General Surgery Coding Alert

Capture steps for insertion, repositioning, and removal.

When your general surgeon manipulates an inferior vena cava (IVC) filter, several code choices and reporting rules could compromise your accurate billing.

Heed the following expert tips to make sure you’re in the know when your face an IVC filter coding scenario in your practice, so you can claim all the pay you deserve.

Tip 1: Recognize the Procedure(s)

Surgeons commonly perform IVC filter manipulation services for patients who develop clots in the leg veins, possibly due to being immobile or bedridden for long periods. The condition is called deep vein thrombosis (DVT), and it can be life-threatening if a piece of the clot breaks off and travels to the heart or lungs. 

“An IVC filter serves to prevent clots from traveling through the vena cava vein to the lungs,” says Christy Hembree, CPC, team leader at Summit Radiology Services in Cartersville, Ga.

Your surgeon may place a new IVC filter, or reposition or remove an existing filter. These manipulation options represent three distinct services that your surgeon might perform, represented by the following three codes:

• 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

• 37192 — Repositioning 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

• 37193 — Retrieval (removal) 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.

Caution: “Never code the insertion, repositioning, and/or removal during the same encounter,” says Christina Neighbors, MA, CPC, CCC, coding quality auditor for Conifer Health Solutions.

For coding purposes, each surgery involves only insertion, or repositioning, or removal. “For instance, if the surgeon inserts an IVC filter, then repositions it in the same session, you should bill only for an insertion,” says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CCC, COBC, CPC-I, internal audit manager at PeaceHealth in Vancouver, Wash.

Tip 2: Know What’s Included

Code 37191 involves several steps — “including vascular access, vessel selection, radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed,” Hembree says.

The IVC codes include prepping and anesthetizing the patient. The surgeon will then select a suitable access vein.  He may choose to insert a needle into the femoral vein at groin level or the internal jugular vein in the neck based on the number and location of identified blood clots within the venous system. You should see these steps described in the op note.

Avoid: Do not report 75825 (Venography, caval, inferior, with serialography, radiological supervision and interpretation) when your surgeon performs an injection to localize the renal veins before deploying the IVC filter. This imaging is also bundled into the codes for IVC filter placement. “You should not report code 75825 with 37191-37193 if the venography is only used as a tool in placing the filter,” Hembree says.

Ignore filter type: You may spot the terms “temporary” or “permanent” in the procedure note. Temporary IVC filters can be subsequently repositioned or removed. However, whether the filter is temporary or permanent does not impact the codes you choose from for reporting the IVC filter procedures.

Tip 3: Focus on Each Step

Read the following examples and descriptions to see what you might see in your surgeon’s op report that will lead you to choose one of the IVC filter manipulation codes.

Placement: Here’s a typical note you might see for an IVC insertion procedure: 

“A thin, long, flexible guide wire and catheter were introduced into the vein. The needle was removed and the catheter was connected to a fluoroscope to obtain digitally subtracted images of the blood vessels. The anatomic structure of the IVC was assessed and the diameter of the target vein was determined. The catheter was removed. An introducer sheath along with the enclosed filter was advanced into the access vein along the guide wire to reach the IVC. With the help of the visual imaging guidance, the filter was gently deployed just below the junction of the IVC and the lowest renal vein. Under fluoroscopy, the deployment and adequate alignment and position of the filter within the IVC were confirmed. The guide wire and introducer sheath were then removed. The images were archived for interpretation. Pressure was applied to the puncture site to stop bleeding.”

“You should submit 37191 for a new permanent or temporary filter that your physician places in the IVC,” Hembree says.

Repositioning: Here is a sample procedure note that can help you confirm the repositioning of an IVC filter, which you should code as 37192:

“The position of the existing filter and anatomy of the IVC was assessed. The position of the filter cone was determined with respect to the caval wall. The filter was checked for any trapped clots and emboli. The catheter was removed and a telescopic filter retrieval sheath and snare were advanced in the IVC along the guide wire. Avoiding any abrasions on the IVC wall, the cone was grasped with the snare and the filter was collapsed into the sheath. Under fluoroscopic guidance, the filter was re-deployed to a new position in the IVC. Position of the filter and alignment were confirmed once again.”

Removal: The op note for an IVC removal may state that your surgeon located the filter, collapsed the filter into the telescopic retrieval sheath, and used the snare to withdraw the filter from the IVC. Your surgeon may document checking for any residual clots in the IVC. Report the procedure as 37193.

Shun: Do not report the IVC filter removal with code 37197 (Transcatheter retrieval, percutaneous, of intravascular foreign body [e.g., fractured venous or arterial catheter], includes radiological supervision and interpretation, and imaging guidance [ultrasound or fluoroscopy], when performed). Code 37193 is specific to IVC filter retrieval. “Remember, it is inappropriate to report 37197 because a more specific code exists for the removal of an IVC filter,” says Hembree.