Understanding and Coding Venous Angiography

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Understanding and Coding Venous Angiography and Intervention, Part 2

Jeff Majchrzak, BA, (RT)NMTCB

(Editor’s note: This is Part II of a two-part article on coding venous angiography and intervention. Part I [Sept. 13, 1999] included a case study and hospital and physician code assignments. Part II presents the rationale behind these assignments.)

Jeff Majchrzak

Code 76499, an unlisted procedure code, defines the ultrasonic guidance used to locate and guide the needle into the right internal jugular vein for access into the inferior vena cava (IVC).

This ultrasound-guided procedure has been commonly billed using code 76942.

However, the American Medical Association (AMA) recently stated that there is “not a specific code in CPT” for an ultrasound guided percutaneous central venous catheter insertion. “To report this procedure you would use the appropriate code for the …catheter…and code 76499…for the ultrasound guidance.” (AMA’s CPT Assistant, July 1999).

Another perspective for coding this comes from the 1999 American College of Radiology (ACR) Ultrasound Coding Users Guide (page 26). “There is no specific code available for arterial or venous catheterization using ultrasound. Limited arterial and venous codes of the extremities would be an appropriate way to code for an examination to localize the vessel. These are 93926, 93931 and 93971.”

While each facility and practice must decide how to report this portion of the procedure, MedLearn recommends that radiologists follow advice from the AMA when it is provided in the CPT Assistant.

Each practice or facility also should review its state-specific Part A or Part B newsletters, bulletins or local review medical policies for billing and coding guidance.

As with submission of any unlisted procedure code (xxx99), be certain that clear and complete dictation and documentation exists to support this. When using any unlisted procedure codes, most third-party payers will request a written report (i.e., paper claim) describing what was done, why it was done and what it cost to perform that portion of the study.

Code 36012 is assigned twice to define the catheters placed in the common femoral veins (to perform the bilateral lower extremity venography described by code 75822).

Code 75825, which describes the imaging of the inferior vena cava, is assigned next. No catheter placement code is used in conjunction with code 75825, as this portion of the procedure is done from a nonselective injection.

According to coding rules, when nonselective and selective injections are performed from the same vascular access site, the selective code takes precedence over the nonselective code.

Radiological supervision and interpretation (S&I) code 75960 and procedural code 37205 define the initial placement of the intravascular stent in the IVC. S&I code 75960 (x2) also describes the additional stents placed in the common iliac veins but, this time, code 37206 (x2) is used to define the procedural portion of the studies.

Only one initial vessel procedural code may be used per operative setting, hence the assignment of code 37206 twice.

Unlike percutaneous transluminal angioplasty (PTA) procedures, there is no S&I code for an initial vessel and additional vessel intravascular stent procedure.

For this reason, code 75960 is used three times. The catheter placement code used to define the intravascular stent placement of the right common iliac vein is 36010.

Catheter placement is defined not by the site of intervention but by the final placement of the catheter to perform the intervention. At first glance it may seem incorrect to assign both nonselective and selective catheter placement codes, but, in this instance, it is correct.

The rationale behind these code assignments is that multiple vascular accesses were gained to accomplish these procedures–via the right internal jugular vein and the right common femoral vein. (See page A5 of the 1999 SCVIR Interventional Radiology Coding User’s Guide, “Each Vascular Access is Coded Separately” for more information.)

It is wholly expected that third-party payers (particularly Medicare) will deny submission of code 36010 with code 36012. To help payers correctly recognize the submission of both codes for claims processing, modifier ­59* (distinct procedural service) must be assigned to code 36010. The CPT manual describes modifier -59 as follows:

“Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier ‘-59’ is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician.

“However, when another already established modifier is appropriate, use it instead of modifier ‘-59’. Only if no more descriptive modifier is available, and the use of modifier ‘-59’ best explains the circumstances, should modifier ‘-59’ be used. Modifier code 09959 may be used as an alternative to modifier ­59.”

A clear-cut guide does not exist for radiology procedures as it does for interventional cardiology procedures. For interventional cardiology, a definite, defined coding hierarchy has been created for stenting, atherectomy and angioplasty.

In the case study from Part I, a complication occurred from the stent deployment into the left common iliac vein via the right internal jugular vein (RIJV) approach. Therefore, it was necessary to dilate the stent to achieve the desired therapeutic result.

Because this PTA was not a routine part of the stent deployment (i.e., pre- or postdilation), charging separately for this portion of the intervention would be appropriate. (A somewhat nebulous statement can be found about this on page H 3.7 of the 1999 SCVIR Interventional Radiology Coding User’s Guide, “Transcatheter Therapy and Biopsy.”)

The codes used to define this, as well as any site-specific venous PTA, are 75978 and 35476.

*Note that the use of modifiers (such as modifier ­59 mentioned above) varies widely from one state-specific payer to the next. *

Jeff Majchrzak is a senior health care consultant with Medical Learning Inc. (MedLearn), St. Paul, MN.

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