Cardiology Coding Alert

When you report endovascular abdominal aortic aneurysm (AAA) repair, knowing the type of prosthesis the cardiologist placed makes a world of difference in your code choice. Follow these four steps and familiarize yourself with the prosthesis types, and you'll choose the primary code for these procedures in a snap.

As an initial step, you should determine if the cardiologist places the prosthesis in the abdominal aorta only, or if a portion of the prosthesis extends into one or more of the iliac (or possibly renal) arteries.

As illustrated (Fig. 1), the abdominal aorta branches into the common iliac arteries below the renal arteries. If the abdominal aorta develops an aneurysm, or bulging due to a weakening of the artery walls, the cardiologist may make an incision in the groin and, under fluoroscopic guidance, thread a catheter through the arteries to the aneurysm site. Using guidewires and catheters, the cardiologist will then guide the prosthesis into place via the catheter. When expanded, the prosthesis reinforces the artery wall, which prevents the aneurysm from further ballooning or bursting.

34800: If the graft remains in the abdominal aorta only (Fig. 2), without extending into either iliac (or renal) artery, you should choose 34800 (Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using aorto-aortic tube prosthesis), says Marcella Bucknam, CPC, CCS-P,CPC-H, CCS, CPC-P, CPC-I, CCC, COBGC, manager of compliance education for University of Washington Physicians. This describes placement of a single-piece tube prosthesis without "docking limbs" (which we'll discuss later).

Note: If the graft prosthesis does extend into one or more iliac (or renal) arteries, you'll have to consider a few additional factors before you can choose the appropriate code.

If the prosthesis extends into one or both iliac arteries (or possibly a renal artery), you must next determine whether the graft is made of one piece (unibody) or of several pieces that the cardiologist places separately and joins together at the aneurysm site (modular).

CPT describes two unibody prostheses, which differaccording to whether the prosthesis enters one or both iliac arteries.

34805: Code 34805 (... using aorto-uniiliac or aortounifemoral prosthesis) describes a tubular graft, much like that described by 34800, except that for 34805, the graft extends into one iliac artery, Bucknam says.

"Codes 34800 and 34805 describe closely related procedures," verifies the AMA's CPT Changes 2004: An Insider's View. The "34800 prosthesis lies only in the aorta and is cylindrical in shape. Alternatively, code 34805 describes a procedure which requires the use of a longer prosthesis that extends into one iliac artery, therefore requiring a tapered cylindrical shape that is smaller in diameter at the distal end" (Fig. 3.1).

Note: You also may report 34805 for a graft that extends downward from a single renal artery (Fig. 3.2).

34804: If the single-piece prosthesis extends from the aorta to both iliac arteries, you'll choose 34804 (... using unibody bifurcated prosthesis). When in place, this prosthesis looks like an upside-down "Y" (Fig. 4). Each such prosthesis may be custom-made to match the patient's anatomy. The procedure includes passing a special contralateral iliac limb guidewire into the aorta. The cardiologist captures the wire using a snare advanced through the arteries from the opposite groin, and she then pulls the contralateral graft limb downward from the aorta into the opposite iliac artery.

All modular prostheses used for AAA repair extend from the aorta into the iliac arteries.

34802: You should report a two-piece graft (in which the cardiologist joins a single docking limb extending up from one iliac artery to the main portion of the prosthesis) using 34802 (... using modular bifurcated prosthesis [one docking limb]). "The prosthesis described by code 34802 is constructed of two separate pieces that are joined inside the patient's body during placement to make the ultimate configuration of an inverted 'Y,'" says CPT 2004 Changes (Fig. 5.1).

A three-piece graft consists of one primary portion in the aorta and two docking limbs extending into each iliac artery, all of which the cardiologist separately places and joins inside the patient's body to form the upside-down "Y" configuration (Fig. 5.2).

34803: Again, this graft, as described by 34803 (... using modular bifurcated prosthesis [two docking limbs]), has three pieces, unlike 34804 (single piece) and 34802 (two pieces).

Fenestration, visceral vessels call for Cat. III code: When the cardiologist places a modular graft with two docking limbs, but the graft employs small "windows" (fenestration) to allow blood flow to the visceral vessels, CPT instructs you to skip 34803 and instead report Category III code 0078T (Endovascular repair using prosthesis of abdominal aortic aneurysm, pseudoaneurysm or dissection, abdominal aorta involving visceral branches [superior mesenteric, celiac and/or renal artery(s)]).

On occasion, the cardiologist may choose to place extension cuffs at the ends of the prosthesis, either because the extension is necessary to reach past the aneurysm or because she has detected an endo-leak at the proximal or distal end(s) of the prosthesis.

34825, +34826: You should report an extension(s) placement in the initial vessel using 34825 (Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, or dissection; initial vessel). If the cardiologist places extensions in more than one vessel, call on a single unit of +34826 (... each additional vessel [List separately in addition to code for primary procedure]) for each additional vessel affected.

Example: If the cardiologist places an extension in a single iliac artery, report one unit of 34825 in addition to the primary prosthesis placement code.

If the cardiologist places extensions into each ilia cartery, report 34825 and +34826 in addition to the code for the primary prosthesis placement.

When the cardiologist must place extensions due to a leak detected postoperatively and within the 90-day global period of the primary procedure (34800-34804), the AMA recommends appending modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period) to the appropriate extension code(s).

Medicare tip: Modifier 78 applies to the service when the physician has to return the patient to the operating room for a related procedure during the postoperative period, said Donna Pisani, provider outreach and education consultant with National Government Services (NGS), during an April 22 global surgery conference call.

Vital distinction: CPT defines 34825-+34826 as "initial" or "additional" vessel, not "initial" or "additional" cuff. From a coding standpoint, only the number of vessels matters -- not the number of cuffs placed -- and you should report multiple cuffs placed in the same vessel only once. For instance, report two cuffs placed in the right iliac artery using 34825 only (because the cardiologist repaired only one vessel).