Cardiology Coding Alert

 Hint: If your cardiologist uses venous transcatheter therapies, you should report 37187.

When your cardiologist performs a mechanical thrombectomy, you should check the medical documentation for specific details such as whether it is an arterial or a venous procedure. You must also know if the arterial mechanical thrombectomy is primary or secondary.

Read on to keep your mechanical thrombectomy procedures in tip-top shape.

Tip 1: Define Mechanical Thrombectomy for Clarity

“Mechanical thrombectomy involves the removal of a thrombus (blood clot) from a vessel (eg, thrombotic occlusion of an extremity artery) to help restore circulation,” according to CPT^® Assistant Vol. 29, No. 9.

You have separate code sets for both arterial (37184-+37186) and venous transcatheter therapies (37187 and 37188).

Don’t miss: Codes 37184-37188 include the intraprocedural fluoroscopic radiological supervision and interpretation services for the thrombectomy guidance, according to the CPT^® guidelines. However, you can separately report catheter placement, diagnostic studies, and other percutaneous interventions such as a transluminal balloon angioplasty and stent placement.

Tip 2: Follow Rules for Primary Arterial Mechanical Thrombectomy

When your cardiologist performs a primary arterial mechanical thrombectomy, he will diagnose the thrombus prior to performing the mechanical thrombectomy procedure. The cardiologist will also preoperatively plan the thrombectomy. After he performs the thrombectomy, he will conduct a post-procedure evaluation.

You should report 37184 (Primary percutaneous transluminal mechanical thrombectomy, noncoronary, non-intracranial, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injection(s); initial vessel) for “endovascular mechanical thrombectomy in the initial arterial vessel,” per CPT^® Assistant. Note: You should never report 37184 in conjunction with intracranial arterial transluminal mechanical thrombectomy code 61645, fluoroscopy code 76000, or injection code 96374, according to the CPT^® guidelines.

Caution: If you are reporting mechanical thrombectomy of an additional vascular family the cardiologist treated through a separate access site, you should append modifier 59 (Distinct procedural service) to 37184 for the mechanical transluminal thrombectomy.

And, you should report +37185 (… second and all subsequent vessel(s) within the same vascular family (List separately in addition to code for primary mechanical thrombectomy procedure)) for the second or all subsequent vessels within the same vascular family. “The phrase ‘second and all subsequent vessel(s)’ in the code descriptor means that code +37185 is reported only once, no matter how many subsequent vessels are treated in a given vascular family,” according to CPT^® Assistant. “… other interventions (eg percutaneous transluminal angioplasty) may be performed in conjunction with the thrombectomy to treat a previously unidentified (revealed only after clearing the thrombus) underlying pathology (eg, stenosis), and may be separately reported.”

Note: You should never report +37185 in conjunction with 76000 or injection code +96375, according to CPT^®. Additionally, you should never report +37185 in conjunction with 61645 for the treatment of the same vascular territory.

Tip 3: Delve Into Secondary Arterial Mechanical Thrombectomy

If your cardiologist performs a “secondary” transcatheter procedure, you should report +37186 (Secondary percutaneous transluminal thrombectomy (eg, nonprimary mechanical, snare basket, suction technique), noncoronary, non-intracranial, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injections, provided in conjunction with another percutaneous intervention other than primary mechanical thrombectomy (List separately in addition to code for primary procedure)).

“A ‘secondary’ transcatheter thrombectomy procedure is performed for the removal or retrieval of segment(s) of a thrombus or embolus, typically after another percutaneous intervention that was complicated by a thrombotic event,” according to CPT^® Assistant. “Alternatively, when arterial pathology is known prior to an endovascular intervention and pre-procedure planning is focused on correction of the pathology (eg angioplasty or stenting), secondary thrombectomy may be performed to remove short segments of thrombus also known to be present to prevent complications (distal clot embolization) or to enhance the correction of the pathology.”

“You may see angioplasty performed to macerate clot,” says Robin Peterson, CPC, CPMA, Manager of Professional Coding, Pinnacle Integrated Coding Solutions, LLC. “Thrombectomy codes include getting rid of clot by any method, including balloon maceration.”

Caution: You should never report +37186 in conjunction with the following codes:

• 37184 and +37185
• 76000
• +96375
• 61645 for the treatment of the same vascular territory

Tip 4: And, Rely on These Codes for Venous Mechanical Thrombectomy

If your cardiologist uses venous transcatheter therapies, you should report code 37187 (Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance) for the initial application.

Don’t forget: If your cardiologist performs a bilateral venous mechanical thrombectomy through a separate access site(s), you should append modifier 50 (Bilateral procedure) to code 37187.

On the other hand, if your cardiologist performs repeat treatment on a subsequent day during the course of thrombolytic therapy, you should report 37188 (Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance, repeat treatment on subsequent day during course of thrombolytic therapy).

Tip 5: Put it All Together With an Example

Coding example: In the hospital, the cardiologist performed a diagnostic angiography on the main pulmonary artery. He also administered a TPA injection. The cardiologist performed an angiojet thrombectomy with multiple passes in the main pulmonary artery and an IVC venogram to identify the renal veins, as well as an IVC filter placement.

Coding solution: For the thrombectomy, you should report 37184. Since this code includes intraprocedural thrombolytic injections, you cannot report the TPA injections separately.

The correct code for the radiological portion of the main pulmonary artery angiography is 75746-26 (Angiography, pulmonary, by nonselective catheter or venous injection, radiological supervision and interpretation; Professional component). Code 75746 is bundled into 37184, so you should report 75746 only if it’s for a truly diagnostic angiogram (no previous ones available, the decision to perform the thrombectomy was based on this angiography, etc.). To report a true diagnostic angiogram, append modifier 59 (Distinct procedural service) to 75746.

For the IVC filter placement, you should report 37191 (Insertion of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance [ultrasound and fluoroscopy], when performed).