Endovascular Coding in 2018

Endovascular Coding in 2018

New, deleted, and revised codes capture the latest in endovascular repair.

Major changes went into effect for coding endovascular repair procedures on Jan. 1. Multiple surgical codes (34800-34806, 34825-34826, 34900) and radiological supervision and interpretation (S&I) codes (75952-75954) were deleted and replaced with new codes describing endovascular repair of the abdominal aorta and/or iliac arteries. The new codes are assigned not only for abdominal aortic aneurysm (AAA) repair, but also for treatment of pseudoaneurysm, dissection, penetrating ulcer, or traumatic disruption of the aorta or iliac arteries. Some existing codes were revised for 2018, as well.

Editor’s Note: See the “Code Descriptors” sidebar for full code descriptions.

Endovascular Repair 

There are two main keys to selecting the correct endovascular repair code: 1) the clinical indication; and 2) the type of device that is placed.

Codes for performing endovascular repair are based on whether the physician treats a ruptured or a non-ruptured aneurysm. Rupture is defined as “clinical and/or radiographic evidence of acute hemorrhage.” A chronic, contained rupture is not considered to be a rupture for coding purposes; it’s considered a pseudoaneurysm and is coded as a non-ruptured aneurysm.

When a clinical indication of atherosclerotic occlusive disease is treated with a covered stent placed in the aorta, assign 37236 and +37237, rather than the endovascular codes. For covered stent placement in the iliac artery for atherosclerotic occlusive disease treatment, assign 37221 and +37223, as applicable.

Device types include:

  • Aorto-aortic tube to cover the aorta (34701-34702)
  • Aorto-uni-iliac tube to cover the aorta and one common iliac artery (34703-34704)
  • Aorto-bi-iliac tube to cover the aorta and both common iliac arteries (34705-34706)
  • Ilio-iliac tube to cover an iliac artery (34707-34708)
  • Bifurcated iliac endograft to cover from the common iliac into both the internal and external iliac arteries (0254T)

Several components of endovascular procedures are now bundled into the new surgical codes: All radiological S&I components necessary to complete the procedure are now bundled with the deletion of the S&I codes 75952-75954; and non-selective catheterization codes (36140, 36200) are bundled with 34701-34711.

Note, however, when 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/or nonselective catheterization(s) required for device placement and all associated radiological supervision and interpretation, unilateral is assigned for placement of a bifurcated iliac stent graft, both non-selective and selective catheter placements are bundled.

Components that remain bundled are pre-procedure sizing and device selection, device positioning, manipulation and deployment, diagnostic angiography of the aorta and ileofemoral arteries, angioplasty and stenting of the treatment zone, and closure of arteriotomy. Diagnostic angiography codes are reported with the endovascular codes only when performed in vessels outside of the target treatment zone.

The treatment zone consists of any vessels that contain the main body of an endograft, and any docking limbs or extensions deployed within the same operative session. For 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.

Several components still may be reported separately, including:

  • Exposure of access vessels;
  • Selective catheterizations outside of the treatment zone;
  • Other interventions (angioplasty, stent, embolization, etc.) performed outside of the target treatment zone; and
  • Intravascular ultrasound (when performed).

Note: Although CPT® instructions indicate that extensive repair of an artery may be reported separately, the National Correct Coding Initiative Policy Manual, Chapter 5, says otherwise: “Repair and closure of a blood vessel utilized for vascular access during the performance of a procedure is an included component of that procedure. Repair of the blood vessel (e.g., CPT codes 35201-35286) should not be reported separately.”

Open Surgical Exposure 

During endovascular repair, access may be gained through a cut-down approach when a vessel is too small in diameter to allow passage of the endograft. When this open arterial exposure is used, it is coded separately. The correct code is selected based on the vessel chosen for exposure and the method of incision — the most common being an open femoral artery exposure via a groin incision (+34812). Other options are +34820 for open iliac artery exposure for iliac occlusion by an abdominal or retroperitoneal incision, +34834 for open brachial artery exposure, or +34715 for open axillary/subclavian exposure by infraclavicular or supraclavicular incision.

If the vessels are too small or diseased to allow introduction of an endograft device, a prosthetic conduit may be needed to place the endograft into the aorta. The conduit may be permanently attached, or it may be temporary. Codes for consideration are +34833, 34714, and +34716, which describe the establishment of cardiopulmonary bypass.

Open exposure add-on codes are reported twice for bilateral open exposure. Do not use modifier 50 Bilateral procedure to report a bilateral procedure, unless specifically requested by a third-party payer to do so.

Note that for 2018, all of these codes are designated add-on codes, to be used with a primary procedure.

Percutaneous Access 

There is a single code (+34713) for percutaneous access and closure of the femoral artery; however, it is assigned only when a large sheath (12 French or larger) is required for delivery of the endograft. It includes ultrasound guided vascular access (e.g., +76937), when performed, and placement of dual closure devices. This code may be reported once, per side. Do not use +34713 with 37221, 37223, 37236, or 37237 when treating atherosclerotic disease with a covered stent.

Placement of Extensions 

Extensions are placed when the main endoprosthesis is not long enough to reach beyond the termination of the aneurysm, or if an endoleak is identified at the proximal or distal end of the device. To be coded separately, 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.

Extensions may be placed at the time of initial endovascular repair, or may be placed at a later date, as necessary. Code +34709 is assigned at the time of initial endograft placement with code range 34701-34708. Report 34710 and +34711 for delayed placement of extensions at a later date.

Code +34709 describes placement of an extension prosthesis distal to (below) the common iliac arteries or proximal to (above) the renal arteries. Do not report +34709 for placement of a docking limb that extends into the external iliac artery. Any endograft extensions that terminate in the common iliac arteries are included in 34703–34708 and are not reported separately.

Report +34709 once per vessel treated, not per extension or “cuff.” When performed, treatment zone angioplasty/stenting is bundled with placement of the extension, just as it is bundled with the main endograft placement. For an endograft placed into a renal artery that is being covered by a proximal extension, see 37236-37237.

When an extension is placed at a later session, it is referred to as a delayed placement of an extension. Codes 34710 and +34711 are assigned for the delayed placement of distal or proximal extensions to repair an infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, endoleak, or endograft migration. As with the endograft placement (34701-34708), pre-procedure sizing, and device selection, all non-selective catheterization(s), all associated radiological S&I, and treatment zone angioplasty/stenting, when performed, are bundled with 34710 and +34711.

Multiple endograft extensions placed in a single vessel may be reported with a single code, only. CPT® parenthetical notes specifically state that codes 34710 and +34711 may be reported only once per operative session.

Code Descriptors

Endovascular Repair Abdominal Aorta and Iliac Arteries

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 radiological supervision and interpretation, 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)

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 radiological supervision and interpretation, 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)

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 radiological supervision and interpretation, 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)

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 radiological supervision and interpretation, 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)

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 radiological supervision and interpretation, 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)

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 radiological supervision and interpretation, 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)

Open Arterial Exposure/Percutaneous Access

+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 for 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 of aortic or iliac 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)

+34713 Percutaneous access and closure of femoral artery for delivery of endograft through a large sheath (12 French or larger), including ultrasound guidance, when performed, unilateral (List separately in addition to code for primary procedure)

+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)

Placement of Extension Prosthesis

+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 radiological supervision and interpretation, and treatment zone angioplasty/stenting, when performed, per vessel treated (List separately in addition to code for primary procedure)

34710 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 radiological supervision and interpretation, 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 radiological supervision and interpretation, and treatment zone angioplasty/stenting, when performed; each additional vessel treated

Iliac Artery Occlusion Device

+34808 Endovascular placement of iliac artery occlusion device (List separately in addition to code for primary procedure)

Endograft Fixation Device 

34712 Transcatheter delivery of enhanced fixation devices(s) to the endograft (eg, anchor, screw, tack) and all associated radiological supervision and interpretation

FEVAR and TEVAR 

For 2018, coding of fenestrated endovascular aortic/aneurysm repair (FEVAR) remains mostly unchanged; however, the new open exposure of access vessel codes and extension prosthesis codes are used to report FEVAR procedures. For FEVAR procedures, extension codes may be reported only for distal extension prostheses that terminate in the internal iliac, external iliac, or common femoral artery. This differs from the rules for endograft placement (34701-34708). These “fenestrated” grafts have holes that maintain patency of visceral vessels and permit selective catheterization of the visceral and renal arteries, allowing for additional treatment of these vessels, when necessary.

For FEVAR procedures, extension codes may not be separately reported for a proximal abdominal aortic extension prosthesis, or for a distal extension prosthesis that terminates in the aorta or the common iliac arteries. This work is included in the FEVAR codes (34841-34848).

Like FEVAR, for thoracic endovascular aortic aneurysm repair (TEVAR) procedures, the new open exposure of access vessel codes may be assigned with these procedures. This is the only change that affects coding of these procedures. These procedures involve placement of an expandable stent graft within the thoracic aorta and are included in code range 33880-33886.

Other Related Procedures

Decompressive Laparotomy (49000)

It may be necessary to perform a decompressive laparotomy with an endovascular repair being performed due to abdominal trauma. Surgical decompression is performed by opening the abdominal wall and fascia to create more space for the abdominal viscera. Assign 49000 Exploratory laparotomy, exploratory celiotomy with or without biopsy(s) (separate procedure) when a decompressive laparotomy is performed.

Endograft Fixation Device (+34712)

New add-on code +34712 describes delivery of an enhanced fixation device such as an anchor, screw, or tack. It includes all associated radiological S&I and is reported only once per operative session. This code may be used at time of initial placement of an endograft or at a later session when placing a delayed extension.

Iliac Artery Occlusion Device (+34808)

Assign +34808 for placement of an iliac artery occlusive device when it is necessary to temporarily block off an iliac artery during a repair.

Examples

Bilateral access to the common femoral artery is obtained via femoral artery cutdown. Catheters were manipulated through both accesses to place a Gore® Excluder® device, a modular bifurcated prosthesis with one docking limb. Clinical indication: AAA.

Codes: 34705, 34812, 34812

Bilateral access to the common femoral artery is obtained via femoral artery cutdown. Catheters were manipulated through both accesses to place a Medtronic Endurant® device, a modular bifurcated prosthesis with one docking limb covering the common iliac. An extension was placed in the aorta above the renal arteries and in the external iliac artery. Clinical indication: AAA, iliac artery aneurysm.

Codes: 34705, 34812, 34812, 34709, 34709

Bilateral access to the common femoral artery is obtained via femoral artery cutdown. Catheters were manipulated through both accesses to place an Endologix Powerlink® System, a unibody bifurcated graft with two limbs. Clinical indication: AAA.

Codes: 34812, 34812, 34705

Access is gained at the right common femoral artery for placement of a Cook Zenith® Branch Iliac Endograft, a bifurcated endoprosthesis at the right iliac artery bifurcation (external and internal), for treatment of an aneurysm. Clinical indication: iliac artery aneurysm.

Codes: 0254T

Bilateral access to the common femoral artery is obtained via femoral artery cutdown. Catheters were manipulated through both accesses to place the fenestrated endograft into the visceral aorta and through the infrarenal abdominal aorta. Three visceral arteries were also treated. An extension was placed, terminating in the external iliac artery.

Codes: 34812, 34812 34847, 34709

Bilateral access to the common femoral artery is obtained via femoral artery cutdown. Catheters were manipulated through both accesses to place a thoracic aorta endoprosthesis, which covered the subclavian artery origin.

Codes: 34812, 34812, 33880, 75956, 36200, 36200-59

Stacie Buck, RHIA, CIRCC, CCS-P, RCC

is an AAPC Fellow and president and senior
consultant at RadRx in Stuart, Fla. (www.radrx.com). She is a national speaker who provides consulting services to providers of diagnostic and interventional radiology services, the author of “Cracking the IR Code: Your Comprehensive Guide to Mastering Interventional
Radiology Coding,” and the creator of Mastering Interventional Radiology & Cardiology Online Education Program. Buck may be contacted at sbuck@radrx.com. She is a member of the Stuart, Fla., local chapter.

Latest posts by Stacie Buck, RHIA, CIRCC, CCS-P, RCC (see all)

About Has 3 Posts

is an AAPC Fellow and president and senior consultant at RadRx in Stuart, Fla. (www.radrx.com). She is a national speaker who provides consulting services to providers of diagnostic and interventional radiology services, the author of “Cracking the IR Code: Your Comprehensive Guide to Mastering Interventional Radiology Coding,” and the creator of Mastering Interventional Radiology & Cardiology Online Education Program. Buck may be contacted at sbuck@radrx.com. She is a member of the Stuart, Fla., local chapter.

3 Responses to “Endovascular Coding in 2018”

  1. Sarah says:

    Procedure: Aorto-bi-iliac endograft placed via bilateral femoral cutdowns and bilateral catheter placements with 12 french sheaths and larger with a closure device. Would you be able to bill 34705 with 34812 and 34713 bilaterally?

    Thank you

  2. Sharon Clarke says:

    I am trying to print this for a reference later. Both paper and PDF print with hyperlinks for AAPC all overtop of the article.

    Is that something embedded on the page as it is pretty useless as it is.

    Thank you

  3. Brad Ericson says:

    I”m sorry, Sharon. Have you tried a different browser?

Leave a Reply

Your email address will not be published. Required fields are marked *