September 9, 2022 | By Stacie L. Buck, RHIA, CCS-P, RCC, RCCIR, CIRCC
Each day thousands of patients are undergoing one or more therapeutic interventions, the most common ones being angioplasty, stent and atherectomy of the lower extremity arteries to treat various forms of peripheral vascular disease. This article will highlight the most common coding errors to be on the look out for when auditing these procedures.
The CPT code assigned for the therapeutic intervention is not correct for the clinical indication (occlusive vs. non-occlusive disease) that was treated.
While most lower extremity interventions are performed for occlusive disease and are assigned to code range 37220 – 37235, there are some instances when an intervention may be performed for non-occlusive disease and these angioplasty and stent procedures will be coded with 37246, +37247 or 37236, +37237 respectively.
For example, when a stent is placed into the superficial femoral artery to treat a stenosis, code 37226 is the correct code, however, when a stent is placed in that same vessel to treat a pseudoaneurysm instead of a stenosis, the correct code for the stent placement is 37236.
Correct code selection based on clinical indication is crucial because it determines whether or not any additional catheterization codes will be assigned for the intervention. Catheterization is bundled with stent placement when occlusive disease is treated (37226), however, catheterization code(s) will be reported separately in addition to code 37236 when non-occlusive disease is treated with placement of a stent.
Unbundling of secondary thrombectomy (+37186) with atherectomy.
According to the NCCI Manual, Chapter 5, Section D.27, secondary thrombectomy performed in the same vascular territory as atherectomy is considered inherent to the atherectomy and should not be coded. However, if secondary thrombectomy is performed in a different territory, it may be reported separately.
For example, when an atherectomy is performed on the superficial femoral artery, and a rescue thrombectomy is performed in the popliteal artery, it is not reported separately because both procedures occurred in the same vascular territory. However, if the rescue thrombectomy had been performed in the TP trunk, code 37186 would be assigned because the thrombectomy occurred in a different vascular territory from the atherectomy.
Coding an intervention of the TP trunk separately when it is considered part of another intervention.
The tibial/peroneal territory consists of four vessels – the tibioperoneal (TP) trunk, anterior tibial, posterior tibial, and peroneal arteries, however, when an intervention is performed on the TP trunk at the same time as the posterior tibial or peroneal arteries, the TP trunk is considered part of either one of these vessels, and the intervention in the TP trunk is not reported separately.
For example, when angioplasty followed by stent is performed in the TP trunk, followed by stent placement in the posterior tibial artery, only code 37230 is assigned for treatment of the posterior tibial. The PTA and stent in the TP trunk are not coded separately.
Unbundling of catheterization codes (36140, 36200, 36245 -36248) with 37220 – 37235 when not permitted.
CPT® guidelines state that codes 37220 – 37235 include all work of accessing and selectively catheterizing the vessel treated. Catheterization codes should not be assigned for the intervention(s) performed.
For example, when access is gained at the right common femoral and the catheter is placed into the common femoral for imaging, followed by angioplasty, stent or atherectomy of occlusive disease in the superficial femoral, no catheterization code is assigned.
Not assigning catheterization codes (36140, 36200, 36245 -36248) with 37220 – 37235 when permitted.
Although CPT® guidelines state that codes 37220 – 37235 include all work of accessing and selectively catheterizing the vessel in the territory treated, there are several instances when catheterization codes (36140, 36200, 36245-36248) may be assigned during the same session and/or on the same date of service.
Catheterization codes may be reported separately with codes 37220 – 37235 in the following instances:
Diagnostic angiography performed at the same time as the intervention requires a higher degree of selectivity than the one used for the lower extremity intervention.
Example: Physician gains access at the right common femoral artery, and performs revascularization of the right internal iliac, followed by catheterization of the left common femoral (36246-XU) and imaging of left leg. The additional catheter work for the imaging is reported because it occurred in the contralateral extremity.
Diagnostic angiography for the revascularization is performed at the same time as revascularization from a separate access.
Example: Physician gains access at the right common femoral artery with catheterization of the aorta (36200-XU) for an aortogram with runoff, then gains access at the left common femoral and performs the revascularization procedure through the left common femoral. The catheterization of the aorta is reported because it occurred from a separate access that was not utilized to perform the intervention. If both puncture sites had been utilized to facilitate performance of the therapeutic intervention, the catheterization of the aorta would not be assigned.
Another catheterization is performed through the same access for another diagnostic or therapeutic procedure requiring catheterization in a different vascular bed or a separate vessel is punctured for an additional access that is not part of the revascularization procedure and another vessel is selectively catheterized for another purpose.
Example: Placing a stent in the superior mesenteric artery (36245-XU) at the same time as a revascularization procedure in the lower extremity whether through the same access or different access.