coding corner
Understanding and Coding Venous Angiography and Intervention, Part 1
Jeff Majchrzak, BA, (RT)NMCB
(Editor’s note: This is Part I of a two-part article on coding venous angiography and intervention. Part II will be published in the Oct. 11, 1999, issue.)
In July, a 64-year-old woman with known endometrial carcinoma presented to her family physician with swollen legs. A cursory exam revealed the possibility that compression of the inferior vena cava (IVC) by enlarged lymph nodes was causing the patient’s lower extremity edema.
As a result, the family physician referred the patient to an interventionalist for a more detailed work-up, angiography and interventional procedures, as needed. The patient arrived at the hospital, spoke with the interventionalist and then was brought into the special procedures suite. The possible benefits, risks and complications associated with the angiographic and interventional procedures were explained, and informed consent was obtained.
Diagnostic Studies
The patient’s right neck was sterilely prepped and draped. The right internal jugular vein (RIJV) was percutaneously punctured under direct ultrasonic guidance. Through the sheath, a Bentson wire was advanced into the IVC. After catheter exchange, the device was negotiated past the lower IVC stenosis into each common femoral vein where injections were made, and bilateral lower extremity venography was performed. Venography demonstrated normal flow bilaterally through each common femoral and external iliac vein. Collateral flow was observed bilaterally following subsequent injection of each common iliac vein.
Once again, catheter exchange was made. A pigtail catheter was inserted into the IVC with diagnostic angiography to follow. This injection demonstrated marked filling of the paravertebral plexus with very little flow up the IVC. A pull-back inferior vena cavogram was done that displayed an external compression stenosis of the IVC estimated to be at 80 percent.
Pressure measurements were performed that demonstrated a high-level gradient across the stenosis. Because of this stenosis, a wall stent was deployed at this site.
Follow-up angiography confirmed the stent’s position in the IVC but also that the stent had shortened. Repeat pressure measurements from the right and left iliac veins demonstrated that the gradient had not significantly decreased across the area of narrowing. It was decided that the patient would best benefit from additional interventional procedures–in this case, bilateral “kissing stents” in the common iliac veins. The right common femoral vein (RCFV) was punctured, and a wire was advanced into the IVC above the previously placed stent. Through the RCFV, a wall stent was placed through the right common iliac vein (RCIV) into the IVC stent.
Through the initially placed RIJV sheath, another stent was placed, once again through the IVC stent, but this time into the left common iliac vein (LCIV). Follow-up angiography demonstrated that the RCIV stent deployed nicely, but the left-sided stent did not fully open. Because of this complica-tion, angioplasty of the LCIV stent was elected in order to achieve the desired result.
Following catheter exchange, the LCIV stent was dilated. Follow-up angiography post-dilation demonstrated a decrease of the left-sided pressure gradient (from a pre-intervention level of 26 to a post-stent/PTA level of 3).
The RIJV and RCFV sheaths were removed, pressure was held at both puncture sites, and the patient was transferred to her unit for observation.
Hospital and Physician Billing
The three columns in the table on page 10 show the procedural component codes that must be assigned.
Hospital Billing
Unless the radiologist is performing these procedures in an entity he or she owns, no charges for drugs, contrast, supplies, etc. should be submitted. Hospitals, however, may capture charges for these items.
If low osmolar or nonionic contrast material is used, a Level II HCPCS code also should be assigned for this material. The code chosen, which can be found in the A4644A4646 range, depends upon the concentration of iodine used. Assign RC 636.
If high osmolar contrast material is used, no Level II code is required. Simply bill this material with RC 255 (drugs incident to radiology and subject to the payment limit) or include it in the charge for the procedure.
Supplies used in conjunction with these studies may be either included into the charge for the exam or broken out separately. If listing separately, report with RC 621 (supplies incident to radiology and subject to the payment limitation). RC 255 and 621 do not require CPT codes. Refer to addendum H of the Medicare Hospital Manual for the complete listing of services pertaining to RC 621.
Jeff Majchrzak is a senior health care consultant at Medical Learning Inc. (MedLearn), St. Paul, MN.
