Interventional Radiology Coding Update

Transcription

1 Interventional Radiology Coding Update 2013 nineteenth edition

2 Interventional Radiology Coding Update Coding for Endovascular and Interventional Procedures and Services Society of Interventional Radiology 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.

3 table of contents 5 Foreword 7 Glossary of Acronyms 9 Categories of CPT Codes 11 The Basics of Coding and Reimbursement 19 Evaluation and Management (E&M) Codes 24 Revised Interventional Radiology Codes for 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) 42 Frequently Asked Questions

4 4 TABLE OF CONTENTS 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

5 5 FOREWORD 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 Professional manual 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

6 6 FOREWORD 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 Reston, Virginia

7 glossary of acronyms 7 GLOSSARY OF ACRONYMS AAA ABN ABPTS ACO ACR AMA APC ASC AV AVF CAC CF CMD CMS CPT DRG E&M GPCI HCFA HCPCS HOPPS ICD-CM ICD-9-CM IDE IDTF IVUS LCD MAC MP Abdominal Aortic Aneurysm Advanced Beneficiary Notice American Board of Physical Therapy Specialties Accountable Care Organization American College of Radiology American Medical Association Ambulatory Payment Classification Ambulatory Surgical Center Arteriovenous Arteriovenous Fistula Carrier Advisory Committee Conversion Factor Carrier Medical Director Centers for Medicare and Medicaid Services Current Procedural Terminology Diagnosis-related Group Evaluation and Management Geographic Practice Cost Index Health Care Financing Administration Healthcare Common Procedure Coding System Hospital Outpatient Prospective Payment System International Classification of Diseases, Clinical Modification International Classification of Diseases, Ninth Revision, Clinical Modification Investigational Device Exemption Independent Diagnostic Testing Facility Intravascular Ultrasound Local Coverage Determination Medicare Adminstrative Contractor Malpractice

8 MPFS MPPR MUE NCCI NEC NCHS NOS NP PA PE PIN POS PTA RAC RAW RBMA RBRVS RFA RS&I RS/IS&I RUC RVS RVU SIR SOAP TAA 2013 Medicare Physician Fee Schedule Multiple Procedure Payment Reduction Medically Unlikely Edit National Correct Coding Initiative Not Elsewhere Classified National Center for Health Statistics Not Otherwise Specified Nurse Practitioner Physician s Assistant Practice Expense Provider Identification Number Place of Service Percutaneous Transluminal Angioplasty Recovery Audit Contractor Relativity Assessment Workgroup Radiology Business Management Association Resource-based Relative Value Scale Radiofrequency Ablation Radiological Supervision and Interpretation Radiological Supervision and Interpretation/Imaging Supervision and Interpretation RVS Update Committee Relative Value Scale Relative Value Unit Society of Interventional Radiology Subjective Evaluation, Objective Evaluation, Assessment and Plan Thoracic Aortic Aneurysm 8 GLOSSARY OF ACRONYMS

9 categories of CPT 2013 codes 9 CATEGORIES OF CPT CODES CATEGORY I CATEGORY II CATEGORY III 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

10 10 CATEGORIES OF CPT CODES OTHER HCPCS CODES 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-Codes These are temporary codes issued by CMS to describe procedures and professional services. S-Codes 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

11 11 THE BASICS OF CODING RBRVS the basics of coding and reimbursement T H E R E L AT I V E VA L U E PAY 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 $ 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 payment is as follows:

12 12 THE BASICS OF CODING CPT PROCESS 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 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.

13 13 THE BASICS OF CODING RUC PROCESS 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, 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

14 14 THE BASICS OF CODING RUC PROCESS 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 officebased 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, Mandated budget neutrality may negatively impact the payment associated with RVUs of existing codes when new codes are created. The extent of any

15 15 THE BASICS OF CODING CMS SCREENS 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

16 16 THE BASICS OF CODING THE FIVE- YEAR REVIEW 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 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.

17 17 THE BASICS OF CODING NCCI 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 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 ( 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,

18 18 THE BASICS OF CODING MUES Effective Jan. 1, 2013, two new NCCI-associated modifiers have been added: modifiers -24 and -57. Modifier -24 Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period Modifier -57 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.

19 19 EVALUATION & MANAGEMENT CODES evaluation and management (E&M) codes Several years ago, CMS eliminated payment for outpatient (99241 to 99245) and inpatient (99251 to 99255) consultation codes. Consultations performed in an outpatient office are coded using the existing codes for new (99201 to 99205) or established (99211 to 99215) patients. Consultations performed on inpatients are coded using the existing codes for initial (99221 to 99223) or subsequent (99231 to 99233) 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

20 20 EVALUATION & MANAGEMENT CODES 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

21 21 EVALUATION & MANAGEMENT CODES 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, one should add modifier 57 to the E&M code, designating that the consult

22 22 EVALUATION & MANAGEMENT CODES 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

23 23 EVALUATION & MANAGEMENT CODES 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;

24 N E W A N D R E V I S E D interventional radiology codes for NEW AND REVISED IR CODES REVISED IR 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 For 2013, a number of revisions and code clarifications were added to several common codes used by interventional radiologists. Ver tebral Body, Embolization or Injection The add-on code (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. Respirator y System New codes for endoscopy procedures have been created for Bronchoscopy Codes include fluoroscopic guidance, when performed Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed, diagnostic, with cell washing, when performed (separate procedure) with brushing or protected brushings

25 with bronchial alveolar lavage with bronchial or endobronchial biopsy(s), single and multiple sites with placement of fiducial markers, single or multiple with computer-assisted, image-guided navigation (list separately in addition to code for primary procedure(s) with transbronchial lung biopsy(s), single lobe with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i) with balloon occlusion, assessment of air leak, with administration of occlusive substance (e.g., fibrin glue) if performed (Do not report in conjunction with 31647, at the same session.) with removal of foreign body (For removal of implanted bronchial valves see ) with balloon occlusion, when performed, assessment of air leak, airway sizing and insertion of bronchial valve(s), initial lobe with removal of bronchial valve(s), initial lobe removal and insertion of bronchial valve at the same session, see 31647, and 31651) (31656 has been deleted. To report, see code ) 25 NEW AND REVISED IR CODES REVISED IR CODES FOR 2013

26 Bronchial Thermoplasty Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 1 lobe 26 NEW AND REVISED IR CODES REVISED IR CODES FOR with bronchial thermoplasty, 2 or more lobes (31715 has been deleted. To report, use code ) Lungs and Pleura (32420 has been deleted. To report, use ) (32421 and have been deleted. To report, see codes 32554, ) (32551 has been revised for tube thoracostomy to indicate that this code is now used for reporting an open procedure.) 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 Imaging guidance codes (76942, 77002, or 77021) and device codes (e.g., A4648 tissue marker, A4650 implantable radiation dosimeter or A4649 surgical supply) are reported separately in conjunction with the percutaneous placement procedure codes.

27 N E W 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 NEW AND REVISED IR CODES NEW 2013 CPT CODES Thoracentesis Four new codes have been created describing thoracentesis and pleural drainage. Codes are NOT to be reported in conjunction with codes 32550, 32551, 76942, 77002, 77012, 77021, Thoracentesis, needle or catheter, aspiration of the pleural space; without imaging guidance with imaging guidance Pleural drainage, percutaneous, with insertion of indwelling catheter; without imaging guidance with imaging guidance To report insertion of indwelling tunneled pleural catheter with cuff, see code Moderate sedation is NOT inherent to procedure codes and should be reported separately when these services are provided. Cervicocerebral Angiography 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, 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.

28 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 and not separately reportable. Moderate sedation is included in the new codes, and is not separately reportable. Codes 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, is reported for nonselective catheter placement, thoracic aorta, with angiography of the aortic arch and great vessel origins. Do not report in conjunction with selective codes, as these include the work of when performed 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 with ) NEW AND REVISED IR CODES NEW 2013 CPT CODES 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 Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision

29 and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed NEW AND REVISED IR CODES NEW 2013 CPT CODES 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 36222, or together for ipsilateral angiography. Select the most comprehensive service following the hierarchy of complexity 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 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 with for ipsilateral angiography. Select the most comprehensive service following the hierarchy of complexity 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 in conjunction with 36222, or ) 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

30 interpretation (e.g., middle cerebral artery, posterior inferior cerebellar artery). (List separately in addition to code for primary procedure.) NEW AND REVISED IR CODES NEW 2013 CPT CODES (Use in conjunction with or ) (Do not report more than twice per side.) Add modifier 50 to codes if the same procedure is performed on both sides. Modifier 59 may be used to indicate when different carotid and/or vertebral arteries are being studied in the same session. Report or for 3D rendering when performed in conjunction with Report for ultrasound guidance for vascular access, when performed in conjunction with Deleted RS&I Codes 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 To report see codes To report see code To report use code and append modifier To report see codes 36223, To report see codes and and append modifier 50 as appropriate.

31 75676 To report see codes NEW AND REVISED IR CODES NEW 2013 CPT CODES To report see codes and append modifier 50 as appropriate To report see codes Foreign Body Retrieval 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, 37203, has been deleted, along with the RS&I code, 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 (75961 has been deleted. To report, use code ) (For percutaneous retrieval of a vena cava filter, use ) Transcatheter Thrombolysis 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 and are used to report the initial day of transcatheter thrombolytic infusion including follow-up

32 arteriography/venography and catheter position change or exchange, when performed. When initiation and completion of thrombolysis occur on the same calendar day, report only or NEW AND REVISED IR CODES NEW 2013 CPT CODES Catheter placement(s), diagnostic studies and other percutaneous interventions may be reported separately. Codes include fluoroscopic guidance and associated RS&I. Ultrasound guidance for vascular access see code may be reported separately when all required elements are performed. Bilateral thrombolytic infusion through separate access site(s) may be reported with modifier 50 in conjunction with 37211, Radiological supervision and interpretation codes and have been revised and are not to be reported in conjunction with for thrombolysis infusion management Transcatheter therapy, arterial infusion for thrombolysis other than coronary, any method, including radiological supervision and interpretation, initial treatment day Transcatheter therapy, venous infusion for thrombolysis, any method, including radiological supervision and interpretation, initial treatment day 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 cessation of thrombolysis including removal of catheter and vessel closure by any method

33 33 NEW AND REVISED IR CODES NEW 2013 CPT CODES The previous code for thrombolysis, 37201, has been deleted see codes Code has been deleted; see codes for reporting exchange of a previously placed intravascular catheter during thrombolytic therapy. Diagnostic Radiology (Diagnostic Imaging) Chest 71040, have been deleted. To report, use Spine and Pelvis Radiologic examination, spine, cervical; 3 views or less or 5 views or more views Epidurography, radiological supervision and interpretation (72275 includes 77003) (For injection procedure, see , , ) (Use only when an epidurogram is performed, images documented, and a formal radiologic report is issued.) (Do not report in conjunction with 22586, 0195T, 0196T, 0309T.)

34 Radiology Guidelines, Vascular Procedures Aorta and Arteries NEW AND REVISED IR CODES ENDOVASCULAR REVASCULARIZATION Parenthetical revisions have been added for aortography codes 75600, and and angiography, pulmonary codes 75746, and 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 lessintense 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

35 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 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 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 NEW AND REVISED IR CODES ENDOVASCULAR REVASCULARIZATION

36 b Includes the common, deep and superficial femoral as well as popliteal NEW AND REVISED IR CODES ENDOVASCULAR REVASCULARIZATION 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 b Report the initial vessel treated as the primary code for the highest level of service provided within the tibial-peroneal territory with addon codes for additional vessels treated (not additional lesions 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 59 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.

37 Iliac Artery Revascularization NEW AND REVISED IR CODES ENDOVASCULAR REVASCULARIZATION Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplast with transluminal stent placement(s), includes angioplasty within same vessel when performed.) 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 37220, for additional iliac segment PTA.) 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 for additional iliac segment stent placement) Femoral/Popliteal Artery Revascularization Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty with atherectomy, includes angioplasty within the same vessel, when performed with transluminal stent placement(s), includes angioplasty within the same vessel, when performed with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed

38 Tibial/Peroneal Artery Revascularization NEW AND REVISED IR CODES ENDOVASCULAR REVASCULARIZATION Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty with atherectomy, includes angioplasty within the same vessel, when performed with transluminal stent placement(s), includes angioplasty within the same vessel, when performed with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed 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 ) with atherectomy, includes angioplasty within the same vessel, when performed. (List separately in addition to code for primary procedure.) (Used in conjunction with 37229, ) 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 ) with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when