Coding Complex Vascular Cases

Test your ability to code cardiovascular disease and surgery.

Cardiovascular coding is not for the faint of heart. Understanding how and why the procedures are performed is half the battle — a battle won by the medical coders who attended the session “Case Based Complex Vascular Coding” at AAPC’s regional HEALTHCON 2021 in Charleston, S.C.

Carmen M. Piccolo III, DO, FACS, FACOS, FSVS, RPVI, and compliance auditor Eva Alexander, CPC, RHIT, both from McLeod Heart & Vascular Institute, guided conference attendees through several real-world scenarios, making sense of the most complex vascular surgical procedures and how to code them.

In this article, we’ll share with you a few of the cases and ask you to code both the diagnoses and procedures. You can check your coding by watching clips of the recorded session in the electronic version of Healthcare Business Monthly (AAPC membership and login required).

Case 1: Covered Repair of the Aortic Bifurcation (CERAB) — Hybrid Aortobifemoral Bypass

A computed tomography angiography (CTA) scan with a 3D representation of the aorta, shown in Figure A, shows the right renal artery disease is severe and the kidneys have pretty much shut down long term. Angiograms are performed to see what’s going on inside the patient. As shown in Figure B, this patient’s aorta is so occluded you can’t see it.

When coding a complex cardiovascular case like this, Alexander said, “it is important to bill to the more specificity that you have for a diagnosis and the comorbid condition because it paints a better picture of the severity of your patient.”

Code the diagnoses: Check your coding by watching the video in the electronic magazine at AAPC.com while signed in to your My AAPC account.

Procedures performed:

• Bilateral open femoral exposure
• Aortoiliac angiogram from bilateral common femoral arterial access
• Catheterization of the aorta from bilateral common femoral artery access
• Kissing distal aorta and bilateral common iliac artery stent grafting with AFX device
• Stent grafting of the remainder of the infrarenal aorta
• Bilateral external iliac artery angioplasty and stenting with stent graft
• Bilateral common femoral artery endarterectomy with bovine pericardial patching and eversion profunda artery endarterectomy

Be careful coding the kissing distal aorta and bilateral common iliac artery stent grafting with AFX® device. “There will be a lot of physicians and even reps from companies saying that you can use the aneurysm code for that, and they were right in the past,” Dr. Piccolo said. In 2017 and before, he explained, ICD-10 included I70.0 Atherosclerosis of aorta and I70.8 Atherosclerosis of other arteries for the aneurysm code (CPT® 34800-34804). That isn’t the case anymore.

According to Alexander, you should sequence the codes from the highest to lowest fee. Depending on the payer, however, “you may want to place the add-on code closest to the main procedure,” she said.

Another variable is modifiers. “As you know, insurance makes a big difference when we append modifiers,” Alexander said. Some payers require right (RT) and left (LT) modifiers; other payers require the line-item format. Just be careful when reporting units, Alexander advised, to “make sure the units and the fee match.” The CPT® code book instructs that modifier 50 Bilateral procedure should not be used on add-on codes; however, always check the payer’s policy and the Medicare Physician Fee Schedule Database, both of which may contradict CPT® guidelines.

Code the procedures: Check your coding by watching the video in the electronic magazine at AAPC.com while signed in to your My AAPC account.

Case 2: Thrombotic May-Thurner Syndrome With Endovascular Repair

Code the diagnoses: Check your coding by watching the video in the electronic magazine at AAPC.com while signed in to your My AAPC account.

Procedures performed:

• Bilateral popliteal venous access with ultrasound guidance and image saved for chart
• Bilateral lower extremity and inferior vena cava (IVC) venogram
• Bilateral IVC catheterization with venogram
• Intravascular ultrasound interrogation of the bilateral femoral veins, bilateral common femoral veins, bilateral external iliac veins, bilateral common iliac veins, and IVC with measurements and images saved for chart
• Left lower extremity and iliac vein percutaneous venous mechanical thrombectomy
• Kissing bilateral common iliac vein stenting with venoplasty and left external iliac vein venoplasty and stenting
• Completion venogram and intravascular ultrasound interrogation

As shown in Figure C, the bilateral popliteal venous access with ultrasound guidance shows the left is completely occluded and the right is open. As shown in Figure D, the venograms show a clot on the left side. An intravascular ultrasound interrogation provides a better visual of the clot and enables the surgeon to assess the occlusion. Figure E shows the patient’s common iliac vein on both sides and a clot in the left inferior vena cava (IVC).

When coding, “always look for images for vascular accesses and intravenous urography procedures saved in the chart that support the documentation,” Alexander said. And be sure to check for any medically unlikely edits, which you can find in the National Correct Coding Initiative file at CMS.gov.

Code the procedures: Check your coding by watching the video in the electronic magazine at AAPC.com while signed in to your My AAPC account.

Case 3: Two-Vessel fEVAR With Iliac Branch Endograft Device

Aneurysm is the Greek term for widening. The most common aneurysms are infrarenal abdominal aortic aneurysms (AAAs), “but not all renal abdominal aortic aneurysms are created equal,” Dr. Piccolo said. It really depends on where the aneurysm is in relation to the mesenteric vessels and renal arteries, and the closer it is the higher the chance of a failure, he said. Surgeons typically fix AAAs in men around 5 to 5.5 cm and in women about 5 cm. “That’s where the risk of rupture is higher than the risk of having a procedural problem,” Dr. Piccolo said.

Code the diagnoses: Check your coding by watching the video in the electronic magazine at AAPC.com while signed in to your My AAPC account.

Procedures performed:

• Bilateral open femoral exposure
• Repair of right common iliac artery aneurysm with right iliac branch endoprosthesis for preservation of the right hypogastric artery
• Two-vessel fenestrated aortic endograft repair of a juxtarenal AAA with Zenith fenestrated endograft and SMA scallop with bilateral aortic cannulation
• Coil embolization of the left hypogastric artery and CIAA
• Left external iliac artery limb extension
• Right external iliac artery angioplasty and stenting for bulky calcified atherosclerotic iliac occlusive disease
• Left external iliac artery angioplasty and stenting for bulky calcified atherosclerotic iliac occlusive disease
• Right common femoral artery endarterectomy with bovine pericardial patch angioplasty
• Left common femoral artery endarterectomy with bovine pericardia patch angioplasty

Figure F shows the common iliac artery with calcium burden. “This vessel was so tight that we actually put a stent in initially just to keep it open while we were putting in our device,” Dr. Piccolo said. The surgeon was then able to drive the device up and over the aortic bifurcation, as shown in Figure G. Dr. Piccolo stepped through the remaining procedures, explaining the difficulty of the procedures and risks to the patient.

Code the procedures: Check your coding by watching the video in the electronic magazine at AAPC.com while signed in to your My AAPC account.

Also, during this presentation, Dr. Piccolo reviewed a case for complex endovascular revascularization for CLI of the left lower extremity with gangrene and digit amputation and subsequent washout and another case for endovascular repair of type B aortic dissection with staged L CCA to SA bypass and proximal SA embolization.

An Experience Like No Other

If you think cardiovascular coding is hard, you’re right. Studying clinical cases is helpful, but the best way to learn how to code complex vascular cases is to listen to a vascular surgeon talk about the procedures they perform and hear the coding rationales from an experienced compliance auditor.

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Renee Dustman

Managing Editor at AAPC

Renee Dustman, BS, AAPC MACRA Proficient, is managing editor - content & editorial at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 30 years' experience in journalistic reporting, print production, graphic design, and content management. Follow her on Twitter @dustman_aapc.

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