Angioplasty Coding ASDIN Coding University 1

Angioplasty Coding Angioplasty may be venous or arterial; these have different codes and special rules that relate to each Additionally, an angioplasty may be done in the upper or lower extremity – Venous angioplasty – the same principles in both – Arterial angioplasty – in the lower extremity, the Lower Extremity Revascularization coding system is used 2 (For arterial angioplasty in the lower extremity see separate unit)

Dialysis Access Definitions Two different definitions: – For diagnostic purposes - the dialysis access is defined as beginning with the arterial anastomosis and extending to the right atrium – For therapeutic purposes - the dialysis access is defined as beginning with the arterial anastomosis and extending up to the beginning of the central veins These apply to both an upper and lower extremity access 3

Venous System Definitions For coding purposes the access is considered to be a separate vessel Peripheral veins – the venous system up to the beginning of the central veins – Upper extremity – up to subclavian – Lower extremity – up to inguinal ligament (external iliac) Central veins: – Upper extremity – veins within the boney thorax – Lower extremity – veins within the boney pelvis 4

Basic Codes For Angioplasty 5

Cannulation Cannulation with angiogram – – The first cannulation of the access – Bundles the angiogram of the access (75791) This includes all necessary angiographic imaging including the adjacent arterial inflow (approximately 2 cm), arterial anastomosis through the entire venous outflow including the inferior or superior vena cava (Refer to the separate unit on Cannulation/Catheterization for more detail on this subject) 6

Aids For Difficult Cannulation In some instances the cannulation of the dialysis access is very difficult to accomplish, this is particularly true in the case of new or failing AVF Two possible aids to assist this process are sometimes used; – Ultrasound guidance for the cannulation procedure – Using some type of device as a target 7

Ultrasound Guided Cannulation Code for ultrasound guided cannulation is – An add-on code, use with cannulation code (36147) Descriptor for this code is – ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry Use of code requires image documentation in record 8

Device as Target Angioplasty balloon or other device may be used Generally done with fluoroscopic guidance Code – fluoroscopic guidance for needle placement Column 2 code to – It can be used but requires a modifier (59 for example) cannot be used in conjunction with

Angiogram This involves the access definition listed for diagnostic purposes (on slide 3) May be performed in 2 ways: – With cannulation of access – bundled with (slide 6) – Without cannulation of access – a separate site, not part of the access as defined is used – coded as Brachial artery (36120) or radial artery (36140) Pre-existing cannulation site 10

Repeat Angiograms Although an angiogram may be repeated several times during the course of the angioplasty procedure, it should be coded only once Angiograms performed in follow-up for procedures such as angioplasty or stent placement are considered to be bundled with the basic procedure itself Only exception is a follow-up angiogram following coil placement - code It requires a 59 modifier since it is a therapeutic RS&I code and it is being used with a therapeutic RS&I code 11

Venous Angioplasty Code is Descriptor – transluminal balloon angioplasty, venous This code should be used for an angioplasty anywhere within the entire venous system – venous portion of access and central veins Used for both upper and lower extremities 12

Column I/Column II Restrictions is a column 2 code when paired with (arterial angioplasty of the upper extremity) The two can be used together, under specific conditions, but with a modifier attached to (59) should be used only once in any case within the access, as defined for therapeutic procedures cannot be used with except when a central vein is treated in addition to the arterial anastomotic lesion If both an arterial and a venous angioplasty are performed within the access as defined for therapeutic purposes, only the arterial procedure (35475) should be recorded 13

Other Requirements The degree of stenosis should be recorded in general terms (exact percentage may be difficult to define) A stenosis of 50% as well as a clinical indication of dysfunction should be required prior to angioplasty 14

Accompanying RS&I Code should always be coupled with its RS&I code Descriptor for this code - transluminal balloon angioplasty, venous, radiological supervision and interpretation 15

Arterial Angioplasty Two categories: – Upper extremity – Lower extremity Coded differently 16

Arterial Angioplasty – Upper Extremity Arterial angioplasty code – Descriptor - transluminal balloon angioplasty, brachiocephalic trunk or branches, each vessel Two situations exist: – Within the access as defined for therapeutic purposes Arterial anastomosis – Within the artery proximal to the access as defined 17

Within the Access The arterial portion of the access as defined is the arterial anastomosis This is also taken to include approximately 2 cm of the adjacent artery The artery proximal to this is not part of the access and its coding is governed by different principles 18

Juxta-Anastomotic Portion of Access The juxta-anastomotic portion of the access is venous When treating a juxta-anastomotic lesion, it is difficult to define radiographically exactly where the anastomosis (the arterial portion) is located The guiding principle is - when the balloon must be in the artery in order to perform the angioplasty, it should be coded as an arterial angioplasty – (35475) If this positioning is not necessary, then the juxta- anastomotic lesion should be coded as venous (35476) 19

Within the Access is a column 1 code when paired with within the access as defined for therapeutic purposes When both and are performed in this region only is recorded If is performed within the central veins, both the and the can be recorded with a 59 modifier on the venous code 20

Within the Artery Proximal to the Access Defined as artery more than approximately 2 cm from the arterial anastomosis Not considered part of the access Each lesion in a separate named artery can be individually coded as Only one code should be used for each named artery If an arterial lesion is continuous with a lesion at the anastomosis it should not be separately coded no matter how extensive it might be 21

RS&I Code For For the first usage of the RS&I code is – Transluminal balloon angioplasty, peripheral artery other than renal, or other visceral artery, iliac or lower extremity, radiological supervision and interpretation All subsequent usages of would require as the RS&I code – Transluminal balloon angioplasty, each additional peripheral artery other than renal, or other visceral artery, iliac or lower extremity, radiological supervision and interpretation 22

Arterial Angioplasty – Lower Extremity Coding for an arterial angioplasty in the lower extremity requires the use of the Lower Extremity Revascularization coding system See separate unit for a discussion of the application of this system to dialysis vascular access 23

Coding for Multiple Angioplasties Situations in which multiple angioplasties may be coded are very limited Most of the principles involved here have already been listed, but will be repeated for completeness In applying these principles the definition of the access for therapeutic purposes is important – Includes the vessels from the arterial anastomosis up to the beginning of the central veins (subclavian) 24

Principles for Multiple Angioplasty Codes Although multiple stenotic lesions may be present within the access as defined, their treatment only warrants only a single code Although multiple stenotic lesions may be present within the central veins as defined, their treatment only warrants only a single code If multiple stenotic lesions are present within the arteries proximal to the access, treatment(s) within each separate named artery can receive a separate code 25

More Multiple Code Principles A code for a lesion within the access cannot be used with a code for a lesion at the arterial anastomosis – is a column 1 code, is a column 2 code A code for a lesion within the access can be used with a code for a lesion in an artery proximal to the access – The code should have a 59 modifier attached 26

More Multiple Code Principles A code for a lesion within the access can be used with a second code for a lesion within the central veins The second code should have a 59 modifier attached Only 2 angioplasty code (any type) can be used in a case related to the access – Anastomotic lesion + central venous lesion – Access venous lesion + central venous lesion 27

Events That Do Not Justify Multiple Codes Performing multiple angioplasties from separate cannulation sites does not warrant multiple codes If the access has a double drainage and both have lesions that are treated, it should be coded as a single angioplasty If the case involves a bidirectional fistula and both limbs have lesions that are treated, it should be coded as a single angioplasty The use of multiple balloon inflations or multiple balloon catheters is not enough to warrant multiple angioplasty codes 28

Secondary Codes 29

Second Cannulation Each additional cannulation requires that the code should be used (1 st is always 36147) – Not true if lower extremity arterial angioplasty is done Descriptor - introduction of needle or catheter; arteriovenous shunt created for dialysis (graft/fistula) as an additional access for therapeutic intervention 30 (See unit on Cannulation/Catheterization for more details on this code)

Arteriogram An arteriogram is commonly done as a routine in most cases, but the code should not be recorded unless there is a clear medical indication The code for an arteriogram is – Descriptor – angiogram, extremity, unilateral, radiological supervision and interpretation – If is applied in conjunction with a therapeutic RS&I code, it should have a 59 modifier attached The technique used to perform the arteriogram does not affect the use of the code 31

Arteriogram Coding Principles An examination of the artery adjacent to the arterial anastomosis is included in the code This should be interpreted as being within approximately 2 cm of the anastomosis Use of the code would be warranted only if you examined a larger segment of the artery Examination of the entire artery is not required The general rule should be – examine that portion of the artery that is necessary to make a diagnostic evaluation related to your medical indication 32

Medical Indications for Arteriogram In general, there are two basic indications for the performance of an arteriogram: – Evaluation of inflow in cases in which it is deemed to be inadequate for access function or where steal syndrome is suspected – Evaluation of the distal arterial run-off in cases suspected of having an arterial embolus 33

Hold True To Indication What is done should hold true to the indication Evaluation of inflow – should include an evaluation up to the aortic arch Evaluation of distal run-off – should include an evaluation of the vessels distal to the bifurcation 34

Direct Cannulation of Artery In some cases it is necessary to cannulate the artery directly The code for cannulation of the brachial artery is – Descriptor - introduction of needle or intracatheter; retrograde brachial artery The code for cannulation of the radial artery is – Descriptor - introduction of needle or intracatheter; retrograde extremity artery In this instance the angiogram code would be used since has not been recorded 35 (See unit on Cannulation/Catheterization for more details on these codes)

Complication Management Codes Stent Placement See separate unit on Stenting for details 36

Important Note This document is for informational purposes only and should serve as a guideline for appropriate coding. The ultimate responsibility for correct coding /documentation remains with the provider of service. ASDIN makes no representation, warranty, or guarantee that this compilation of information is error-free, nor that the use of this guide will prevent differences of opinion or disputes with CMS or any other carrier. ASDIN will bear no responsibility or liability for the results or consequences that may grow out of the use of this guidance.