More on Coding Changes Effective January 2015
A detailed look at reporting for stent placement in the lower extremities for nonocclusive disease and in the innominate artery.
A summary of coding changes for 2015 was published in the November 2014 edition of Endovascular Today. This month’s article looks at two of those areas with additional detail: reporting of stent placement for nonocclusive disease in lower extremities and stent placement in the innominate artery. A CPT Assistant article is expected to be published this spring that may add further guidance in reporting these procedures.
REPORTING STENT PLACEMENT FOR NONOCCLUSIVE VASCULAR DISEASE IN LOWER EXTREMITIES
Effective January 1, 2015, there was a change in CPT that affects reporting specific endovascular services provided in the lower extremities. The introductory language and code descriptors in CPT have been modified, altering the use of codes 37220–37235 and 37236–37237. The lower extremity revascularization set of codes (37220–37235) are now specifically defined for treatment of lower extremity occlusive disease. This means that treatment of nonocclusive disease entities such as aneurysms, pseudoaneurysms, and/or rupture/extravasation with endovascular stents (either covered or noncovered) in the infrainguinal vessels will not be reported with the lower extremity endovascular revascularization family of codes, 37224–37235. Instead, arterial vascular stent codes 37236–37237 would be reported.
The descriptors for 37236–37237 have been modified to reflect this change:
- 37236: transcatheter placement of an intravascular stent(s) (except lower extremity artery[s] for occlusive disease, cervical carotid, extracranial vertebral, or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation (RS&I) and including all angioplasty within the same vessel, when performed; initial artery
- +37237: each additional artery
Codes used to report treatment of nonocclusive iliac artery disease (eg, aneurysms) with endovascular stent (prosthesis) placement will not change. These procedures will continue to be reported with codes 34900/75954. If iliac extension prostheses are placed in the same iliac, 34825/75953 may also apply.
- 34900: endovascular repair of iliac artery (eg, aneurysm, pseudoaneurysm, arteriovenous malformation, trauma) using ilio-iliac tube endoprosthesis
- 75954: endovascular repair of iliac artery aneurysm, pseudoaneurysm, arteriovenous malformation, or trauma, using ilio-iliac tube endoprosthesis, RS&I
- 34825: placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, or dissection; initial vessel
- 75953: placement of proximal or distal extension prosthesis for endovascular repair of infrarenal aortic or iliac artery aneurysm, pseudoaneurysm, or dissection, RS&I
Reporting Treatment of Nonocclusive Disease in Infra-Aortic Arteries
Using aneurysmal disease as a nonocclusive disease example, the codes used to report aneurysm repair in the infra-aortic arteries (37236, 37237, 34900/75954) include the work of stent placement and any angioplasty performed before, during, or after stent placement within the target treatment zone. Catheterization of the vessel is not included in the work of codes 37236, 37237, or 34900 and may be separately reported. Codes 36246–36247 also include all the imaging and RS&I required to provide the therapy. Code 34900 does not include angiography and RS&I work, which may be separately reported using 75954. Codes 36246–36247 are reported once per vessel treated, regardless of the number of stents placed. Codes 34900/75954 are used to report the first stent/covered stent/stent graft placed for iliac artery aneurysm repair. If more than one stent is required, 34825/75953 (placement of an extension) is reported once regardless of how many additional stents are required to accomplish the repair.
Code 37236 should be reported once for treatment of the initial vessel, regardless of the number of stents required to repair the aneurysm. Code 37237 is reported for each additional vessel treated with a stent, regardless of location. In the lower extremities, the vascular territory definitions used for the lower extremity revascularization codes apply to the use of 37236 and 37237 as well. For instance, if a popliteal artery and a femoral artery aneurysm are repaired in the same leg, 37236 would be reported for the repair (this applies if the aneurysm is treated with a single stent or multiple stents).
The use of codes 37220–37235 is not the same as 37236 and 37237 because of differences in structure for the two sets of codes. Because the work of catheterization and vessel access is included in the work of 37220–37235 but not in the work described by 37236 and 37237, catheterization codes should be additionally reported with 37236 and 37237. The catheterization work associated with treatment of occlusive disease in the lower extremity vessels is included in 37220–37235 and is not additionally reported. This also creates differences in the use of the add-on codes with the 37220– 37235 family versus 37236 and 37237.
If aneurysms are repaired in both legs, 37236 would be reported for repair of the initial vessel, and the add-on code 37237 is used to report treatment of additional vessels in the same extremity and/or the contralateral extremity. As an example, treatment of bilateral popliteal artery aneurysms with stents would be reported with 37236, 37237. This is different from stent placement for treatment of bilateral popliteal artery occlusive disease, which would be reported with primary codes for each extremity: 37226-50 (or 37226-RT + 37226-LT, or 37226 + 37226-59. Carrier preference for modifier use may vary. Some carriers may require -50 for bilateral procedures, some will ask for –RT and –LT to distinguish services, and others may recognize the -59 modifier. It is always best to check with the carrier to determine how they recognize modifiers). This difference is due to the bundling of catheterization work in the 37220–37235 family but not in codes 36236–36237.
If occlusive disease is treated in the lower extremity during the same procedure as a treatment of nonocclusive disease such as an aneurysm, that treatment may be separately reported if it is in a separate vessel from the target treatment zone for the aneurysm repair. (Remember that for coding purposes, the definitions of “vessels” in the lower extremity are not anatomic, but follow the vascular territory definitions outlined in CPT.) Because the work of catheterization of the vessel is included in the lower extremity revascularization codes 37220–37235, however, the same catheterization would not be reported a second time with the vascular stent code(s) 37236–37237 used to report the aneurysm repair. If both occlusive disease and aneurysmal disease are treated in the same vessel in the same session, only one therapeutic code should be reported. Select the code that describes the dominant disease entity treated.
Additional catheterizations are reported when the occlusive disease and nonocclusive disease are treated in two separate vascular territories from the same entry/access site and the degree of selective catheterization is higher for the nonocclusive vessel treatment than for the treatment of the occlusive disease. It is also reported when the vessels are treated from separate entry/puncture sites. A separate catheterization code may also be reported with 37236–37237 when the work of catheterization is an equal or lesser order than for the occlusive disease, but the vessel being treated for nonocclusive disease is in a separate vascular family than the vessel being treated for occlusive disease. When an additional catheterization code is reported with 36236–36237 in conjunction with a lower extremity revascularization code for occlusive disease, the additional catheterization code should be modified with -59 to indicate that the catheterization is in addition to the work of the catheterization being reported inherently with the code(s) for occlusive disease.
This can be a confusing concept, but it follows the long-standing rules for reporting selective catheterizations. To illustrate, here are some coding scenarios:
1. From a right common femoral artery (CFA) approach, a left external iliac artery (EIA) stenosis and a left superficial femoral artery (SFA) stenosis are treated with stent placements.
- 37226: stent placement left SFA for occlusive disease
- 37221: stent placement left EIA for occlusive disease (All the work of catheterizing the vessels is included in the work described by 37226 and 37221, so no additional catheterization codes are reported.)
2. From a right CFA approach, a left external iliac aneurysm and a left SFA aneurysm are treated with stent placements.
- 34900, 75954: stent placement for nonocclusive disease, iliac artery (left EIA)
- 37236: stent placement for nonocclusive disease, initial artery (left SFA)
- 36247: third-order selective catheterization, left SFA
(Because 34900 is used for the iliac aneurysm treatment, 37236 must be used for the SFA aneurysm treatment because it is the initial vessel reported with the arterial stent code 37236. 37237 may not be reported without 37236. Because the work of the left EIA catheterization is part of the work of catheterizing the left SFA, no additional catheterization is coded for the left EIA in this case.)
3. From a right CFA approach, a right common iliac artery (CIA) aneurysm is treated with stent placement (requiring placement of catheter into the aorta). From a left CFA antegrade approach, a left popliteal artery aneurysm is treated with stent placement.
- 34900/75954: stent placement for nonocclusive disease, iliac artery (right CIA)
- 37236: stent placement for nonocclusive disease, initial artery (left popliteal artery)
- 36246: second-order selective catheterization, left popliteal artery
- 36200-59: catheterization of aorta to treat right CIA
(In this case, both catheterizations are reported because they were from separate vessel punctures. Modifier -59 is added to 36200 to designate that it is a separate procedure. Despite being the second vessel treated, 36236 must be used to report the popliteal artery treatment because it is the first vessel reported with the arterial stent code 36236. 36237 may only be reported with 36236 and may not be reported alone.)
4. From a right CFA approach, a left EIA stenosis is treated with a stent, and a left popliteal artery aneurysm is treated with a stent.
- 37221: left external iliac artery stent placement for stenosis (includes second-order selective catheterization of left EIA)
- 37236: left popliteal artery stent placement for aneurysm
- 36247-59: third-order selective catheterization of left popliteal artery from right CFA puncture
(The degree of selectivity is greater for the nonocclusive vascular treatment, so 36247 is additionally reported with a -59 modifier to indicate that it is work over and above what is included in the second-order catheterization bundled into 37221.)
5. From a right CFA approach, a left external iliac artery aneurysm is treated with a covered stent, and a left popliteal artery stenosis is treated with stent placement.
- 37226: left popliteal artery stent placement for stenosis (includes third-order selective catheterization of left popliteal artery)
- 34900, 75954: left EIA stent placement for nonocclusive disease (aneurysm)
(In this case, no additional catheterization is reported because the work of second-order selection of the left EIA is included in the work of the higher-order selective catheterization of the left popliteal artery, so no additional work is performed for selective catheterization of the left EIA.)
6. From a right CFA approach, a right hypogastric artery stenosis is treated with angioplasty, and two stents are placed to treat a left SFA/popliteal artery aneurysm.
- 37220: balloon angioplasty of the right hypogastric artery (includes first-order selective catheterization of the right hypogastric artery)
- 37236: stent placement for treatment of left SFA/ popliteal aneurysm (reported once despite lesion involving both the SFA and popliteal segments and the use of two separate stents)
- 36247-59: third-order selective catheterization of the left SFA/popliteal artery
7. From a right CFA approach, a right hypogastric artery pseudoaneurysm is treated with stent placement, and a left CIA stenosis is treated with stent placement.
- 37221: left CIA stent placement for stenosis (includes first-order selective catheterization of the left CIA)
- 34900, 75954: stent placement for treatment of right hypogastric artery pseudoaneurysm
- 36245-59: first-order selective catheterization right hypogastric artery
(Despite both treated vessels being first-order selective catheterizations, the work is different because they are in different vascular families (right iliac vs left iliac), and the work to select each vessel is not duplicative.)
8. From a right CFA approach, a right external iliac artery stenosis is treated with a stent. From a left CFA approach, a left EIA aneurysm is treated with a stent. Catheters are placed into the aorta from each groin for these therapies.
- 37221: right EIA stent placement for stenosis (includes the work of nonselective catheterization of the right EIA)
- 34900, 75954: left EIA stent placement for nonocclusive disease
- 36200-59: catheter placement into the aorta from left CFA puncture
(Despite the catheter placement work being equivalent in both vessels, it is not duplicated work because separate punctures were used. Therefore, the catheterization may be reported with 34900, 75954.)
9. From a right CFA antegrade approach, a stenosis of the right peroneal artery is treated with angioplasty. From a left CFA approach, a left EIA aneurysm is treated with stent placement, requiring placement of the catheter into the aorta for the procedure.
- 37228: angioplasty of right peroneal artery (includes third-order selective catheterization)
- 34900, 75954: stent placement for left EIA aneurysm
- 36200-59: Nonselective catheter placement into the aorta for treatment of left EIA aneurysm
- (In this case, even though the degree of selectivity is lower for the vessel treated for nonocclusive disease, the work is not duplicative because the treatments were performed through separate access sites, and can be separately reported for the aneurysm treatment.)
10. From a right CFA antegrade approach, a stenosis of the left common peroneal trunk is treated with angioplasty. A left SFA aneurysm is also treated with covered stent placement.
- 37228: angioplasty of left common peroneal trunk (includes third order selective catheterization)
- 37236: stent placement for left SFA aneurysm (In this case, the catheterization work used to get to the left SFA lesion is less than is used for the peroneal artery angioplasty, and duplicates the work required to perform the peroneal artery angioplasty. Therefore, no additional catheterization code is reported.)
11. From a right CFA approach, aneurysmal disease in the left SFA and proximal popliteal artery is treated with placement of two covered stents. In addition, a stenosis in the mid-SFA above the aneurysm is treated with placement of a third stent.
- 37236: stent placement for nonocclusive disease (left SFA/popliteal), initial artery
- 36247: third-order selective catheterization
(In this case, the predominant disease being treated is the aneurysm, so 37236 is reported for treatment of non-occlusive disease. Treatment of concomitant occlusive disease in the same vessel as defined for coding purposes would not be separately reported. If the treating physician determines that the occlusive disease is the dominant etiology being treated, 37226 could be reported instead of 37236, and no additional catheterization code would be reported.)
STENT PLACEMENT IN THE INNOMINATE ARTERY
There is a new code for antegrade placement of a stent in the innominate artery, which would typically be performed from a femoral or iliac approach (either with percutaneous or open exposure of the entry vessel):
- 37218: transcatheter placement of intravascular stent(s), intrathoracic common carotid artery or innominate artery, open or percutaneous antegrade approach, including angioplasty, when performed, and RS&I
There is also a code for retrograde placement of a stent in the innominate artery, describing this procedure done from an open exposure of the carotid artery:
- 37217: transcatheter placement of intravascular stent(s), intrathoracic common carotid artery or innominate artery by retrograde treatment, open ipsilateral cervical carotid artery exposure, including angioplasty, when performed, and radiological supervision and interpretation
These two codes are not applicable when the innominate artery is stented from a retrograde approach other than open carotid exposure, such as ipsilateral brachial artery puncture. For innominate artery stent placement from an ipsilateral retrograde approach other than open common carotid artery exposure, code 37236, arterial vascular stent placement, may be reported. In this case, the work of accessing the vessel is not included with the work of 37236, and catheterization may be separately reported.
Katharine L. Krol, MD, FSIR, FACR, is an interventional radiologist and has recently retired from active clinical practice. She has disclosed that she has no financial interests related to this article. Dr. Krol may be reached at (317) 595-9413.