Interventional Radiology Coding Update

2 0 1 3

American College of Radiology Edition 2013

Copyright © 2013 by the Society of Interventional Radiology and the American College of Radiology. All rights reserved. No part of this

publication covered by the copyright hereon may be reproduced or copied in any form or by any means—graphic, electronic or mechanical, including photocopying, taping or information storage and retrieval systems—without written permission of the publishers.

CPT® _{five-digit codes, nomenclature and other data are copyright © 2012}

American Medical Association. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. CPT is a listing of descriptive terms and five-digit numeric identifying codes and modifiers for reporting medical services performed by physicians. This edition of the Update contains only CPT terms, codes and modifiers that were selected by SIR for inclusion in this publication.

11

The Basics of Coding and Reimbursement

19

Evaluation and Management (E&M) Codes

24

Revised Interventional Radiology Codes for 2013

24

Vertebral Body, Embolization or Injection

24

Respiratory System

27

New 2013 CPT Codes Common to Interventional Radiology

27

Thoracentesis

27

Cervicocerebral Angiography

30

Deleted RS&I Codes

31

Foreign Body Retrieval

31

Transcatheter Thrombolysis

33

Diagnostic Radiology (Diagnostic Imaging)

34

Endovascular Revascularization

39

Special Coding Note for 2013: Embolization Therapy for

Benign Prostatic Hyperplasia (BPH)

45

Individual Coverage Request Sample Letters

45

Percutaneous Radiofrequency Ablation of Pulmonary Tumor(s)

50

Ovarian Vein Embolization (OVE) to Treat Pelvic Congestion

Syndrome (PCS)

56

MRI of the Pelvis for UFE

60

Sample 2013 Charge Sheets

TA B L E O F C O N T E N T S

foreword

The 2013 Interventional Radiology Coding Update provides coding

information to physicians, coders and administrators on what is new for 2013 in coding and reimbursement in the specialty of interventional radiology. By providing specialized information, as well as presenting some common coding scenarios, the intent is to supplement the Current Procedural

Terminology (CPT) manual. Readers should always consult the CPT

Professionalmanual as the definitive source of coding information. Other

AMA resources, such as the CPT Assistant series, also commonly cover

coding topics of interest to endovascular specialties.

In 2013, the trend of bundling existing codes continued. In response to coding “screens” utilized by the Centers for Medicare and Medicaid Services (CMS), and implemented by the American Medical Association’s Specialty Society RVS Update Committee (RUC), specialty societies were instructed to develop new CPT codes that combined the procedure codes with the

radiological supervision and interpretation (RS&I) code. New CPT codes were established for foreign body retrieval, carotid angiography,

thrombolysis and chest tube procedures. These new codes are described in this Update.

Coding of interventional radiology procedures can often seem a daunting task. While the transition to bundled codes is ongoing, many codes that are part of the component coding system remain in effect. This has resulted in something of a hybrid coding system, with new bundled codes existing alongside older component codes. Physicians and coders should exercise care, as there are some scenarios where the two coding systems can be utilized together. In this Update, we point out several of those scenarios. Over the past years, the amount of volunteer time that SIR and ACR members contribute to the coding and reimbursement process has

F O R E W O R D

continued to grow. The efforts of the volunteer coders, physicians and associates are gratefully acknowledged by the Society of Interventional Radiology and American College of Radiology. Their work and insightful

comments have directly resulted in this 2013 Update.

Fairfax, Virginia

AAA Abdominal Aortic Aneurysm

ABN Advanced Beneficiary Notice

ABPTS American Board of Physical Therapy Specialties

ACO Accountable Care Organization

ACR American College of Radiology

AMA American Medical Association

APC Ambulatory Payment Classification

ASC Ambulatory Surgical Center

AV Arteriovenous

AVF Arteriovenous Fistula

CAC Carrier Advisory Committee

CF Conversion Factor

CMD Carrier Medical Director

CMS Centers for Medicare and Medicaid Services

CPT Current Procedural Terminology

DRG Diagnosis-related Group

E&M Evaluation and Management

GPCI Geographic Practice Cost Index

HCFA Health Care Financing Administration

HCPCS Healthcare Common Procedure Coding System

HOPPS Hospital Outpatient Prospective Payment System

ICD-CM International Classification of Diseases, Clinical Modification

ICD-9-CM International Classification of Diseases, Ninth Revision,

Clinical Modification

IDE Investigational Device Exemption

IDTF Independent Diagnostic Testing Facility

IVUS Intravascular Ultrasound

LCD Local Coverage Determination

MAC Medicare Adminstrative Contractor

MPFS Medicare Physician Fee Schedule

MPPR Multiple Procedure Payment Reduction

MUE Medically Unlikely Edit

NCCI National Correct Coding Initiative

NEC Not Elsewhere Classified

NCHS National Center for Health Statistics

NOS Not Otherwise Specified

NP Nurse Practitioner

PA Physician’s Assistant

PE Practice Expense

PIN Provider Identification Number

POS Place of Service

PTA Percutaneous Transluminal Angioplasty

RAC Recovery Audit Contractor

RAW Relativity Assessment Workgroup

RBMA Radiology Business Management Association

RBRVS Resource-based Relative Value Scale

RFA Radiofrequency Ablation

RS&I Radiological Supervision and Interpretation

RS/IS&I Radiological Supervision and Interpretation/Imaging Supervision

and Interpretation

RUC RVS Update Committee

RVS Relative Value Scale

RVU Relative Value Unit

SIR Society of Interventional Radiology

SOAP Subjective Evaluation, Objective Evaluation, Assessment and Plan

TAA Thoracic Aortic Aneurysm

G L O S S A R Y O F

C AT E G O R Y I I I

categories of

CPT

®

codes

CPT code proposal requests submitted to the AMA CPT Editorial Panel must identify what category of CPT code is being sought. The Panel reviews requests for three types of CPT codes.

C AT E G O R Y I C O D E S

These represent established services and procedures, performed by a variety of providers, in multiple geographical locations, with appropriate FDA

approval for all aspects of the procedure.

C AT E G O R Y I I C O D E S

These codes are used to track performance measures. They are intended to facilitate data collection and not serve for billing purposes. Category II codes also are used in the Physician Quality Reporting System (PQRS) to report quality measures related to services provided under the Medicare Physician Fee Schedule. The PQRS is a voluntary pay-for-performance program in Medicare. It offers a financial incentive to physicians and other eligible professionals who successfully satisfy quality measures related to their services.

C AT E G O R Y I I I C O D E S

These are issued for emerging technologies not meeting standards for a Category I code.

Additional information regarding the different categories of CPT codes can be found on the AMA Web site at

www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt/about-cpt/category-iii-codes.shtml.

C AT E G O R I E S O F C P T C O D E S

O T H E R H C P C S C O D E S

O T H E R H C P C S C O D E S

CMS may also issue Level II Healthcare Common Procedure Coding System (HCPCS) codes to report physician services, including

G - C o d e s These are temporary codes issued by CMS to describe procedures and professional services.

S - C o d e s These are temporary codes issued by CMS, often at the request of a commercial carrier. While S-codes are NOT eligible for use within the Medicare program, commercial carriers may elect to utilize these codes to facilitate claims processing.

A listing of current HCPCS Level II codes may be found at

the basics of coding

and reimbursement

T H E R E L AT I V E VA L U E P AY M E N T S Y S T E M ( R B R V S )

In 1992, Medicare adopted a national system of payment using the

Resource-based Relative Value Scale (RBRVS). Under the RBRVS, procedures are weighted and assigned a value on the basis of their difficulty, intensity, time and resource utilization. In the RBRVS system, a procedure’s RVU total is derived by summing the physician’s work (time and intensity), the

practice expense (PE) related to performing the service, and malpractice costs associated with the procedure.

Additionally, in order to take into account regional cost variations, CMS folds in what is termed the Geographic Practice Cost Index (GPCI). The GPCI rates are reviewed annually by CMS for their relevancy and accuracy. Finally, every year, CMS publishes in the Final Rule for the Physician Fee Schedule a figure called the conversion factor (CF). For CY 2013, the CF is $34.0230.

Determining how much a service is paid is not a straightforward task. In recent years, most of the Medicare Administrative Contractors (MACs) have published on their Web sites helpful tables that show the physician fee schedule for the coming year for their covered region.

Depending on whether a provider practices in the nonfacility (i.e., physician office) or facility (i.e., hospital) setting, the actual formula for provider

2013 Nonfacility Pricing Amount = [(Work RVU * Work GPCI) +

(Transitioned Nonfacility PE RVU * PE GPCI) + (MP (Malpractice) RVU * MP GPCI)] * CF

2013 Facility Pricing Amount = [(Work RVU * Work GPCI) +

(Transitioned Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * CF On the member’s homepage of www.SIRweb.org, SIR has created tables that display all of the RVU component values for the common interventional radiology CPT codes.

C P T P R O C E S S

CPT codes are developed by the AMA CPT Editorial Panel in consultation with CMS and the CPT Advisory Committee which includes representatives from numerous specialty and subspecialty societies and allied medical societies. CPT Advisory Committee membership is limited to those national medical societies seated in the AMA House of Delegates.

Since the practice of medicine is dynamic, the need for new CPT codes to reflect changes in practice often arises. Code change proposals are

submitted to the AMA through the medical specialty societies, or individually, through a standard application process. Assessment of the supporting scientific literature and informal survey by the societies of a number of individuals performing the procedure in question helps assess the need for the new procedural code, its validity and the language that will be proposed to describe it. After a case can be made to support editing CPT to include a new procedure, the application is heard by the CPT Editorial Panel, which contains representatives of approximately 20 medical and allied organizations.

T H E B A S I C S O F C O D I N G

The AMA holds three CPT Editorial Panel meetings per year, most commonly in February, May and October. To ensure release of the upcoming year’s updated CPT manual each fall, all proposed additions or revisions to

Category I CPT codes for the upcoming calendar year must be heard by the Panel by the preceding February meeting. For example, new Category I codes approved by the Panel at the May 2011, October 2011 and February 2012 Panel meeting are reflected in the 2013 edition of CPT. The CPT cycle has stringent deadlines for submission of proposals that are well in advance of Panel meetings to ensure all advisers have an opportunity to review and comment.

The general public is allowed to register for and attend AMA CPT Editorial Panel meetings. Information regarding CPT submission deadlines and Panel meetings can be found on the AMA Web site,

www.ama-assn.org/ama/pub/category/3113.html.

R U C P R O C E S S

When the CPT Editorial Panel approves a new Category I CPT code, including newly bundled codes, the RUC process is initiated and a

recommended relative value is developed. This provides Medicare and other payers a uniform scale on which to base payment. In the case of a revised code, depending on the nature of the change, the code’s value may be reevaluated through the RUC process. Category III codes are not referred to the RUC for valuation; instead reimbursement levels are set directly by those carriers electing to provide coverage for the performance of these

“emerging technologies.”

The RVS Update Committee (RUC) develops physician work RVU

recommendations for new and revised CPT codes. Specialties comprising the RUC Advisory Committee designate their level of interest for developing

work RVU recommendations based on recent actions taken by the CPT Editorial Panel. The supporting societies must survey members of their organizations using a standardized survey tool for data on time, intensity and risk of the procedure, including all the necessary pre- and postprocedural work. Based on the amount of physician work involved, each individual surveyed is asked to weigh the procedure in comparison to a defined standard procedure with which they are familiar. These data are assimilated and summarized for the valuation process. If more than one specialty is involved, a consensus value must be reached.

Direct practice expenses including supplies, equipment and clinical staff time are also examined for both in-facility(hospital) and nonfacility (office) settings. For example, even for facility-based services there is often a direct practice expense for clinical staff time spent on the completion of

preservice diagnostic/referral forms, coordination of presurgery services, scheduling of facility space for a procedure, review of test and exam results, follow-up phone calls and prescriptions. As with the physician work value, these data are also summarized for consideration by the RUC and, if more than one specialty is involved, consensus regarding these inputs must be reached.

The proposed work value along with practice expense inputs for office-based procedures are submitted for consideration by the (RUC). After debate, the RUC will recommend physician work and practice expense values that serve as recommendations to the Centers for Medicare and Medicaid Services (CMS), which is the final decision-maker regarding RVUs. CMS’ final decision on RVUs and other payment policies usually appear each November in the Federal Register. (A copy of the Physician Fee Schedule is available to the general public for download via the CMS Web page,

www.cms.hhs.gov/PhysicianFeeSched/PFSRVF/list.asp.)

Mandated “budget neutrality” may negatively impact the payment associated with RVUs of existing codes when new codes are created. The extent of any

T H E B A S I C S O F C O D I N G

change is determined by the number of RVUs assigned to the procedure and the number of times the procedure is performed annually. This provides a clear incentive to societies with representatives on the RUC to assure that all valuations are fair and accurate.

The Medicare RVS is designed to pay for services on the basis of the amount of work involved without regard to the specialty of the provider(s)

performing the service. Since 1992, all physician specialty types use the same code(s) to report the procedural component of an interventional radiology service. Similarly, the supervision of imaging personnel and interpretation of images obtained during the procedure is reported by the use of radiological supervision and interpretation/imaging supervision and interpretation (RS/IS&I) code(s) without regard to the specialty of the physician who performs the service. If a single physician performs both phases of the service, that single physician utilizes both codes (i.e.,

procedural and RS/IS&I). If several physicians perform portions of a service, each reports only those codes reflecting the procedure that they performed.

C M S S C R E E N S A N D H O W C O D E S A R E A S S I G N E D T O T H E R U C P R O C E S S

In their rule-making process, CMS has identified groups of codes they feel are misvalued using 12 different screens including: New Technology, High Volume Growth, Fastest Growing Procedures and old Harvard-valued codes with utilization over 30,000 procedures annually. For additional information on the RUC screening process, see

T H E F I V E - Y E A R R E V I E W

Since the implementation of the Medicare Resource-based Relative Value Scale (RBRVS) Physician Fee Schedule in January 1992, Congress (through the Omnibus Budget Reconciliation Act of 1990) has required CMS to review the physician’s work relative value units within the Medicare Fee Schedule (MFS). CMS is required to conduct these reviews at least once every five years. This process, known as the Five-year Review, is used to identify, and reconsider the valuation of, potentially misvalued codes. The results from the first Five-year Review were implemented on Jan. 1, 1997, and subsequent reviews have been implemented every five years with the most recent implementation in 2012. Currently, the review process focuses only on the physician work RVU values. However, it is expected that future reviews will include re-examination of the practice expense RVU values for potentially misvalued codes as well.

T H E R U C R O L L I N G F I V E - Y E A R R E V I E W

In 2006, prompted by concerns raised by MedPAC, legislators, CMS and others, the AMA established the Five-year Review Identification Workgroup as a subcommittee under the RUC. The Five-Year Review Identification Workgroup (now known as the Relativity Assessment Workgroup [RAW]) engages in a “rolling,” ongoing process to identify potentially misvalued codes outside the traditional, formal Five-year Review process. Since its inception, the Workgroup has targeted more than 320 codes for further review by the RUC including many radiology and interventional radiology codes.

T H E B A S I C S O F C O D I N G

T H E F I V E - Y E A R R E V I E W

N AT I O N A L C O R R E C T C O D I N G I N I T I AT I V E ( N C C I )

In order to prevent payment of perceived abuses in procedural reporting,

Congress authorized HCFA (now CMS) to begin the National Correct

Coding Initiative (NCCI) in 1996. The primary intent of the NCCI has been to identify coding pairs that cannot or should not be performed at the same time (so called "mutually exclusive" pairs), and to promote “correct coding” of services reported together including the prevention of billing of inherent procedures in conjunction with comprehensive procedures (commonly referred to as “unbundling”).

NCCI edits are developed by CMS through a subcontract with Correct

Coding Solutions LLC (http://correctcodingsolutions.com/). Most proposed

new NCCI edits are distributed by the AMA to specialty societies for

comment, which may include critique of the appropriateness of the edits, as well as applicable use of the NCCI modifier indicator. CMS and Correct Coding Solutions review comments with follow-up communication when necessary. Following the comment process, edits to be implemented go forward as part of regular quarterly carrier system updates.

An NCCI modifier indicator of “0” indicates that NCCI-associated modifiers cannot be used to bypass the edit. A modifier indicator of “1” indicates that NCCI-associated modifiers can be used to bypass an edit under appropriate circumstances. (Please see the Modifier chapter for additional information.) NCCI edits including identification of the associated modifier indicator status are available to the public free-of-charge and can be downloaded from the CMS Web page,

Effective Jan. 1, 2013, two new NCCI-associated modifiers have been added: modifiers - 2 4 and - 5 7.

M o d i f i e r - 2 4 Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period

M o d i f i e r - 5 7 Decision for surgery

M E D I C A L LY U N L I K E LY E D I T S ( M U E S )

Beginning in January 2007 CMS began using national “medically unlikely edits” (MUEs). These edits are commonly referred to as frequency unit edits; they result in the limitation of the frequency (or number of units) that a particular service can be reported by the same provider/provider group for a given date of service.

A D D - O N C O D E E D I T S

Edits are also known to exist that limit the use of certain “add-on” codes

(those codes are identified with a “+” designation). These edits result in

rejection of the add-on code when reported in conjunction with a code not on the approved list. CMS has asserted that these edits are determined at the local level.

The SIR and ACR coding advisers carefully review all the proposed NCCI edits, and the Society frequently comments and submits opinion letters objecting to a proposed edit if clinical scenarios and typical patient care practices indicate that the edit might be in error.

T H E B A S I C S O F C O D I N G

evaluation and

management (

E

&

M

) codes

Several years ago, CMS eliminated payment for outpatient (9 9 2 4 1 to

9 9 2 4 5) and inpatient (9 9 2 5 1 to 9 9 2 5 5) consultation codes.

Consultations performed in an outpatient office are coded using the existing codes for new (9 9 2 0 1 to 9 9 2 0 5) or established (9 9 2 1 1 to 9 9 2 1 5) patients. Consultations performed on inpatients are coded using the existing

codes for initial (9 9 2 2 1 to 9 9 2 2 3) or subsequent (9 9 2 3 1 to

9 9 2 3 3) hospital care visits. This does not mean that consultations should not be performed on Medicare patients. The CPT codes for consultation services have not been eliminated. When these services are provided to Medicare patients, they will be billed with different codes as outlined above.

Elimination of payment for consultation codes has been evolving for several

years because of discrepancies between the CMS requirements for

consultations and the AMA interpretation of these requirements. This led to a CMS finding that consultation services were often billed inappropriately by not meeting the definition of a consultation or not having appropriate documentation to support the use of consultation codes. Furthermore, the documentation requirements for consultations, which were initially stricter than for other types of E&M services, are now similar to these other services and, therefore, do not warrant the higher payment that was associated with consultation services.

The work relative value units (RVUs) for new and established office visits have increased by approximately 6 percent to reflect the elimination of the office consultation codes. The work RVUs for initial hospital and facility

E VA L U AT I O N & M A N A G E M E N T C O D E S

visits are increased by approximately 2 percent. This has increased the payments for both of these services. In addition, the increased use of these visits will be incorporated into PE and MP RVU calculations.

Finally, the incremental work RVUs for the E&M codes that are built into the 10-day and 90-day global surgical codes were increased as well.

Third-party payers have not released information about reporting

consultations. Payers may or may not choose to follow this policy. Therefore, all physicians providing consultation services must be aware of the payment policies from their local and regional providers to know which codes to submit when rendering these services.

E & M C O D I N G A N D I N T E R V E N T I O N A L R A D I O L O G I S T S

Over the past several years, SIR has encountered a handful of instances in which some hospital systems or payers deny payment for E&M claims submitted by radiologists and interventional radiologists. SIR’s standing position is that E&M services are allowable and can be appropriately

claimed by any provider performing the services, including radiologists and interventional radiologists. Interventional radiologists perform total patient care; it is fully appropriate for interventional radiologists to document such care with E&M codes. We understand that some carriers have denied

payments for E&M services provided by all radiologists because they have assumed that the services that were being reported were not true E&M services but rather focused history and physicals to satisfy Joint Commission (formerly Joint Commission on Accreditation of Healthcare Organizations) requirements for current documentation on the chart for invasive

procedures.

Our Society has worked with several of these carriers to educate them on the actual E&M work provided by clinical interventional radiologists and to

differentiate these E&M services from the work that is already included in invasive procedure valuations.

Many interventional radiology procedures require longitudinal care, identical to many other fields of medicine. Patients are evaluated preprocedure to determine their state of health, presenting illness and underlying conditions. Appropriate testing is ordered to fully diagnose their pathology. The patient is advised of all potential treatment options

including, but not limited to, options provided by interventional

radiologists. If the patient’s condition is deemed suitable for treatment by the interventional radiologist, then he or she is scheduled for treatment and the service is rendered. Follow-up care is given as appropriate, and patients are often followed in a clinical office to monitor the effectiveness of the therapy and the progress of the underlying condition. Additionally,

radiologists providing breast care, specifically mammography services, also perform separate E&M services, advising patients on treatment options. This is entirely analogous to services as provided by medical and surgical

specialists such as gastroenterologists, surgeons and cardiologists. In another example of appropriate E&M, an interventional radiologist is asked to provide his or her clinical opinion regarding the appropriateness of a procedure for a given patient. When a patient is referred by another

physician, the specialist physician routinely documents his or her services with an E&M code. For example, interventional radiologists see patients who have been referred for possible procedures for spinal fractures

(vertebroplasty/kyphoplasty), peripheral arterial disease, uterine fibroids and oncologic cases (e.g., ablation therapies and Y-90 spheres).

For inpatients, it is appropriate to perform and document consults. If the consult is performed and fully documented on the same day as a procedure,

led to a decision to treat and is a separate service. Inpatient rounds also lead to frequent changes in patient management. For inpatient rounds, IR

physicians should follow the global period rules for billing.

As a result of these evaluations, many patients referred for a specific

procedure may ultimately have care that differs from the procedure named on the request. A procedure may be cancelled or changed to a different procedure and follow-up or additional imaging may be recommended rather than a procedure. Hospitals may use different information systems, but it is important to note that, when a physician orders a procedure from the interventional radiology department, the interventional radiologist will still be required to exercise his or her clinical evaluative skills and judgment before performing the procedure. There are easily conceivable scenarios in which a procedure is ordered but, after a review of all medical information, the interventional radiologist decides that such a procedure is not

warranted. The interventional radiologist would communicate this decision to the referring physician and would document and charge for his or her consultation but not the procedure. If the procedure is indeed warranted and performed by the IR, the IR will still have been required to evaluate the patient.

For inpatient rounds, interventional radiologists should follow the global period rules for billing. Inpatient rounds lead to frequent changes in patient management. All of the above clinical actions are appropriately billed with E&M codes. E&M coding is appropriate for IR clinical work and indicates that a higher level of care is being offered to patients under the care of that IR practice. SIR has always made a distinction between routine

preprocedure care and the more complex and time-consuming patient interaction that takes place as part of a formal consult. To help clarify the guidelines, SIR stated in 2006: “If you are asked to see a patient for input into that patient’s management and you evaluate that patient to develop an

E VA L U AT I O N & M A N A G E M E N T C O D E S

assessment and plan and then document the encounter and your

recommendations appropriately, then you have performed the work of a consultation and should bill the correct E&M code. However, if you are seeing a patient before a previously arranged procedure and the purpose of that visit is to confirm that the patient can go through that procedure and to obtain informed consent for the procedure, then consider that encounter to be bundled into the procedure itself and do not bill separately for that encounter. Only you will know the reason for the encounter and therefore only you can make that decision.” (“Coding for Consultations in

Interventional Radiology,” IR News, Nov./Dec. 2006, p. 14;

N E W A N D R E V I S E D

interventional radiology

codes for

2013

R E V I S E D I N T E R V E N T I O N A L R A D I O L O G Y C O D E S F O R 2 0 1 3

For 2013, a number of revisions and code clarifications were added to several common codes used by interventional radiologists.

Ve r t e b r a l B o d y, E m b o l i z a t i o n o r I n j e c t i o n

The add-on code + 2 2 5 2 2 (each additional thoracic or lumbar vertebral

body [List separately in addition to code for primary procedure]) has been revised to include moderate (conscious) sedation. The AMA CPT manual

denotes the inclusion with the bull’s eye symbol

☉

.

R e s p i r a t o r y S y s t e m

New codes for endoscopy procedures have been created for 2013.

B r o n c h o s c o p y

Codes 3 1 6 2 2 – 3 1 6 4 8 include fluoroscopic guidance, when performed.

☉

3 1 6 2 2 Bronchoscopy, rigid or flexible, including fluoroscopic

guidance, when performed, diagnostic, with cell washing, when performed (separate procedure)

☉

3 1 6 2 3 with brushing or protected brushings

N E W A N D R E V I S E D I R C O D E S R E V I S E D I R C O D E S F O R 2 0 1 3

☉

3 1 6 2 4 with bronchial alveolar lavage

☉

3 1 6 2 5 with bronchial or endobronchial biopsy(s), single and multiple sites

☉

3 1 6 2 6 with placement of fiducial markers, single or multiple

☉

3 1 6 2 7 with computer-assisted, image-guided navigation (list separately in addition to code for primary procedure(s)

☉

3 1 6 2 8 with transbronchial lung biopsy(s), single lobe

☉

3 1 6 2 9 with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i)

☉

3 1 6 3 4 with balloon occlusion, assessment of air leak, with administration of occlusive substance (e.g., fibrin glue) if performed

(Do not report 3 1 6 3 4 in conjunction with 3 1 6 4 7,

3 1 6 5 1 at the same session.)

☉

3 1 6 3 5 with removal of foreign body

(For removal of implanted bronchial valves see 3 1 6 4 8 – 3 1 6 4 9.)

☉

3 1 6 4 7 with balloon occlusion, when performed, assessment of air leak, airway sizing and insertion of bronchial valve(s), initial lobe

☉

3 1 6 4 8 with removal of bronchial valve(s), initial lobe removal and insertion of bronchial valve at the same session, see 3 1 6 4 7, 3 1 6 4 8 and 3 1 6 5 1)

(3 1 6 5 6 has been deleted. To report, see code 3 1 8 9 9.)

C O D E S F O R 2 0 1 3

B r o n c h i a l T h e r m o p l a s t y

☉

3 1 6 6 0 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 1 lobe

☉

3 1 6 6 1 with bronchial thermoplasty, 2 or more lobes (3 1 7 1 5 has been deleted. To report, use code 3 1 8 9 9.)

L u n g s a n d P l e u r a

(3 2 4 2 0 has been deleted. To report, use 3 2 4 0 5.)

(3 2 4 2 1 and 3 2 4 2 2 have been deleted. To report, see codes 3 2 5 5 4, 3 2 5 5 5.)

(3 2 5 5 1 has been revised for tube thoracostomy to indicate that this code is now used for reporting an open procedure.)

☉

3 2 5 5 3 Placement of an interstitial device(s), for radiation therapy guidance (e.g., fiducial markers, dosimeter), percutaneous, intrathoracic, single or multiple

(Report supply of device separately.)

For percutaneous placement of an interstitial device(s), such as fiducial marker or dosimeter, for radiation therapy guidance within the abdomen,

pelvis (except prostate) and/or retroperitoneum, report

☉

4 9 4 1 1.

Imaging guidance codes (7 6 9 4 2, 7 7 0 0 2, 7 7 0 1 2 or 7 7 0 2 1) and

device codes (e.g., A 4 6 4 8 tissue marker, A 4 6 5 0 implantable radiation

dosimeter or A 4 6 4 9 surgical supply) are reported separately in

conjunction with the percutaneous placement procedure codes.

N E W A N D R E V I S E D I R C O D E S R E V I S E D I R C O D E S F O R 2 0 1 3

N E W 2 0 1 3 C P T C O D E S C O M M O N T O I N T E R V E N T I O N A L R A D I O L O G Y

T h o r a c e n t e s i s

Four new codes have been created describing thoracentesis and pleural

drainage. Codes 3 2 5 5 4 – 3 2 5 5 7 are NOT to be reported in conjunction

with codes 3 2 5 5 0, 3 2 5 5 1, 7 6 9 4 2, 7 7 0 0 2, 7 7 0 1 2, 7 7 0 2 1, 7 5 9 8 9.

3 2 5 5 4 Thoracentesis, needle or catheter, aspiration of the pleural space; without imaging guidance

3 2 5 5 5 with imaging guidance

3 2 5 5 6 Pleural drainage, percutaneous, with insertion of indwelling catheter; without imaging guidance

3 2 5 5 7 with imaging guidance

To report insertion of indwelling tunneled pleural catheter with cuff, see code 3 2 5 5 0.

Moderate sedation is NOT inherent to procedure codes 3 2 5 5 4 – 3 2 5 5 7

and should be reported separately when these services are provided.

C e r v i c o c e r e b r a l A n g i o g r a p h y

Eight new cervicocerebral angiography codes have been created to report nonselective and selective arterial catheter placement and diagnostic

imaging of the aortic arch, carotid and vertebral arteries, 3 6 2 2 1 – 3 6 2 2 8.

Accompanying the new codes is extensive introductory language describing the new codes and reporting instructions. This new section starts on p. 207

of the CPT 2013, Professional Edition code book.

These codes describe arterial contrast injections with arterial, capillary and venous-phase imaging, when performed. Accessing the vessel, placement of catheter(s), contrast injection(s), fluoroscopy, RS&I and the closure of the arteriotomy by pressure or by application of an arterial closure device is

inherent in codes 3 6 2 2 1 – 3 6 2 2 6 and not separately reportable.

Moderate sedation is included in the new codes, and is not separately reportable.

Codes 3 6 2 2 1 – 3 6 2 2 6 progress up a hierarchy in which the lesser

intensive services are included in the higher intensity code—i.e., use the

code of the most intensive service provided. For example, 3 6 2 2 1 is

reported for nonselective catheter placement, thoracic aorta, with angiography of the aortic arch and great vessel origins. Do not report 3 6 2 2 1 in conjunction with 3 6 2 2 2 – 3 6 2 2 6 selective codes, as these

include the work of 3 6 2 2 1 when performed.

☉

3 6 2 2 1 Nonselective catheter placement, thoracic aorta, with

angiography of the extracranial carotid, vertebral, and/or intracranial vessels, unilateral or bilateral, and all associated radiological supervision and

interpretation, includes angiography of the cervicocerebral arch, when performed.

(Do not report 3 6 2 2 1 with 3 6 2 2 2 – 3 6 2 2 6.)

☉

3 6 2 2 2 Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral

extracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed.

☉

3 6 2 2 3 Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral

intracranial carotid circulation and all associated radiological supervision

N E W A N D R E V I S E D I R C O D E S

N E W 2 0 1 3 C P T C O D E S

and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed.

☉

3 6 2 2 4 Selective catheter placement, internal carotid artery, unilateral, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed.

Do not report 3 6 2 2 2, 3 6 2 2 3 or 3 6 2 2 4 together for ipsilateral

angiography. Select the most comprehensive service following the hierarchy of complexity.

☉

3 6 2 2 5 Selective catheter placement, subclavian or innominate artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed.

☉

3 6 2 2 6 Selective catheter placement, vertebral artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed.

Do not report 3 6 2 2 5 with 3 6 2 2 6 for ipsilateral angiography. Select the

most comprehensive service following the hierarchy of complexity.

☉

+ 3 6 2 2 7 Selective catheter placement, external carotid artery, unilateral, with angiography of the ipsilateral external carotid circulation and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure.)

(Use 3 6 2 2 7 in conjunction with 3 6 2 2 2,3 6 2 2 3 or 3 6 2 2 4.)

☉

+ 3 6 2 2 8 Selective catheter placement, each intracranial branch of the internal carotid or vertebral arteries, unilateral, with angiography of the selected vessel circulation and all associated radiological supervision and

interpretation (e.g., middle cerebral artery, posterior inferior cerebellar artery). (List separately in addition to code for primary procedure.)

(Use 3 6 2 2 8 in conjunction with 3 6 2 2 4 or 3 6 2 2 6.)

(Do not report 3 6 2 2 8 more than twice per side.)

Add modifier – 5 0 to codes 3 6 2 2 2 – 3 6 2 2 8 if the same procedure is

performed on both sides. Modifier – 5 9 may be used to indicate when

different carotid and/or vertebral arteries are being studied in the same session.

Report 7 6 3 7 6 or 7 6 3 7 7 for 3D rendering when performed in

conjunction with 3 6 2 2 1 – 3 6 2 2 8.

Report 7 6 9 3 7 for ultrasound guidance for vascular access, when

performed in conjunction with 3 6 2 2 1 – 3 6 2 2 8.

D e l e t e d R S & I C o d e s

As part of the new bundled cervicocerebral angiography codes, several angiography supervision and interpretation codes have been deleted. These

are in the radiology section of CPT, under the subheading Vascular

System—Aorta and Arteries RS&I_.

7 5 6 5 0 To report see codes 3 6 2 2 1 – 3 6 2 2 6.

7 5 6 6 0 To report see code 3 6 2 2 7.

7 5 6 6 2 To report use code 3 6 2 2 7 and append modifier – 5 0.

7 5 6 6 5 To report see codes 3 6 2 2 3, 3 6 2 2 4.

7 5 6 7 1 To report see codes 3 6 2 2 3 and 3 6 2 2 4 and append modifier – 5 0 as appropriate. N E W A N D R E V I S E D I R C O D E S N E W 2 0 1 3 C P T C O D E S

7 5 6 7 6 To report see codes 3 6 2 2 2 – 3 6 2 2 4.

7 5 6 8 0 To report see codes 3 6 2 2 2 – 3 6 2 2 4 and append modifier – 5 0 as appropriate.

7 5 6 8 5 To report see codes 3 6 2 2 5 – 3 6 2 2 6.

Fo r e i g n B o d y R e t r i e v a l

For 2013, a new bundled CPT code has been created that bundles the

procedure with the radiological supervision and interpretation. The previous

CPT code for foreign body retrieval, 3 7 2 0 3, has been deleted, along with

the RS&I code, 7 5 9 6 1.

☉

3 7 1 9 7 Transcatheter retrieval, percutaneous, of intravascular foreign body (e.g., fractured venous or arterial catheter), includes radiological supervision and interpretation, and imaging guidance (ultrasound or fluoroscopy), when performed

(7 5 9 6 1 has been deleted. To report, use code 3 7 1 9 7.)

(For percutaneous retrieval of a vena cava filter, use 3 7 1 9 3.)

Tr a n s c a t h e t e r T h r o m b o l y s i s

Four new codes have been created to report transcatheter thrombolytic arterial or venous infusion. These new codes cover the entire therapeutic period of time. Critical guidance on these new codes is shown on p. 218 of the CPT 2013 Professional Edition printed_{code book.}

Codes 3 7 2 1 1 and 3 7 2 1 2 are used to report the initial day of

transcatheter thrombolytic infusion including follow-up

arteriography/venography and catheter position change or exchange, when performed. When initiation and completion of thrombolysis

occur on the same calendar day, report only 3 7 2 1 1 or 3 7 2 1 2.

Catheter placement(s), diagnostic studies and other percutaneous interventions may be reported separately.

Codes 3 7 2 1 1 – 3 7 2 1 4 include fluoroscopic guidance and associated

RS&I. Ultrasound guidance for vascular access—see code 7 6 9 3 7—may be

reported separately when all required elements are performed.

Bilateral thrombolytic infusion through separate access site(s) may be

reported with modifier – 5 0 in conjunction with 3 7 2 1 1,3 7 2 1 2.

Radiological supervision and interpretation codes 7 5 8 9 6 and 7 5 8 9 8

have been revised and are not to be reported in conjunction with 3 7 2 1 1 – 3 7 2 1 4 for thrombolysis infusion management.

3 7 2 1 1 Transcatheter therapy, arterial infusion for thrombolysis other than coronary, any method, including radiological supervision and

interpretation, initial treatment day.

3 7 2 1 2 Transcatheter therapy, venous infusion for thrombolysis, any method, including radiological supervision and interpretation, initial treatment day.

3 7 2 1 3 Transcatheter therapy, arterial or venous infusion for thrombolysis other than coronary, any method, including radiological supervision and interpretation, continued treatment on subsequent day, during course of thrombolytic therapy, including follow-up catheter contrast injection, position change, or exchange, when performed

3 7 2 1 4 cessation of thrombolysis including removal of catheter and vessel closure by any method

N E W A N D R E V I S E D I R C O D E S

N E W 2 0 1 3 C P T C O D E S

The previous code for thrombolysis, 3 7 2 0 1, has been deleted—see codes 3 7 2 1 1 – 3 7 2 1 4.

Code 7 5 9 0 0 has been deleted; see codes 3 7 2 2 1 – 3 7 2 1 4 for reporting

exchange of a previously placed intravascular catheter during thrombolytic therapy.

D i a g n o s t i c R a d i o l o g y ( D i a g n o s t i c I m a g i n g )

C h e s t

7 1 0 4 0, 7 1 0 6 0 have been deleted. To report, use 7 6 4 9 9.

S p i n e a n d P e l v i s

7 2 0 4 0 Radiologic examination, spine, cervical; 3 views or less

7 2 0 5 0 4 or 5 views

7 2 0 5 2 6 or more views

7 2 2 7 5 Epidurography, radiological supervision and interpretation (7 2 2 7 5 includes 7 7 0 0 3)

(For injection procedure, see 6 2 2 8 0 – 6 2 2 8 2, 6 2 3 1 0 – 6 2 3 1 9, 6 4 4 7 9 – 6 4 4 8 4.)

(Use 7 2 2 7 5 only when an epidurogram is performed, images documented,

and a formal radiologic report is issued.)

(Do not report 7 2 2 7 5 in conjunction with 2 2 5 8 6, 0 1 9 5 T, 0 1 9 6 T, 0 3 0 9 T.)

R a d i o l o g y G u i d e l i n e s , Va s c u l a r P r o c e d u r e s — A o r t a a n d A r t e r i e s

Parenthetical revisions have been added for aortography codes 7 5 6 0 0,

7 5 6 0 5 and 7 5 6 3 5 and angiography, pulmonary codes 7 5 7 4 6, 7 5 7 5 6 and 7 5 7 7 4. Providers may review these changes in the CPT® 2013

codebook.

E N D O VA S C U L A R R E VA S C U L A R I Z AT I O N

Guidelines have been updated for lower-extremity endovascular procedures for 2013 to inform users of specific types of closure procedures that are inherent to these procedures, and which specify services that are separately reportable.

When treating multiple vessels within a territory, report each additional vessel using an add-on code, as applicable. Select the base code that represents the most complex service using the following hierarchy of complexity (in descending order of complexity): atherectomy and stent> atherectomy >stent >angioplasty. When treating multiple lesions within the same vessel, report one service that reflects the combined procedures, whether done on one lesion or different lesions, using the same hierarchy. These codes take into account that multiple techniques may be needed in order to open areas of disease in some vessels, and that these interventions may take place in different vascular territories. In general, the codes for interventions progress up a hierarchy of intensity with the work of the less-intense intervention included in the higher intensity code. For example, angioplasty prior to a stent placement would be a progression up this hierarchy and only the stent code would be reported. Each of these codes includes the work of accessing the artery, selecting the vessel, crossing the lesion, interpreting the images, performing therapeutic intervention(s) in

N E W A N D R E V I S E D I R C O D E S

ENDOVASCULAR REVASCULARIZATION

the entire vessel segment, using any embolic protection device, performing final image interpretation and closing the arteriotomy by any method. If angioplasty is performed in addition to facilitate a more advanced

procedure, such as atherectomy, or stenting, it is included in the code for the more advanced procedure. Moderate sedation is also included in each of these codes. Mechanical thrombectomy and thrombolysis are not included

in the work of codes 3 7 2 2 0 – 3 7 2 3 5 and can be reported additionally

with the appropriate component codes when these techniques are used in combination with PTA/stenting/atherectomy to restore flow to areas of occlusive disease. As in the past, thrombolysis used as part of mechanical thrombectomy is not separately reportable. When a thrombolytic infusion is performed either subsequent or prior to mechanical thrombectomy, it is separately reported. The codes apply to the procedure if performed percutaneously or open.

Revascularization procedures are grouped into three vascular territories based on the anatomy and are specific to the procedures of angioplasty, stenting or atherectomy. (PTA is considered an inherent part of stenting or atherectomy procedures and is not separately reportable.) Each code applies to a single extremity.

1 Iliac territory: subdivided into common, internal and external iliac artery

a 3 7 2 2 0 – 3 7 2 2 3

b Single code used for a single vessel

c Add-on codes used for additional iliac vessels that are treated

(common, internal or external)

2 Femoral/popliteal territory: this entire territory is considered a single

vessel

a 3 7 2 2 4 – 3 7 2 2 7

b Includes the common, deep and superficial femoral as well as popliteal

c Since it is a single vessel, only a single code may be reported,

even if multiple lesions are treated

d If two procedures are performed in different areas of the vessel

territory, report the code that includes all therapies provided in that region.

3 Tibial/peroneal territory: subdivided into anterior tibial, posterior tibial

and peroneal

a 3 7 2 2 8 – 3 7 2 3 5

b Report the initial vessel treated as the primary code for the highest

level of service provided within the tibial-peroneal territory with add-on codes for additiadd-onal vessels treated (not additiadd-onal lesiadd-ons or procedures in the same vessel)

c The tibioperoneal trunk is not considered a separate vessel

If a lesion extends across the margin of a territory, but is opened with a single therapy, report with only a single code. For example, if a distal

popliteal artery stenosis extends into the tibioperoneal trunk and the lesion is treated with a single angioplasty spanning both lesions, only code a single vessel treatment.

If both legs are treated at the same time, use modifier – 5 9 to indicate

separate and distinct services performed on the same day.

A “+” sign indicates an add-on code that must be used after the appropriate

code for the initial vessel treated.

N E W A N D R E V I S E D I R C O D E S

ENDOVASCULAR REVASCULARIZATION

I l i a c A r t e r y R e v a s c u l a r i z a t i o n

3 7 2 2 0 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplast

3 7 2 2 1 with transluminal stent placement(s), includes angioplasty within same vessel when performed.)

+ 3 7 2 2 2 Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty (List separately in addition to code for primary procedure)

(Used in conjunction with 3 7 2 2 0, 3 7 2 2 1 for additional iliac segment

PTA.)

+ 3 7 2 2 3 with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure)

(Used in conjunction with 3 7 2 2 1 for additional iliac

segment stent placement)

F e m o r a l / P o p l i t e a l A r t e r y R e v a s c u l a r i z a t i o n

3 7 2 2 4 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty

3 7 2 2 5 with atherectomy, includes angioplasty within the same vessel, when performed

3 7 2 2 6 with transluminal stent placement(s), includes angioplasty within the same vessel, when performed

3 7 2 2 7 with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed

Ti b i a l / P e r o n e a l A r t e r y R e v a s c u l a r i z a t i o n

3 7 2 2 8 Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty

3 7 2 2 9 with atherectomy, includes angioplasty within the same vessel, when performed

3 7 2 3 0 with transluminal stent placement(s), includes angioplasty within the same vessel, when performed

3 7 2 3 1 with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed

+ 3 7 2 3 2 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal angioplasty (List separately in addition to code for primary procedure.)

(Used in conjunction with 3 7 2 2 8 – 3 7 2 3 1.)

+ 3 7 2 3 3 with atherectomy, includes angioplasty within the same vessel, when performed. (List separately in addition to code for primary procedure.)

(Used in conjunction with 3 7 2 2 9, 3 7 2 3 1.)

+ 3 7 2 3 4 with transluminal stent placement(s), includes angioplasty within the same vessel, when performed. (List separately in addition to code for primary procedure.)

(Used in conjunction with 3 7 2 2 9 – 3 7 2 3 1.)

+ 3 7 2 3 5 with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when

N E W A N D R E V I S E D I R C O D E S

ENDOVASCULAR REVASCULARIZATION

performed. (List separately in addition to code for primary procedure.)

(Used in conjunction with 3 7 2 3 1.)

S P E C I A L C O D I N G N O T E F O R 2 0 1 3 : E M B O L I Z AT I O N

T H E R A P Y F O R B E N I G N P R O S T AT I C H Y P E R P L A S I A ( B P H )

Benign prostatic hyperplasia (BPH) is a common ailment affecting many men as they age. Symptomatic patients often suffer considerable lower-urinary-tract discomfort, and decreased quality of life is often associated with BPH symptoms.

Embolization of the prostatic arteries is a procedure that has shown some promise as a method to treat BPH in early small research studies, mostly done in Europe and South America. Further clinical research and trials are expected to commence in 2013 in the United States. SIR supports research on this procedure and will be supporting and closely following these trials to assess the early data and outcomes.

In terms of coding and reimbursement, given the experimental nature of the procedure, SIR’s position is that physicians should discuss any proposed prostatic embolization procedure with their patients’ relevant Carrier Medical Directors. Since embolization for BPH is clearly an investigational procedure at this time, physicians should check with the insurance carrier prior to performing the procedure to determine if the procedure will be covered and how the procedure should be coded. The carriers could request

that the procedure be coded with CPT code 3 7 7 9 9 (Unlisted Procedure,

vascular surgery) to indicate its investigational nature. If component coding is allowed, the appropriate codes could include:

P R O S TAT I C H Y P E R P L A S I A

• 3 7 2 0 4 (x1) (Transcatheter occlusion or embolization (e.g., for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method, noncentral nervous system, non-head or neck), • 7 5 8 9 4 (x1) (Transcatheter therapy, embolization any method,

radiological supervision and interpretation)

• 3 6 2 4 7 (Up to maximum of 2 times) (Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic or lower-extremity artery branch, within a vascular family)

• 3 6 2 4 8 catheter placement, arterial system; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch,

within a vascular family). 3 6 2 4 8 may be used if 2 branches have to be

catheterized for study and/or embolization on the same side

• 7 5 8 9 8 (x1) (Angiography through existing catheter for follow-up study for transcatheter therapy, embolization or infusion, other than for

thrombolysis)

Diagnostic angiography would, in most cases, not be additionally reported since the imaging of the pelvic vessels done prior to the embolization would be done for roadmapping purposes rather than diagnosis of BPH. However, if an interventional radiologist is performing the embolization as part of a clinical trial site, the physician should likewise discuss the trial and get pre-approval from the carrier prior to enrolling patients. There should be agreement with the carrier prior to enrolling patients as to how the

procedures will be coded and paid. Some FDA IDE trials will allow use of existing CPT codes while others may designate that existing CPT codes are not applicable.

In 2013, SIR will draft a new Category III CPT code to describe prostatic artery embolization for presentation to the American Medical Association’s

N E W A N D R E V I S E D I R C O D E S B E N I G N P R O S TAT I C H Y P E R P L A S I A

CPT Editorial Panel. Category III codes describe emerging technologies or investigational procedures and also allow for data collection. If the new code is approved, SIR will inform members promptly through its outreach and educational venues, and it is anticipated that most carriers will require use of the new Category III code for reporting prostatic artery embolization to treat BPH.

P R O S TAT I C H Y P E R P L A S I A

frequently asked questions

FA Q 1 How do I code for internal iliac artery embolizations at the time of EVAR?

Embolization performed at the time of an endovascular repair of an aneurysm (thoracic endovascular aortic repair [TEVAR] and endovascular aneurysm repair [EVAR]), including embolization of a hypogastric artery, is separately billable. Codes 3 7 2 0 4, 7 5 8 9 4, 7 5 8 9 8 and typically 3 6 2 4 5 are all appropriate to report this procedure. Use of a selective catheter

placement code for embolization obviates the use of the 3 6 2 0 0 for

placing a catheter in the aorta under coding convention rules.

FA Q 2 What are the appropriate codes to report for

sclerotherapy of nonvascular structures, such as seromas, cysts, lymphoceles or abscesses?

The following CPT codes are reported for all nonvascular sclerosis procedures (e.g., seroma, cyst, lymphocele, abscess):

2 0 5 0 0 (Injection of sinus tract; therapeutic [separate procedure]) 7 6 0 8 0 (Radiologic examination, abscess, fistula or sinus tract study, radiological supervision and interpretation)

The use of different agents (e.g., alcohol, tetracycline, betadine) does not limit or alter the reporting of these codes.

Moderate sedation is notinherent to code 2 0 5 0 0 and is separately

reportable.

9 9 1 4 4 Age 5 years or older, first 30 minutes intra-service time + 9 9 1 4 5 Each additional 15 minutes intra-service time

Note that this is an add-on code (+) and must be used in

conjunction with 9 9 1 4 4.

If the patient is being seen for new or worsening symptoms and E&M

services provided by the interventionalist to evaluate those symptoms, those E&M services should be separately documented and coded. This E&M

service may need to be reported with the use of appropriate modifiers

(e.g., – 2 4, – 2 5) as the patient’s recent operative history demands.

FA Q 3 What are the appropriate codes to use when microwave ablation is the energy source used for liver, lung or renal lesions?

The existing CPT codes for tumor ablation are defined for radiofrequency ablation. This definition has led to some confusion, occasionally resulting in the use of unlisted procedure codes for microwave ablation.

SIR does not recommend the use of unlisted procedure codes for microwave ablation of kidney, lung or liver tumors.

Microwave is part of the radiofrequency spectrum and uses a different part of the radiofrequency spectrum to generate heat energy to destroy

abnormal soft tissue. Microwave ablation equipment is substantially

comparable to operate in practice, which is also reflected in the U.S. Food and Drug Administration (FDA) approval of microwave devices under the 510(K) clearance process as equivalent to radiofrequency.

As such, SIR recommends that CPT codes 4 7 3 8 2, 3 2 9 9 8 and 5 0 5 9 2

be used for both microwave and radiofrequency ablation in their respective anatomic locations, in conjunction with the appropriate imaging guidance code:

4 7 3 8 2 Ablation, 1 or more liver tumor(s) percutaneous, radiofrequency;

with appropriate image guidance code: 7 7 0 1 3 (CT), 7 6 9 4 0 (US),

7 7 0 2 2 (MRI)

3 2 9 9 8 Ablation therapy for reduction or eradication of 1 or more

pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, radiofrequency, unilateral; with appropriate image

guidance code: 7 7 0 1 3 (CT), 7 6 9 4 0 (US), 7 7 0 2 2 (MRI)

5 0 5 9 2 Ablation, 1 or more renal tumor(s), percutaneous, unilateral,

radiofrequency; with appropriate image guidance code: 7 7 0 1 3 (CT),

7 6 9 4 0 (US), 7 7 0 2 2 (MRI)

individual coverage

request sample letters

The following are examples of a few common coverage request letters. The examples include letters for coverage for radiofrequency ablation of pulmonary tumor(s), ovarian vein embolization for pelvic congestion syndrome and MRI imaging of the uterus prior to uterine fibroid

embolization. These templates include data, arguments for need and benefit and can save you considerable work

P E R C U T A N E O U S R A D I O F R E Q U E N C Y A B L AT I O N O F P U L M O N A R Y T U M O R ( S )

[DATE]

[CARRIER MEDICAL DIRECTOR]

[COVERAGE RECONSIDERATION DEPARTMENT] [CARRIER NAME]

[CARRIER ADDRESS] [CARRIER CITY, STATE ZIP]

RE: [PATIENT NAME]

[PATIENT ID]

Request for coverage for Percutaneous Radiofrequency Ablation (RFA) of Pulmonary Tumor(s)

[CARRIER MEDICAL DIRECTOR]:

On [INSERT DATE OF PRECERTIFICATION/COVERAGE REQUEST DENIAL], notice was received from your company that radiofrequency ablation (RFA) of pulmonary tumor(s) is considered experimental and investigational, and, therefore, a noncovered service. This is a formal request for individual

consideration to extend coverage for RFA of pulmonary tumor(s) for [PATIENT NAME], who has been diagnosed with [INSERT DIAGNOSIS: lung cancer, lung metastases, lung malignancies, including stage].

[PATIENT NAME] has been seen and evaluated by a [SELECT REFERRING PHYSICIAN TYPE: thoracic surgeon/oncologist/oncology physician team] who [is/are] in agreement that pulmonary tumor RFA is the best treatment option

for [PATIENT NAME] at this time.

[PATIENT NAME] is not alone in suffering from [INSERT CONDITION: lung cancer, lung metastases, lung malignancies, including stage]. Lung cancer kills more Americans than any other type of malignancy. The disease kills some 160,000 Americans a year—more than breast cancer, colon cancer and prostate cancer combined.

Pulmonary Tumor RFA Is Safe and Effective

The Society of Interventional Radiology “finds that RFA of pulmonary tumor(s) is a safe and effective treatment for a subset of patients with

metastases to the lung, and patients with primary lung malignancies who are poor surgical candidates or refuse resection. In addition to tumor

eradication, radiofrequency ablation is used to ‘debulk’ or reduce lung tumor increasing the effectiveness of adjunctive chemo- and/or radiation therapy or as a stand-alone treatment after failed conventional therapy for chest wall pain palliation.”

Pulmonary tumor RFA has been shown to be an effective palliative therapy providing tumor control and pain relief. In order to provide an appropriate framework in which to accurately evaluate the efficacy of pulmonary RFA, we provide background information regarding traditional treatments.

Life Expectancy, Rate of Tumor Growth and Tumor Control, for Lung Cancer Patients.Life expectancies for lung cancer patients vary according

S A M P L E L E T T E R S

to the stage and overall health of the patient. For patients with metastases to the lung, nodule size typically doubles in 2–10 months. The rate of lung cancer spread varies greatly with each individual and cell type. However, tumor growth is typically seen over a few months and may result in the patient’s demise. For stage IV NSCLC patients, those “who do not receive any treatment live for an average of four months and approximately 5–10% remain alive one year from diagnosis.” For those patient receiving

chemotherapy, the “average duration of patients’ survival was similar for all four [chemotherapy] treatment regimens and was between seven and eight months.”

http://patient.cancerconsultants.com/lung_cancer_treatment.aspx?id=805

Typically, the only cure for lung cancer is surgical removal of the tumor(s). Typically, surgical intervention is only considered for stage I and II patients, with stage III patients occasionally found to be viable candidates. Surgery is rarely considered a treatment option for stage IV patients. The majority of lung cancer patients are found to have advanced disease at the time of initial diagnosis and are not considered viable surgical candidates. Even for those treated surgically, recurrence rates are quite high. The American Cancer Association does not present surgery as a definitive cure but rather advises that surgery “may cure lung cancer.” Historically, the surgical options offered are local wedge resection, lobectomy and pneumonectomy, several of which have been in use for well over a century.

According to the National Cancer Institute (NCI), the efficacy of traditional surgical treatments for lung cancer is equivalent to the odds associated with tossing a coin: according to one study, recurrence rates are as high as 50% for stage I patients treated with wedge or segment resection. Per the NCI, the mortality rate for lobectomy is 3–5% and according to the Southern Illinois University Division of Cardiothoracic Surgery, a provider of these services, a thoracotomy incision is considered to be “one of the more

painful incisions.” Recovery time after these invasive surgical treatments is substantial with at least a two-day stay in the Intensive Care Unit (ICU), and a total hospital stay of 5–10 days after lung resection. Chemotherapy and radiation can be considered as adjunctive therapies to surgical intervention. These techniques cannot be given earlier than 8 weeks after surgery since they may interfere with the body’s ability to heal.

At this time, just as with traditional invasive surgical treatments, it is not known whether pulmonary RFA is a definitive “cure” for lung cancer. However, as adeptly stated by the Radiological Society of North America, “RFA is a relatively quick procedure that does not require general

anesthesia. Recovery is rapid so that chemotherapy may be resumed almost immediately. Even when RFA does not remove all of a tumor, a reduction in the total amount of tumor may extend life for a significant time.”

Control and Comfort

It is generally accepted that tumor control results in increased life

expectancy for patients with lung cancer. The FDA defines an “effective” drug [treatment] as one that achieves a 50% or more reduction in tumor size for 28 days. At this time, the focus of RFA is tumor control and at this time there are numerous studies that support that RFA is effective in tumor

control. Tumor control is also commonly associated with relief of symptoms, providing patients with an increased quality of life.

Body of Scientific Literature Supporting RFA of Pulmonary Tumor(s) As an Effective Treatment

Studies show that patients who have pulmonary tumor(s) treated with RFA experience reduction and, in many instances, complete eradication of tumor(s). This is believed to extend life expectancy and/or result in increased comfort. Please see “Attachment A” for a list of supporting

S A M P L E L E T T E R S

scientific literature for radiofrequency ablation of pulmonary tumor(s). Also, enclosed is a table (see Attachment B) summarizing the scientific articles available supporting RFA as an effective treatment.

Proposed Treatment Plan for [INSERT PATIENT NAME]

In this procedure, the interventional radiologist guides a small needle

through the skin into the tumor. Radiofrequency energy is transmitted to the tip of the needle, where it produces heat in the tissues. The tumor tissue shrinks and slowly forms a scar. It is ideal for nonsurgical candidates and those with smaller tumors.

Once a patient such as [PATIENT NAME] has been diagnosed with [INSER