Get Busy Learning New Non-cardiac Endovascular Codes
2013 CPT® changes for interventional radiology are extensive; here’s where to start.
By David Zielske, MD, CPC-H, CIRCC, CCC, CCS, RCC
The American Medical Association (AMA) was very busy last year, creating 74 new interventional radiology, endovascular, cardiac chamber, and coronary arterial interventional codes for 2013, while deleting 32 codes for many of the same types of procedures. We’ll focus on the chest drainage procedures and non-cardiac endovascular codes changes, which include retrieval of intravascular foreign body and thrombolysis.
2013 Breathes New Life into Chest Drainage Codes
Non-vascular interventional radiology codes 32421 and 32422, which described needle or catheter-drainage of chest fluid, have been deleted for 2013, replaced with 32554 Thoracentesis, needle or catheter, aspiration of the pleural space; without imaging guidance and 32555 Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance.
The old codes allowed for separate reporting of image guidance (e.g., 76942, 77002, 77012), when performed. The new codes describe chest drainage by a needle or catheter that is removed at the end of the procedure. Code 32554 is used when imaging guidance is not necessary; while 32555 is for procedures with imaging guidance.
Two additional codes for percutaneous chest drainage by placement of non-tunneled chest drainage catheters are 32556 Pleural drainage, percutaneous, with insertion of indwelling catheter; without imaging guidance and 32557 Pleural drainage, percutaneous, with insertion of indwelling catheter; with imaging guidance. Imaging guidance includes any combination of fluoroscopy ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI).
Code 32551 Tube thoracostomy, includes connection to drainage system (eg, water seal), when performed, open (separate procedure) has been revised, and now represents an open placement of a chest tube (usually for empyema, traumatic hemothorax, or pneumothorax). These tubes are placed without imaging guidance.
There is no change to the tunneled chest tube placement code (32550 Insertion of indwelling tunneled pleural catheter with cuff), which allows separate reporting of 75989 Radiological guidance (ie, fluoroscopy, ultrasound, or computed tomography), for percutaneous drainage (eg, abscess, specimen collection), with placement of catheter, radiological supervision and interpretation for image guidance during placement.
One Code Describes Intravascular FB Removal
A single code now describes retrieval of an intravascular foreign body (FB): 37197 Transcatheter retrieval, percutaneous, of intravascular foreign body (eg, fractured venous or arterial catheter), includes radiological supervision and interpretation, and imaging guidance (ultrasound or fluoroscopy), when performed replaces 37203 and 75901.
The procedure requires placement of a catheter and retrieval device or snare to the location of the foreign body. Make certain to report the appropriate catheter placement code (36010–36012 for venous; 36013–36015 for the right atrium and pulmonary artery; 36200 for the aorta; 36245–36248 for selective vessels below the diaphragm; and 36215–36218 for selective vessels above the diaphragm) for the retrieval.
Example 1: Patient is a 40-year-old with fractured central venous access catheter noted on the chest X-ray. The catheter tip is in the main pulmonary artery. Via right femoral vein approach, a retrieval device is advanced into the right atrium. Snare is placed around the catheter tip in the pulmonary artery and the catheter is retrieved and slowly removed from the body.
Proper coding is:
36013 Introduction of catheter, right heart or main pulmonary artery for catheter placement
37197 for retrieval of the foreign body
Note: Usually, a diagnostic angiogram is not necessary because broken catheters, lost coils, stents, and other intravascular foreign bodies are easily visible with fluoroscopy. Contrast injections are mostly used for guidance, as needed.
Thrombolysis Now a “Per Date” Service
Percutaneous non-coronary catheter directed thrombolysis is now a “per date of therapy” procedure, for coding purposes. Thrombolysis infusion, follow-up angiography, and catheter exchanges performed on a single date of therapy (12 a.m. to 11:59 p.m.) are described by a single code.
Code 37211 Transcatheter therapy, arterial infusion for thrombolysis other than coronary, any method, including radiological supervision and interpretation, initial treatment day describes the initial date of treatment for arterial thrombolysis, while 37212 Transcatheter therapy, venous infusion for thrombolysis, any method, including radiological supervision and interpretation, initial treatment day describes the initial day for venous thrombolysis.
If the infusion continues past the initial day, 37213 Transcatheter therapy, arterial or venous infusion for thrombolysis other than coronary, any method, including radiological supervision and interpretation, continued treatment on subsequent day during course of thrombolytic therapy, including follow-up catheter contrast injection, position change, or exchange, when performed is used for arterial or venous thrombolysis on the subsequent day(s) of therapy. Use 37214 Transcatheter therapy, arterial or venous infusion for thrombolysis other than coronary, any method, including radiological supervision and interpretation, continued treatment on subsequent day during course of thrombolytic therapy, including follow-up catheter contrast injection, position change, or exchange, when performed; cessation of thrombolysis including removal of catheter and vessel closure by any method for the final day of therapy, when the infusion is concluded.
If an infusion is three days or longer, 37213 will be repeated for each additional day that is not the initial or final day of treatment. Code 37213 cannot be reported the same day as 37211, 37212, or 37214. For a single day of therapy, only 37211 or 37212 may be reported for the thrombolysis. Do not report 37214 the same day as 37211 or 37212.
Example 2: A 62-year-old patient has an ischemic right leg. Via left femoral arterial puncture, a contralateral sheath is placed into the right external iliac artery. Diagnostic angiography reveals acutely thrombosed right femoral-popliteal bypass graft with chronically occluded native superficial femoral artery (SFA) (75710 Angiography, extremity, unilateral, radiological supervision and interpretation). A thrombolysis catheter is advanced into the graft (36247 Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family) and catheter-directed thrombolytic infusion is initiated (37211). The patient is sent to ICU for monitoring.
The patient is brought back later the same day. Follow-up imaging and catheter exchange for a longer infusion catheter is performed (no additional code because 37211 describes a single day of therapy).
The patient is brought back on day two with imaging performed, showing resolution of thrombus and an underlying 90 percent distal anastomotic stenosis. This is treated with a stent (37226 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed). Excellent result is obtained. The sheath is removed (37214) for the final day of thrombolytic therapy.
Note: If the entire procedure had been performed on a single day, you would not report 37214.
Differentiate Separate from Bundled Thrombolysis Services
Routinely, at the start of thrombolysis care, an angiographic catheter is placed near the site of thrombus and a diagnostic angiographic study is performed. Both the catheter placement and the imaging supervision and interpretation are reported; however, when intracranial thrombolysis is performed, the new cervico-cerebral codes (36222–36228) bundle the catheter placement.
With the change of the thrombolysis codes to “date of therapy” codes, there are no additional codes submitted when the patient returns to the angiography suite for follow-up imaging, or when the infusion catheter is repositioned or replaced. Do not report 75898 Angiography through existing catheter for follow-up study for transcatheter therapy, embolization or infusion, other than for thrombolysis during thrombolytic infusion therapy because it is bundled. Catheter exchange codes 37209 and 75900 are deleted in 2013 because this catheter exchange is bundled with the new thrombolysis codes.
Usually, after completion of the thrombolysis, an underlying cause (such as a stenosis) is identified. Treatment of that abnormality is additionally reported (e.g., angioplasty, atherectomy, stent placement). Mechanical arterial or venous thrombectomy may be reported in addition to prolonged thrombolysis infusion procedures. Codes 37184-37188 are used to describe these associated percutaneous thrombectomy procedures, when performed.
Although the new codes for thrombolysis do simplify coding, it may be disappointing to the on-call physician who performs a follow-up angiogram and catheter exchange (both included with 37211, submitted earlier in the day) at 11:30 pm, and has nothing to code.
David Zielske, MD, CPC-H, CIRCC, CCC, CCS, RCC, is an interventional radiologist and president of ZHealth Consulting and ZHealth Publishing in Brentwood, Tenn.