Anesthesia Coding Alert

The insertion of a transjugular intrahepatic portal systemic shunt (TIPS or TIPSS) is a procedure usually performed in a radiology setting with anesthesia. There is no specific code for TIPS from the surgical standpoint, which can make coding the anesthesia portion a challenge.

The TIPS procedure is often performed on patients whose livers have become so scarred from conditions such as hepatitis or cirrhosis that the organ no longer filters blood efficiently. As a result, the blood pools in it. A TIPS procedure is performed when other options such as sclerotherapy have failed to control that congestion of blood.

Under general anesthesia, a catheter is inserted in the jugular vein and manipulated into the portal vein system to place a shunt. This device ensures that the portal vein stricture or stenosis is opened and blood flow is unobstructed.

Carriers Have Different Requirements

Because coding guidelines for the procedure are highly regional, it is important to work with your local carrier and be familiar with local policies regarding TIPS.

Some carriers have local codes they want providers to use when reporting TIPS, and others have local medical review policies (LMRPs) on the subject. Indianas Medicare is typical of many, says Scott Groudine, MD, chairman of the government, legal and economic affairs committee of the New York Anesthesia Society and an anesthesia specialist in Latham, N.Y. Since there is no specific CPT code for TIPS, the policy lists several options for coding the surgical portion of the procedure, depending on the physicians involvement. Two codes used most often under this policy are:

35476 transluminal balloon angioplasty, percutaneous; venous

37205 transcatheter placement of an intravascular stent(s), (non-coronary vessel), percutaneous; initial vessel

Other carriers suggest coding for TIPS with 37799 (unlisted procedure, vascular surgery). However, Mary Klein, CPC, coding specialist with the anesthesia billing group Panhandle Medical Services in Pensacola, Fla., says, Using an unlisted vascular procedure code is risky for anesthesia because it requires sending an operative report with the claim as support. Carriers can be very picky about paying these codes, and the documentation you get from the radiologist may not be sufficient to convince the carrier to pay you 10 base units for TIPS.

Vessel access and integral components of the procedure (such as selective catheter placement, venous system; first order branch [e.g., renal vein, jugular vein] [36011], percutaneous portal vein catheterization by any method [36481] or percutaneous transhepatic portography with or without hemodynamic evaluation, radiological supervision and interpretation [75885 or 75887]) may or may not be considered part of the primary procedure code 35476. In areas, such as Indiana, where these components are considered part of 35476, they should not be billed separately. However, most [...]