Radiology Coding Alert

The number of components comprising a TIPS procedure (transjugular intrahepatic portosystemic shunt) often means coders have a difficult time assigning the correct codes for this operation. In many cases, some of the steps that comprise the overall procedure arent being billed because each discreet activity isnt clearly documented in the radiologists written report.

Surgically speaking, these are very time-consuming and technical procedures, explains Stacey Hall, ART, CPC, CCSP, director of corporate coding and documentation for Medical Management Professionals Inc., headquartered in Chattanooga, TN. The complexity makes coding a genuine challenge. If coders have a clearer understanding of everything that takes place during a TIPS procedure, they will be able to increase their level of reimbursement.

Typically, a TIPS procedure comprises five discreet steps (as outlined below), each with medical and supervision and interpretation (S&I) coding options. If coders understand each component, can confirm appropriate documentation, and assign appropriate codes, increased payment becomes possible.

TIPS is a Difficult and Time-consuming Procedure

TIPS describes a procedure typically performed on patients suffering from cirrhosis. In a healthy liver, blood enters the liver through the hepatic artery and exits through a portal vein. These two vessels are not directly connected, but the blood nonetheless flows through the organ smoothly, through myriad small vessels.

However, this flow is obstructed by scar tissue in a liver damaged by cirrhosis. The obstruction causes portal hypertension (ICD-9-CM diagnosis code 572.3), and the increased blood pressure is transmitted backward through the portal system. To compensate, the body develops collateral blood vessels in the lower esophagus, stomach, rectum and abdominal wall to decrease the pressure by carrying the blood from the portal system into the systemic venous system. This may cause esophageal varices that often rupture and hemorrhage (varices/esophagus without mention of bleeding, 456.1; bleeding, 456.0; in cirrhosis of liver, 571.5).

To reduce portal hypertension and the risk of variceal hemorrhage, a TIPS procedure may be performed. During the operation the physician surgically creates a shunt that forms a tunnel through the liver, allowing blood to once again flow freely.

Five-step Procedure has Five Codes

Typically five stepseach with specific codes assignedmust be followed to successfully place the stent:

1. Ultrasound guidance. The complex nature of correctly coding the procedure becomes apparent right from the start. In virtually all cases, ultrasound is used to guide the internal jugular vein puncture. However, there is controversy surrounding the appropriate radiologic code to assign for this step. According to the July 1999 issue of CPT Assistant , published by the American Medical Association (AMA), [...]