Angioplasty Coding

ASDIN Coding University

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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

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(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

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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

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Basic Codes For Angioplasty

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Cannulation

• Cannulation with angiogram – 36147– 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)

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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

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Ultrasound Guided Cannulation

• Code for ultrasound guided cannulation is +76937– 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

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Device as Target

• Angioplasty balloon or other device may be used• Generally done with fluoroscopic guidance• Code – 77002 - fluoroscopic guidance for needle

placement • Column 2 code to 36147– It can be used but requires a modifier (59 for example)

• +77001 cannot be used in conjunction with 77002

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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 36147 (slide 6)– Without cannulation of access – a separate site, not part

of the access as defined is used – coded as 75791 • Brachial artery (36120) or radial artery (36140)• Pre-existing cannulation site

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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 75898 • It requires a 59 modifier since it is a therapeutic RS&I code

and it is being used with a therapeutic RS&I code

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Venous Angioplasty

• Code is 35476• 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

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Column I/Column II Restrictions

• 35476 is a column 2 code when paired with 35475 (arterial angioplasty of the upper extremity)

• The two can be used together, under specific conditions, but with a modifier attached to 35476 (59)

• 35476 should be used only once in any case within the access, as defined for therapeutic procedures

• 35476 cannot be used with 35475 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

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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

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Accompanying RS&I Code

• 35476 should always be coupled with its RS&I code 75978

• Descriptor for this code - transluminal balloon angioplasty, venous, radiological supervision and interpretation

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Arterial Angioplasty

• Two categories:– Upper extremity– Lower extremity

• Coded differently

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Arterial Angioplasty – Upper Extremity

• Arterial angioplasty code – 35475• 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

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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

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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)

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Within the Access

• 35475 is a column 1 code when paired with 35476 within the access as defined for therapeutic purposes

• When both 35475 and 35476 are performed in this region only 35475 is recorded

• If 35476 is performed within the central veins, both the 35475 and the 35476 can be recorded with a 59 modifier on the venous code

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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 35475• 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

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RS&I Code For 35475

• For the first usage of 35475 the RS&I code is 75962– Transluminal balloon angioplasty, peripheral artery other

than renal, or other visceral artery, iliac or lower extremity, radiological supervision and interpretation

• All subsequent usages of 35475 would require +75964 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

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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

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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)

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Principles for Multiple Angioplasty Codes

• Although multiple stenotic lesions may be present within the access as defined, their treatment only warrants only a single 35476 code

• Although multiple stenotic lesions may be present within the central veins as defined, their treatment only warrants only a single 35476 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 35475 code

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More Multiple Code Principles

• A 35476 code for a lesion within the access cannot be used with a 35475 code for a lesion at the arterial anastomosis– 35475 is a column 1 code, 35476 is a column 2 code

• A 35476 code for a lesion within the access can be used with a 35475 code for a lesion in an artery proximal to the access– The 35476 code should have a 59 modifier attached

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More Multiple Code Principles• A 35476 code for a lesion within the access can be

used with a second 35476 code for a lesion within the central veins

• The second 35476 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

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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

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Secondary Codes

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Second Cannulation

• Each additional cannulation requires that the code +36148 should be used (1st 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

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(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 75710– Descriptor – angiogram, extremity, unilateral, radiological

supervision and interpretation– If 75710 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

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Arteriogram Coding Principles• An examination of the artery adjacent to the arterial

anastomosis is included in the 36147 code• This should be interpreted as being within

approximately 2 cm of the anastomosis• Use of the 75710 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

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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

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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

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Direct Cannulation of Artery• In some cases it is necessary to cannulate the artery

directly • The code for cannulation of the brachial artery is 36120– Descriptor - introduction of needle or intracatheter;

retrograde brachial artery• The code for cannulation of the radial artery is 36140– Descriptor - introduction of needle or intracatheter;

retrograde extremity artery• In this instance the angiogram code 75791 would be

used since 36147 has not been recorded

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(See unit on Cannulation/Catheterization for more details on these codes)

Complication Management CodesStent Placement

See separate unit on Stenting for details

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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.