Radiology Coding Alert

If you're sending in endovascular abdominal aortic aneurysm (AAA) repair claims sporting a single CPT code, more than likely you're doing something wrong-- and losing out on hundreds of hard-earned dollars.

Use the tips below to identify all separately reportable services, including radiologic supervision and interpretation (S&I), catheterization, and more. Note: For information on properly choosing endovascular aneurysm repair (EVAR) codes, see Radiology Coding Alert, Vol. 11,No. 12, "Part 1: Clinch Endovascular AAA Repair Code by Asking 5 Key Questions."

CPT's guidelines preceding 34800-34805 (Endovascular repair of infrarenal abdominal aortic aneurysm or dissection ...) are a must-read collection of rules explaining when you may report interventional procedures in addition to EVAR.

Don't: You should not report balloon angioplasty within the target treatment zone along with EVAR, according to CPT guidelines, says Jolynn Van Ert, ARRT, CPC, CIRCC, radiology support specialist with Luther Midelfort hospital and clinic in Eau Claire, Wis. You also should not report stent deployment in the target area. The AMA designed EVAR codes to include services such as angioplasty used to inflate or a stent used to anchor an endovascular prosthesis.

Do: CPT guidelines state that when the radiologist performs interventional procedures in a separate area, you may report them as distinct from the EVAR, Van Ert says.

Example: The following are procedures you may consider reporting separately when performed outside the endoprosthesis target zone:

• Renal transluminal angioplasty (such as 35471, Transluminal balloon angioplasty, percutaneous ...)

• Arterial embolization (such as 37204, Transcatheter occlusion nor embolization ...)

• Intravascular ultrasound (such as +37250, Intravascular ultrasound ...)

• Balloon angioplasty or stenting of native artery(s) (such as 37205, Transcatheter placement of an intravascular stent[s] ...).

Remember: Watch for whether the procedure is open or percutaneous, says Michele Midkiff CPC-I, PCS, RCC, executive director of interventional coding service Coding Affiliates Inc. in Mountain View, Calif.

If a prosthesis's smaller size allows the physician to place it percutaneously, "then you may bill the above codes for procedures performed outside the target landing zone," Midkiff says. But if another physician, such as a vascular surgeon, "provides open exposure via femoral cutdowns, then any additional procedures performed outside the target landing zone are coded as open procedures," she explains. "The lion's share of EVARs tend to be via cutdown, due to the sheer size of the prosthetics being used," Midkiff says.

Example: A vascular surgeon performs femoral cutdown. To code stenting of a native artery, you would use a code such as 37207 (Transcatheter placement of an intravascular stent[s] [non-coronary vessel], open; initial vessel), Midkiff says.

In addition to non-target area services, you also may report certain EVAR-related services. In particular, "Introduction of guidewires and catheters should be reported separately" using codes such as the following, CPT states:

• 36200 -- Introduction of catheter, aorta

• 36140 -- Introduction of needle or intracatheter; extremity artery

• 36245-36248 -- Selective catheter placement,arterial system ...

Selective: The national Medicare rate for 36200 in a facility is roughly $156 while 36245's fee is closer to $254, so you don't want to miss legitimate opportunities to report the selective code.

You should report the appropriate selective code, such as 36245, rather than 36200, when the radiologist places the catheters selectively into the renal arteries (which are first-order aortic branches) rather than the  aorta. You also should look at the selective codes when the radiologist performs contralateral (opposite side) lower extremity catheterization.

CPT also allows you to report radiographic studies separately.

You should select 75952 (Endovascular repair of infrarenal abdominal aortic aneurysm or dissection, radiological supervision and interpretation) for an angiogram for EVAR (34800-34805). The national Medicare rate for the professional component is roughly $229, so you don't want to forget this code.

For extension cuff placement (34825-+34826, Placement of proximal or distal extension prosthesis ...) radiographic studies, report 75953 (Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal aortic or iliac artery aneurysm, pseudoaneurysm, or dissection, radiological supervision and interpretation). If you capture this service, you'll bring home an additional $69.

When warranted, the radiologist also may place an occlusion device to block a stenosed or otherwise diseased iliac artery to prevent retrograde blood flow into the aorta. You should report this using +34808 (Endovascular placement of iliac artery occlusion device [List separately in addition to code for primary procedure]), which has a national Medicare rate of $212.79.

Code +34808 is an add-on code, which you should not report alone. CPT lists the acceptable codes with which you may claim +34808, including:

• Endovascular AAA repair codes 34800, 34805 • Graft code +34813 (Placement of femoral-femoral prosthetic graft ...)

• Extension prosthesis codes 34825-+34826.

While scouring the documentation for separately reportable services, you also should be alert for signs thatyou need to split the fees with a co-surgeon, such as a vascular surgeon. In this case, you need to watch for the services that the radiologist provides alone and those she performs as a co-surgeon.

Tip: The paired approach means you need to consider when to use modifier 62 (Two surgeons). Both physicians dictate their own operative notes to describe their roles in that single procedure, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC, senior coder and auditor for The Coding Network, and president of CRN Healthcare Solutions. "The sum of the two operative notes added together describes the CPT code being billed and coded," she says. Medicare pays each surgeon roughly 62 percent of the billed code.

Shared procedures may include endograft placement (such as 34802, Endovascular repair of infrarenal abdominal aortic aneurysm or dissection ...) or placement of extension prosthesis, such as 34825.