Temporary Code Helps Clear Confusion on Percutaneous Declotting Procedures
Published on Wed Dec 01, 1999
The Health Care Financing Administrations (HCFA) final rule for Medicare reimbursement begins the process of clarifying correct coding for percutaneous declotting procedures.
The final rule, as reported in the Nov. 2, 1999, Federal Register, announces a temporary Level II HCFA Common Procedure Coding System (HCPCS) code: G0159percutaneous thrombectomy and/or revision, arteriovenous fistula, autogenous or nonautogenous dialysis graft.
According to Gary Dorfman, MD, FACR, FSCVIR, representative to the American Medical Associations (AMA) CPT advisory committee and president of Healthcare Value Systems in Rhode Island and past president of the Society for Cardiovascular and Interventional Radiology, G0159 pertains to percutaneous thrombectomy of a dialysis graft or fistula. It describes percutaneous declotting by any methodincluding mechanical devices, lyse and wait, and short infusion.
Code G0159 will be used until the AMA creates a permanent CPT Code , expected no sooner than 2001, according to Dorfman. It is possible that more than one code may ultimately be required to describe percutaneous thrombectomy services, because it is not clear at this time which services other than those directly related to removing a clot from the graft, may be bundled into the new CPT code.
Until that time, G0159 is considered analogous to open surgical procedure codes 36831 (thrombectomy, arteriovenous fistula without revision, autogenous or nonautogenous dialysis graft [separate procedure]), 36832 (revision, arteriovenous fistula; without thrombectomy, autogenous or nonautogenous, dialysis graft [separate procedure]) and 36833 (revision, arteriovenous fistula; with thrombectomy, autogenous or nonautogenous dialysis graft [separate procedure]).
The temporary code carries a 90-day global period for the service, which is consistent with the open surgical procedure codes. Because HCFA had no independent evaluation of the work Relative Value Units (RVUs), the intent of the Final Rule is that individual local carriers determine pricing, using the open surgical codes for comparison.
Background: Clarifying 36860 and 36861
Adoption of this temporary code was prompted by the elimination of CPT procedure codes 36860 (external cannula declotting [separate procedure]; without balloon catheter) and 36861 (external cannula declotting [separate procedure]; with balloon catheter) to describe percutaneous thrombectomy procedures, Dorfman explains. Codes 36860 and 36861 are now correctly used for open surgical procedures describing the process of declotting a cannula.
To clarify the issue, he says, the AMA revised 36860 and 36861 in January 1999, adding the word external to both descriptions. However, this editorial revision did nothing to address the lack of CPT Codes for percutaneous thrombectomy or revision of an arteriovenous fistula.
As the overwhelming majority of patients with renal failure receive their health insurance coverage through the Medicare program, alternative coding and payment methods will not be prevalent in the description of these services, Dorfman says. In the past, alternatives that had been used (and might continue to be used outside of Medicare by some payers) include the combined use of thrombolytic codes, mechanical removal of intravascular substances codes and the surgical dialysis declotting and revision codes previously referenced.
Under those circumstances where coverage is outside the Medicare program, it is strongly suggested that the individual provider discuss the preferred coding and billing strategy with the payer in question prior to submitting for reimbursement. Although it is still early after the introduction of the new HCPCS code, it is at least possible that some payers might adopt the news HCPCS code until a new CPT code is available, he says.
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Three Recommendations
HCFA proposed the Medicare reimbursement rule in July 1999 and received input from several professional organizations, virtually all of which supported the creation of the Level II code. Three major issues were raised between July and November, when the proposed rule was adopted as final.
1. The AMA commented that adding a HCPCS Level II code, rather than a CPT code, adds to the potential for confusion and incorrect coding. HCFA responded that percutaneous declotting procedures are being performed and that it was necessary to develop a billing code even though no CPT code has been developed.
2. Both the Society for Cardiovascular & Interventional Radiology (SCVIR) and the American College of Radiology recommended that a 000 global period be designated, instead of the 90-day global rule. HCFA retained its original language, however, stating that the effectiveness of percutaneous declotting procedures has been compared to open thrombectomies, which carry the 90-day global period. In a related argument, SCVIR and one device manufacturer suggested that interim RVUs could be assigned for G0159 instead of encouraging the vagaries inherent in allowing the procedure to be carrier-priced. HCFA reaffirmed its decision because there was no evaluation of RVUs available.
3. In addition, SCVIR requested that HCFA drop the word revision from the code description since a graft revision and declotting usually occur at separate sessions and a revision typically involves another physician. HCFA expressed confidence that carriers would be able to adjust payment appropriately if there were variations in how the percutaneous thrombectomy is performed, and if a revision is or is not conducted simultaneously.
When addressing each of these issues, HCFA noted that it would collect data regarding the procedure variations and would consider revisions of the code definition, global period and alternate codes after it had reviewed the new data.
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