Cardiology Coding Alert

Pinpoint the method to avoid a $340 mistake.

If you’re one of the cardiology practices that has added endovenous ablation therapy (EVAT) to its slate of services, be sure your coding team has done the prep work required for bulletproof claims. 

Start With CPT® Descriptors and Notes

Your first stop in researching proper coding for EVAT (also called EVA) is your CPT® resource. “When coders start coding new procedures for their practice, they need to make sure they read the code explanation and the instructions below the code explanation carefully to ensure they code the procedure correctly,” says Catherine Brink, BS, CMM, CPC, CMSCS, CPOM, president of Healthcare Resource Management Inc. in Spring Lake, NJ.

Watch the Method: It Makes a $340 Difference

The procedure: In a typical EVAT procedure, the cardiologist uses ultrasound to map the veins and guide insertion of the laser or radiofrequency catheter into the vein. After positioning the catheter, the cardiologist applies energy at the site and during removal of the catheter to seal the problem vein and divert blood to healthier veins.

The codes: The first two EVAT codes are specific to radiofrequency:

• 36475, Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated
  
• +36476, … second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure). 
  

The next two are specific to laser:

• 36478, Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated
  
• +36479, … second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure). 
  

You want to be sure you properly identify the method, both to ensure compliant coding and because Medicare’s national nonfacility rate for 36475 ($1,561.05) is roughly $340 more than the rate for 36478 ($1,221.74).

Double Up the Add-On Service Documentation

Be sure to note the code structure. You use one code for the first vein treated in a single extremity, such as 36475 for radiofrequency. You then use a second code for each access site used for a second or subsequent vein, such as +36476, says Brink. The add-on code applies to services performed at the same session using the same method as the primary procedure.

Documentation tip: Ask providers to document the second insertion for +36476 and +36479 in both the summary and body of the report so auditors don’t overlook the services, says Terry Fletcher, BS,CPC, CCC CEMS, CCS-P, CCS, CMSCS, CMC, ACS-CA, SCP-CA, of Terry Fletcher consulting in her Peripheral Cardiology 2015 Updates presentation for audioeducator.com. 

Doubling the documentation will make your job of identifying services to code easier, too, says Fletcher. And that’s a good thing because each add-on code pays about $300 in the nonfacility setting.

Example: The cardiologist uses laser to treat an incompetent vein in the right leg. He then uses a separate access site to treat two additional veins in the same leg. You should report one unit of 36478 for the first vein and one unit of +36479 to represent the single access site used for the two additional veins.

Factor in Forbidden Combos From CPT® and CCI

You need to get a handle on the “Do not report with …” notes with the EVAT codes, too, Brink advises.

The notes for 36475/+35476 are almost identical to the notes for 36478/+36479, instructing you not to report the EVAT codes with the following codes when the cardiologist performs them in the same surgical field:

• Compression system codes 29581-29582 
• Injection and intravenous codes 36000, 36002, 36005, 36410, 36425
• Radiology codes 75894, 76000, 76001, 76937, 76942, 76998, 77022
• Duplex scan codes 93970, 93971.

The notes also instruct you not to report 36475 and +36476 with 36478 and +36479.

CCI fills in the blank: The note with 36475/+36476 tells you not to report the codes with vascular embolization and occlusion codes 37241-37244. The note with 36478/+36479 mentions only 37241. But don’t assume that means you can report 37242-37244 with 36478/+36479. Correct Coding Initiative (CCI) edits bundle 36478 into 37242-37244, so Medicare and other payers that apply CCI edits will pay you for only the embolization code if you also report the EVAT code. 

This rule from CCI is a good reminder that you have to look beyond the CPT® instructions to get the complete picture for proper coding. 

Locate Your MAC’s LCD for Conservative Therapy Rules

After reviewing the official CPT® rules, you need to take a look at relevant payer policies, such as your Part B MAC’s LCD.

You can expect the LCD to require the patient’s medical record to have documentation of failed conservative therapy to support performing the services 36475-+36479 describe, Fletcher says.

A typical LCD states EVAT coverage requires documentation of six to eight weeks of conservative therapy that failed to relieve the varicose vein symptoms, Fletcher says. Examples of conservative therapy include weight loss, exercise, and wearing compression stockings with a documented goal of treating the varicose veins.

Plan Ahead for ICD-10 Diagnosis Requirements

You also need to be sure the patient record supports one of the approved diagnoses to avoid a Medicare denial, Fletcher says. The procedure must be for medically necessary reasons rather than cosmetic purposes for Medicare coverage.

Fletcher indicates the following are typical ICD-9-CM codes for EVAT:

• 454.0, Varicose veins of lower extremities with ulcer
  
• 454.1, Varicose veins of lower extremities with inflammation
  
• 454.2, Varicose veins of lower extremities with ulcer and inflammation
  
• 454.8, Varicose veins of lower extremities with other complications.
  

The four ICD-9-CM codes above cross to about 30 ICD-10-CM codes, Fletcher says.

You’ll find those codes in category I83.- (Varicose veins of lower extremities).

To choose the correct ICD-10-CM codes, you’ll need documentation of the specific location of any ulcer, inflammation, any other complications, the leg involved, and the area involved, such as the thigh, calf, ankle, heel, midfoot, other part of the foot, or other part of the lower leg, says Fletcher.

Final tip: After you’ve familiarized yourself with all of the specifics of your MAC’s LCD, your job isn’t over. “Coders should check their Medicare carrier’s website for the latest updates on LCDs so they are current,” Brink says.