codes for 2012, 37191-37193, bundle all component codes previously used for these procedures: catheter placement(s), diagnostic venography, ultrasound guidance for vascular access, guiding shots and confirmatory venograms, and placement and deployment (or repositioning, removal) of the vena cava filter. All fluoroscopy and ultrasound imaging guidance is included.
37191 Insertion of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed
37192 Repositioning of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed
37193 Retrieval (removal) of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed
Codes 37620 and 75940 are deleted for 2012.
Procedure: Patient is a 32-year-old male status post motor vehicle accident with pelvic fractures. Patient had temporary IVC filter placed four weeks earlier and has now requested to have it removed. Using ultrasound guidance for vascular access, a 10-French sheath is placed in the jugular vein. A catheter is advanced to the IVC and imaging performed, showing a patent filter and vena cava. The filter legs do not appear to penetrate the IVC wall. A snare is placed over the tip of the filter, and the sheath and snare are used to collapse and retrieve the filter. This is pulled into the sheath, and the entire apparatus is removed from the jugular vein. Pressure and dressing are applied.
Coding: 37193 (describes the entire procedure)
Several codes for nonvascular interventions also now bundle imaging guidance.
New paracentesis codes describe drainage of abdominal fluid for diagnostic or therapeutic reasons without imaging guidance (49082 Abdominal paracentesis (diagnostic or therapeutic); without imaging guidance), with imaging guidance (49083 Abdominal paracentesis (diagnostic or therapeutic); with imaging guidance), and for peritoneal lavage with or without imaging guidance (49084 Peritoneal lavage, including imaging guidance, when performed).
Codes 49080 and 49081 previously described paracentisis, but have been deleted for 2012.
New codes for destruction by a neurolytic agent of paravertebral joint of the spine also now bundle imaging guidance (fluoroscopy or computed tomography (CT)):
64633 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint
+64634 each additional facet joint (List separately in addition to code for primary procedure)
64635 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint
+64636 each additional facet joint (List separately in addition to code for primary procedure)
As well, sacroiliac joint arthrography is now bundled with anesthetic/steroid injection in a single code (27096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed), which also includes imaging guidance. The former imaging code 73542 is deleted in 2012. If a sacroiliac joint injection does not include fluoroscopy or CT guidance, report 20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) rather than 27096.
On a final note, vertebroplasty (22520-22522) now specifically includes biopsy of the same bone.
CPT® Clarifies AV Shunt/Fistula Coding
Physicians continue to perform increasingly complex interventions related to arteriovenous (AV) shunts/fistulas, which has caused some confusion as to how to code some of these procedures. The American Medical Association (AMA) helps clarify correct coding for these complex AV shunt/fistula interventions for 2012. Several well written paragraphs describing the procedures, along with the appropriate coding, can be found in CPT® 2012 and 2012 CPT® Changes: An Insider’s View. These references should be reviewed closely and applied to such cases in your practice.
David Zielske, MD, CPC-H, CIRCC, CCC, CCS, RCC, is an interventional radiologist and president of ZHealth and ZHealth Publishing in Brentwood, Tenn.