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General Surgery Coding Alert

Reader Question:

Stent To Support AAA Endograft not Payable

Published on Wed Aug 01, 2001

Question: Your February 2001 article about new codes for AAA repairs did not discuss the implantation of self-expanding stents.
 
The Ancure endograft limbs are unsupported. On occasion, the completion arteriogram may demonstrate the appearance of a stenosis of one or both limbs due to plaque or tortuous vessels. In this instance, do you agree that implantation of a self-expanding stent is indicated and clearly a separate and distinct service and not part of a routine endograft implantation?

Noel Parent, MD
Norfolk Surgical Group, Virginia
 
Answer: Many endovascular abdominal aortic aneurysm (AAA) patients have calcified vessels. Depending on the system, a self-expanding stent may be placed after the endograft is deployed to prevent calcification from damaging the endograft and cutting off blood flow.
 
The Ancure endograft does not rely on radial force. Instead, it uses an Endo-Hooks Attachment System that creates a circumferential seal between the graft and the vascular wall.
 
Because the mesh of the Ancure endograft is not self-expanding, it is susceptible to damage from plaque, and therefore the stent may be placed preventively to sustain the endograft, says Diane Elvidge, CPC, a coding and reimbursement specialist with Princeton Reimbursement Group in Minneapolis.
 
Because the stent is placed in the same vessel during the same session as a preventive measure, it is not a separately payable procedure, Elvidge says. She notes, however, that a more difficult procedure -- inserting a stent to support a kinked endograft -- is separately payable.
 
These kinks sometimes occur when a portion of the endograft section -- typically, the iliac section -- twists around itself while being deployed. The surgeon tries to catch and remove any such twists and kinks before the endograft is fully deployed. If kinks remain after the endograft is deployed, the stent will likely be placed inside the graft to work them out.
 
Note: Placing the endograft means getting it to the right spot. Deploying the endograft means making it take its full shape and size.
 
According to CPT Changes 2001: An Insiders View, occasionally, concurrent interventional procedures are performed at the time of the endovascular AAA repair. These should be coded in addition to the new codes for AAA repair by endovascular techniques. [emphasis added] They include ... stent placement within the aortic or iliac portions of the endograft to treat kinks or endoleaks.
 
The insertion of the stent should be reported using 37205 (transcatheter placement of an intravascular stent[s], [noncoronary vessel], percutaneous; initial vessel), Elvidge says.
 
Note: Stent placement to stop an endoleak may also be payable separately. Such leaks rarely occur with the Ancure system, however, because it uses a unibody prosthesis. Endoleaks treated via stenting typically occur between the joints of a modular bifurcated system.

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