Consider New Interventional Radiology Coding Concepts

7 Significant changes—including code deletion and new bundling concepts—are critical to know for accurate coding.

By David Dunn, MD, FACS

CPT® 2014 includes significant changes to interventional radiology (IR) coding. This article will discuss code changes related to stenting, fenestrated stent grafts for repair of visceral aorta, embolizations, drainage procedures, and breast biopsies. We’ll also take a quick look at new Category III codes for renal sympathetic denervation and pulmonary tumor ablations.

Editor’s note: Because of the number of codes and the richness of their nomenclature, which would take a good deal of extra space, we have paraphrased the code descriptions in this article. A glossary is provided on page 20. Please consult your CPT® 2014 codebook for the official descriptions.

Stents

For 2014, there is one new code (37217) for common carotid or innominate stent placement, when performed via a carotid cut-down.

Notes: 

  • Ipsilateral catheter selection and imaging is bundled to 37217.
  • Angioplasty within the deployment zone is bundled to 37217.

Example: In the operating room, the cervical carotid is exposed via an incision. A puncture is made, and angioplasty followed by stent placement in the innominate stenosis is performed.

Proper coding is 37217, which includes the open exposure, catheter selection, angioplasty, and stent.

The remaining stent code changes relate to non-carotid, non-vertebral, and non-lower extremity stent placements.

Codes 37205-37208 and 75960 are deleted. New, replacement codes are 37236 for the initial stent placement in the artery and +37237 for each additional artery; and 37238 for the initial stent placement in the vein and +37239 for each additional vein.

Notes: 

  • Use these codes for either open or percutaneous approach.
  • Codes include access creation and routine closure.
  • Supervision and interpretation (S&I), guiding, and completion imaging are included.
  • Angioplasty within the stent area, or within the same vessel that is stented, is not additionally reported.
  • Code per vessel treated (not per lesion or per stent placed).
  • You may report catheter selections and first-time diagnostic angiography.
  • You may report intravascular ultrasound (IVUS) when performed.
  • You may report ultrasonic guidance for access when performed and documented appropriately.
  • Only one initial arterial and/or venous stent is reported per encounter.
  • Bridging lesions between two vessels are reported with one stent placement.
  • Report stent if used as the sole treatment for aneurysm, pseudoaneurysm, or vessel trauma.
  • Do not code for stent if used to facilitate vessel occlusion with other embolization techniques, such as coils.

Example: A patient has bilateral, severe subclavian artery stenosis. Via a common femoral approach, the bilateral stenoses are angioplastied, followed by a stent placement in the left subclavian artery.

Proper coding is 36216, 36215-59, 37236 for the left subclavian angioplasty (included) and stent, as well as 35475 and 75962 for the right subclavian angioplasty.

Fenestrated Visceral Endograft

Category III endovascular repair codes 0078T-0081T are deleted. New, replacement codes for repair of visceral aorta by deployment of a fenestrated visceral aortic endograft are:

34841 Repair of visceral aorta; including one visceral artery endoprosthesis

34842 including two visceral artery endoprosthesis

34843 including three visceral artery endoprosthesis

34844 including four or more visceral artery endoprosthesis

If the anatomy requires placement of the fenestrated graft through the infrarenal aorta into the common iliac arteries, you will select from the following new codes:

34845 Repair of visceral aorta into the common iliacs; including one visceral prosthesis

34846 including two visceral artery endoprostheses

34847 including three visceral artery endoprostheses

34848 including four or more visceral artery endoprostheses

These codes are for the repair of abdominal aortic aneurysm, pseudoaneurysm, dissection, penetrating ulcer, hematoma, or disruption. The visceral aortic vessels include the celiac, superior mesenteric artery (SMA), and renal arteries.

Notes: 

  • Do not use 34841-34848 for chimneys, snorkels, or periscope procedures.
  • Imaging and angioplasty/stent placement within the deployment zone is bundled.
  • Catheter placements within the graft deployment zone are bundled, but catheter placements outside of the deployment zone may be reported separately.
  • Extensions that terminate distally in the common iliac artery (CIA) and/or proximal aortic extensions are bundled.
  • If performed, extensions into the internal or external iliacs or common femoral may be reported using 34825, 75953, 34826, or 75953-59.
  • You may separately report embolization if performed.
  • You may report 34812 for open approach when performed.

Example: Via a cut-down of the right common femoral and percutaneous access of the left common femoral, a fenestrated endograft is deployed from the suprarenal aorta extending into the common iliacs. Through fenestrations in the graft, three endoprotheses were deployed into the renals and the SMA.

Proper coding is 34847 and 34812 because the graft extended into the common iliacs, and three visceral endoprostheses were deployed. Only one cut-down (34812) was performed, on the right.

Embolizations

Endovascular embolization is used to treat abnormal blood vessels. Embolization codes 37204 and 37210 are deleted. The new codes for 2014 are:

37241 Non-hemorrhagic venous abnormalities (i.e., venous malformation, hemangioma, varicocele, dialysis fistula side branches)

37242 Non-tumor and non-hemorrhagic arterial abnormalities (i.e., arteriovenous malformations (AVM), aneurysm, arteriovenous (AV) fistula)

37243 Tumors or organ infarction (i.e., benign or malignant tumors, including uterine fibroids)

37244 Hemorrhagic arterial, or venous or lymphatic, extravasation (i.e., hemorrhage related to postpartum, gastrointestinal, trauma; Thoracic duct for chylous effusion)

Notes: 

  • There are no changes to codes for central nervous system (61624) or head and neck (61626) embolizations.
  • There may be overlap in the new codes; choose the appropriate code based on the primary reason for the current embolization procedure.
  • You may separately report diagnostic angiography and catheter placements.
  • Report only one embolization code per surgical field.
  • S&I is included in the new embolization codes; do not report 75894 with 37241-37244.
  • Follow-up embolization angiography is included in the new embolization codes; do not report 75898 with 37241-37244.

Example: A patient presents with significant hemorrhage secondary to the rupture of a splenic artery aneurysm. Coils are placed in the splenic artery, with occlusion noted on the follow-up angiogram. Report 37244 because the primary indication is hemorrhage (by contrast, 37242 is for arterial abnormality (aneurysm)). The follow-up angiogram (75898) is bundled; you may not report it separately.

Drainage Procedures

Abscess drainage codes 32201, 44901, 47011, 48511, 49021, 49041, 49061, 50021, and 58823 are deleted. The new codes are:

10030 Image guided drainage by catheter; soft tissue

49405 Image guided drainage by catheter; visceral (not for thoracentesis, pleural drainage, or cholecystostomy)

49406 Image guided drainage by catheter; peritoneal or retroperitoneal, percutaneous approach (not for paracentesis or peritoneal lavage)

49407 Image guided drainage by catheter; peritoneal or retroperitoneal, transvaginal or transrectal approach

Notes:

  • These codes are specific to the drained anatomical area as well as the approach.
  • Code for each drained collection with a separate catheter.
  • The new, image guided drainage codes bundle all imaging; do not additionally report 75989, 76942, 77002, 77003, 77012, or 77021.

Example: A percutaneous puncture is made under ultrasound guidance into a subcutaneous abscess in the right thigh. Purulent material is obtained and a catheter is left. Proper coding is 10030, which includes the imaging.

Breast Procedures

Breast biopsy codes 19102, 19103, 19290, 19291, 19295, 77031, and 77032 are deleted. New codes are:

19081 Percutaneous breast biopsy; first lesion, with stereotactic guidance

+19082 each additional lesion, stereotactic

19083 Biopsy; first lesion, with ultrasound guidance

+19084 each additional lesion, ultrasound

19085 Biopsy, first lesion, with magnetic resonance imaging (MRI) guidance

+19086 each additional lesion, MRI

Notes: 

  • Imaging guidance is bundled to codes 19081-19086.
  • If performed, specimen radiograph (76098) is bundled.
  • For breast procedures, the placement of markers is bundled with percutaneous biopsies.
  • Use add-on codes for additional biopsies when the same imaging modality is used.
  • Use another primary code if an additional percutaneous biopsy is performed with a different imaging modality.

Example: A percutaneous breast biopsy is performed with stereotactic guidance of a solid mass in the left breast, with a clip also placed to mark the site. This is followed by percutaneous breast biopsy with ultrasound guidance performed in a separate breast lesion in the left breast.

In this case, you’d report both 19081 and 19083 because different imaging modalities were used. The clip is bundled, as is the imaging guidance.

There are also new codes for breast marker/device placement for localization (when performed without a percutaneous image-guided breast biopsy). Markers might include clips, wires, needles, or seeds/pellets:

19281 Percutaneous placement of breast localization device(s); first lesion, mammographic guidance

+19282 each additional lesion, mammographic

19283 Device placement; first lesion, stereotactic guidance

+19284 each additional lesion, stereotactic

19285 Device placement; first lesion, ultrasound guidance

+19286 each additional lesion, ultrasound

19287 Device placement; first lesion, MR guidance

+19288 each additional lesion, MR

Notes:

  • Imaging guidance is bundled with 19281-19288
  • Use add-on codes for additional localization device placements with the same imaging modality.
  • Use a primary code if an additional localization device placement is performed with a different imaging modality.

Category III Codes

There are two new codes for renal sympathetic denervation: 0338T (unilateral) and 0339T (bilateral). Radiofrequency energy is applied to the renal arteries to help control resistant hypertension.

Notes:

  • S&I, including aortography and renal angiography, is bundled.
  • Pressure gradients, if performed, are bundled.
  • There is also a new code, 0340T, for cryoablation of pulmonary tumor(s).

Notes:

  • Code 0340T is unilateral.
  • Imaging is bundled.
  • The procedure includes extension of tumor to chest wall/pleura.

Incorporate Changes

New codes can be learned, but old habits die hard. When coding interventional radiology procedures performed in 2014, be ever vigilant of the new bundling concepts.

CODES

10030 Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst), soft tissue (eg, extremity, abdominal wall, neck), percutaneous

19081 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including stereotactic guidance

+19082
each additional lesion, including stereotactic guidance (List separately in addition to code for primary procedure)

19083 first lesion, including ultrasound guidance

+19084
each additional lesion, including ultrasound guidance (List separately in addition to code for primary procedure)

19085 first lesion, including magnetic resonance guidance

+19086
each additional lesion, including magnetic resonance guidance (List separately in addition to code for primary procedure)

19281 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including mammographic guidance

+19282
each additional lesion, including mammographic guidance (List separately in addition to code for primary procedure)

19283 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including stereotactic guidance

+19284
each additional lesion, including stereotactic guidance (List separately in addition to code for primary procedure)

19285 first lesion, including ultrasound guidance

+19286
each additional lesion, including ultrasound guidance (List separately in addition to code for primary procedure)

19287 first lesion, including magnetic resonance guidance

+19288
each additional lesion, including magnetic resonance guidance (List separately in addition to code for primary procedure)

34812 Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral

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 each additional vessel (List separately in addition to code for primary procedure)

34841 Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including one visceral artery endoprosthesis (superior mesenteric, celiac or renal artery)

34842
including two visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery(s))

34843
including three visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery(s))

34844
including four or more visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery(s))

34845 Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including one visceral artery endoprosthesis (superior mesenteric, celiac or renal artery)

34846
including two visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery(s))

34847
including three visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery(s))

34848
including four or more visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery(s))

35475 Transluminal balloon angioplasty, percutaneous; brachiocephalic trunk or branches, each vessel

36215 Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family

36216 initial second order thoracic or brachiocephalic branch, within a vascular family

37217 initial third order or more selective thoracic or brachiocephalic branch, within a vascular family

37236 Transcatheter placement of an intravascular stent(s) (except lower extremity, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; initial artery

+37237 each additional artery (List separately in addition to code for primary procedure)

37238 Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; initial vein

+37239 each additional vein (List separately in addition to code for primary procedure)

37241 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles)

37242
arterial, other than hemorrhage or tumor (eg, congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms)

37243 for tumors, organ ischemia, or infarction

37244 for arterial or venous hemorrhage or lymphatic extravasation

49405 Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); visceral (eg, kidney, liver, spleen, lung/mediastinum), percutaneous

49406 peritoneal or retroperitoneal, percutaneous

49407 peritoneal or retroperitoneal, transvaginal or transrectal

61624 Transcatheter permanent occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method; central nervous system (intracranial, spinal cord)

61626 non-central nervous system, head or neck (extracranial, brachiocephalic branch)

75894 Transcatheter therapy, embolization, any method, radiological supervision and interpretation

75898 Angiography through existing catheter for follow-up study for transcatheter therapy, embolization or infusion, other than for thrombolysis

75953 Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal aortic or iliac artery aneurysm, pseudoaneurysm, or dissection, radiological supervision and interpretation

75962 Transluminal balloon angioplasty, peripheral artery other than renal, or other visceral artery, iliac or lower extremity, radiological supervision and interpretation

75989 Radiological guidance (ie, fluoroscopy, ultrasound, or computed tomography), for percutaneous drainage (eg, abscess, specimen collection), with placement of catheter, radiological supervision and interpretation

76098 Radiological examination, surgical specimen

76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation

77002 Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device)

77003 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid)

77012 Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation

77021 Magnetic resonance guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation

0338T Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural roadmapping and radiological supervision and interpretation, including pressure gradient measurements, flush aortogram and diagnostic renal angiography when performed; unilateral

0339T bilateral

0340T Ablation, pulmonary tumor(s), including pleura or chest wall when involved by tumor extension, percutaneous, cryoablation, unilateral, includes imaging guidance

Modifier 59 Distinct procedural service

David Dunn, MD, FACS, is vice president of ZHealth. He oversees physician coding, instructs ZHealth educational programs, and contributes to Dr. Z’s Medical Coding Series. A graduate of Texas A&M University, Dunn completed his M.D. at the University of Texas, his surgical residency at Scott & White Hospital, and his vascular surgery fellowship at Baylor College of Medicine. A diplomat of the American Board of Surgery, Dunn is also certified in vascular surgery. He is a fellow of the American College of Surgeons and a member of the Southern Association for Vascular Surgery. Dunn is president of the AAPC National Advisory Board and a member of the Nashville, Tenn., local chapter.

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Renee Dustman

Renee Dustman

Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.
Renee Dustman

About Has 423 Posts

Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.

One Response to “Consider New Interventional Radiology Coding Concepts”

  1. Surgery1 says:

    Reporting open excision of breast lesions (such as lesions of the breast ducts, cysts, benign or malignant tumors), without specific attention to adequate surgical margins,markers using 19125-19126. (Source: CPT instructional notes) is causing editing for NCCI edit when billed the same date/claim with the preoperative placement of radiological clip/device 19283 done by radiologist. Is this accurate? The biopsy 19125 is an open procedure done by surgeon and the clip is placed at a separate encounter preoperatively by radiologist. Please provide guidance on the appropriate way to bill from a CMS or AMA perspective. Thanks.

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