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Recent changes in revascularization coding
by Ray Howard and Jeff Howard
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Effective Jan. 1, 2011, there were significant changes in the CPT codes for peripheral endovascular revascularization (open or percutaneous, transcatheter). These codes became bundled so that instead of providers billing the individual component codes as they have billed in the past, one bundled code represents all components. These have been broken into three arterial anatomy territories, which are as follows:
Iliac vascular territory: These are the common iliac, internal iliac and external iliac vessels. These services are billed using CPT codes 37220, 37221, 37222 and 37223.
Femoral/popliteal vascular territory: These are the common femoral, lateral circumflex, profunda femoris, medial descending, lateral descending, perforating branches, superficial femoral, popliteal and geniculate vessels. These services are billed utilizing CPT codes 37224, 37225, 37226 and 37227.
Tibial/peroneal territory: These are the common-peroneal trunk, anterior tibial, peroneal and the posterior tibial. These services are billed using CPT codes 37228, 37229, 37230, 37231, 37232, 37233, 37234 and 37235.
Key considerations
It is important to keep in mind that some of these codes are add-on codes and can only be billed if the primary code is billed. An add-on code is noted by having a plus (+) in front of the CPT code.
If the territories of both legs are treated at the same session, a 59 modifier indicating “a separately identifiable procedure” should be appended to the code utilized for the second revascularization.
When IVUS services are performed in addition to the endovascular revascularization, bill CPT codes 37250 for the initial vessel and 37251 for each additional vessel in addition to the primary code. Also, for the radiologic supervision and interpretations, CPT code 75945 should be billed for the initial vessel and CPT code 75946 for each additional vessel.
These new endovascular revascularization codes do not include angiography when it is for diagnostic purposes and performed before revascularization. Any angiography performed confirmatory to revascularization would be bundled into revascularization. If diagnostic angiography is performed (ie, CPT codes 36245, first order; 36246, second order; 36247, third order; and 36248 for each additional second or third order), the appropriate radiologic supervision and interpretation codes (ie, CPT codes 75710, peripheral unilateral S&I; 75716, peripheral bilateral S&I; 75774, each additional selective artery S&I) should be billed in addition to the code for catheter placement. When selective angiography is performed, the physician needs to document where the catheter is selectively placed in the vessel to denote the appropriate order. A 59 modifier should be appended to each of these codes when billed concurrently to endovascular revascularizations.
A word of caution
Providers will need to check the national carrier determinations (NCDs) and local carrier determinations (LCDs) for their region. Many of these NCDs and LCDs will list medical necessity requirements, diagnosis requirements and coding guidelines in addition to documenting limitations of what can and cannot be billed, such as FDA-approved stents being eligible for non-FDA-approved purposes. Each provider should visit the websites for CMS or their local contractor to download the NCDs and LCDs, if applicable, not only for the endovascular revascularization procedures, but also for all procedures the provider performs.
Endovascular revascularization procedures can be performed in ambulatory surgery centers; however, they are limited to only the iliac vascular territory. Additional territories of femoral/popliteal and tibial/peroneal are not approved by CMS. Providers will need to ensure they comply with these requirements because there can be significant expenses related to performing these procedures.
Jeff Howard is the owner of Ray Howard & Associates, a management consulting firm for health care professionals; Ray Howard is a partner and senior consultant at Ray Howard & Associates.
Disclosure: Jeff and Ray Howard report no relevant financial disclosures.