General Surgery Coding Alert

+37222, +37223 add on ipsilateral iliac vessel

With an entire new section for endovascular revascularization in CPT 2011, you'll need to institute lots of coding changes for these procedures in your general surgery practice. Let our experts start you off right with five keys to iliac artery revascularization.

What's changing: "Sixteen new codes for lower extremity revascularization will help you more accurately report procedures your surgeon performs to treat occlusive disease," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle.

The following four new codes focus on what CPT 2011 calls the "iliac vascular territory":

• 37220 -- Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty
• 37221 -- ...with transluminal stent placement(s), includes angioplasty within the same vessel, when performed
• +37222 -- Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty (List separately in addition to code for primary procedure)
• +37223 -- ... with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure).

Principle:Whether your surgeon performs one of these procedures percutaneously, via open exposure, or via a combination will not affect your code choice. All four codes are appropriate for any of those methods.

1. Include Catheterization, Radiology, and More in 37220-+37223

In 2010, you used component billing for your endovascular revascularization procedures, but all that's changed in 2011.

The new codes 37220-+37223 bundle selective catheterization, radiological supervision and interpretation, and treatment, according to Sean P. Roddy, MD, FACS,AMA CPT Advisory Committee member, Gary R. Seabrook, MD, AMA Specialty Society Relative Value Scale Update Committee member in theirpresentation at the AMA's CPTand RBRVS 2011 Annual Symposium.

See the Clip and Save on page 14 for a complete list of services bundled in these codes.

2. Distinguish 'Initial' and 'Additional' Vessels

The codes for iliac services differ based on whether you're coding a service in an initial vessel (37220, 37221) or in an additional vessel (+37222, +37223) on the same side (ipsilateral).

Key: CPT specifies that, in each leg, "the iliac territory is divided into 3 vessels: common iliac, internal iliac, and external iliac." Codes 37220 and 37221 apply to the first iliac artery treated in a single leg. If the physician treats one or two additional iliac vessels in the same leg, then you should choose from +37222 and +37223. You may use up to two add-on codes per leg, because there are three iliac vessels.

Caution: Don't use +37222 or +37223 if the additional vessel is on the other side. See step 5 for that scenario.

Tackle vessel vs. lesion:Because the codes apply per vessel, you should not report add-on codes for additional lesions in a single vessel. CPT is very clear that "when more than one stent is placed in the same vessel, the code should be reported only once."

3. Learn How Stent and Angioplasty Affect Coding

Your coding options differ based on whether you're reporting (1) angioplasty alone or (2) stenting, with angioplasty, if performed. (See the Clip and Save on page 14 for a visual representation of how these new codes break down.)

Angioplasty only: Report 37220 or +37222 if the surgeon performs angioplasty only.

Angioplasty and stent: When the surgeon performs a stent placement in the initial iliac vessel, you should report only 37221. That code covers both stent placement and angioplasty, but angioplasty is not required to use the code. You should not report 37220 (angioplasty) in addition to 37221 in this scenario. Similarly, you should use +37223 for stent placement (and angioplasty, if performed) in an additional iliac artery in the same leg.

4. Check Rule for 1 Intervention in 2-Artery Lesion

In some cases, a lesion may extend from one artery into another. If the surgeon can treat that lesion with a single intervention, then you should choose a single code to report that service. CPT offers the example of stenosis that extends from a common iliac into the proximal external iliac. If the surgeon uses a single stent to treat the lesion, CPT instructs you to report initial vessel code 37221. You should not also report additional vessel code +37223.

On the other hand, if the stenotic lesions involve two separate iliac arteries divided by a bifurcation with a break in stenosis requiring multiple therapies, then you should report an "initial" code as well as an "additional" code.

5. Look Out for Work in Both Legs

Codes 37220-37221 state that they're unilateral, which means they apply to a service on a single side of the body. Similarly, +37222 and +37223 state that they're for each "ipsilateral" vessel, which means they apply to a service on the same side of the body.

For instance: That means if your surgeon performs angioplasty in an iliac artery in one leg and then performs angioplasty in another iliac artery in the other leg, you should report two units of 37220 instead of 37220 and +37222.

Use modifiers: CPT suggests that if the physician treats the identical territory (such as iliac) in both legs at the same session, you should use modifier 59 (Distinct procedural service) to show both legs are involved. This holds true even when the mode of therapy is different in each leg, such as angioplasty in the left leg and both angioplasty and stent in the right leg. Keep alert for payers' modifier preferences, though, as some may prefer you to use modifier 50 (Bilateral procedure), modifiers RT (Right side) and LT (Left side), or some combination of modifiers for procedures on both legs.