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

39 performed. (List separately in addition to code for primary procedure.) 39 NEW AND REVISED IR CODES BENIGN PROSTATIC HYPERPLASIA (Used in conjunction with ) S P E C I A L C O D I N G N O T E F O R : 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 TAT 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 lowerurinary-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 (Unlisted Procedure, vascular surgery) to indicate its investigational nature. If component coding is allowed, the appropriate codes could include:

40 (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), 40 NEW AND REVISED IR CODES BENIGN PROSTATIC HYPERPLASIA (x1) (Transcatheter therapy, embolization any method, radiological supervision and interpretation) (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) catheter placement, arterial system; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch, within a vascular family) may be used if 2 branches have to be catheterized for study and/or embolization on the same side (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

41 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. 41 NEW AND REVISED IR CODES BENIGN PROSTATIC HYPERPLASIA

42 FAQS 42 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 37204, 75894, and typically are all appropriate to report this procedure. Use of a selective catheter placement code for embolization obviates the use of the 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): (Injection of sinus tract; therapeutic [separate procedure]) (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 not inherent to code and is separately reportable.

43 FAQS Age 5 years or older, first 30 minutes intra-service time Each additional 15 minutes intra-service time Note that this is an add-on code (+) and must be used in conjunction with 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., 24, 25) 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 47382, and be used for both microwave and radiofrequency ablation in their respective anatomic locations, in conjunction with the appropriate imaging guidance code:

44 FAQS Ablation, 1 or more liver tumor(s) percutaneous, radiofrequency; with appropriate image guidance code: (CT), (US), (MRI) 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: (CT), (US), (MRI) Ablation, 1 or more renal tumor(s), percutaneous, unilateral, radiofrequency; with appropriate image guidance code: (CT), (US), (MRI)

45 45 SAMPLE LETTERS 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 TA 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

46 46 SAMPLE LETTERS 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

47 47 SAMPLE LETTERS 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. 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

48 48 SAMPLE LETTERS 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

49 49 SAMPLE LETTERS 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 [INSERT CONDITION lung cancer, lung metastases, lung malignancies including stage], it is imperative to implement treatment as quickly as possible. Depending on the size of the tumor, RFA can reduce the size and often completely eradicate the tumor. By decreasing the size of a large mass, or treating new tumors in the lung as they arise, the pain and other debilitating symptoms caused by the tumors are often relieved. While the tumors themselves may not be painful, they can cause mass affect on nerves or vital organs, eliciting pain. I respectfully request that you extend coverage to [PATIENT NAME] for pulmonary tumor RFA. I hope you have found this information helpful in support of [reversing the previous denial authorizing coverage] for this procedure. Please feel free to contact me if you require any further information. Sincerely, [SIR/ACR MEMBER NAME], MD CC: [PATIENT NAME] [STATE INSURANCE COMMISSIONER]

50 50 SAMPLE LETTERS O VA R I A N V E I N E M B O L I Z AT I O N ( O V E ) T O T R E AT P E LV I C C O N G E S T I O N S Y N D R O M E ( P C 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 Ovarian Vein Embolization (OVE) to treat Pelvic Congestion Syndrome (PCS) [CARRIER MEDICAL DIRECTOR]: On [INSERT DATE OF PRECERTIFICATION/COVERAGE REQUEST DENIAL], notice was received from your company that ovarian vein embolization (OVE) is considered experimental and investigational and therefore, a noncovered service. This is a formal request for individual consideration to extend coverage for OVE for [PATIENT NAME], who is believed to be suffering from pelvic congestion syndrome (PCS). [PATIENT NAME] has presented with symptoms consistent with pelvic congestion syndrome, which is a well defined condition. She has been seen by a vascular medicine physician, [VASCULAR MEDICINE PHYSICIAN NAME], MD. Both Dr. [VASCULAR MEDICINE PHYSICIAN NAME] and my findings are consistent; confirming that [PATIENT NAME] has had recurrent varicose veins in the lower extremity(ies). Additionally, [LIST RELEVANT DIAGNOSTIC STUDY(IES). FOR EXAMPLE: an MR venogram of the pelvis shows large ovarian and

51 51 SAMPLE LETTERS pelvic veins, and an ultrasound of the pelvis has been performed, which demonstrated enlarged pelvic varicosities, more prominent on the left than the right. Reflux was noted in the left greater saphenous vein as well] supporting a diagnosis of PCS for this patient. OVE has been found to be an effective minimally invasive procedure to treat the symptoms of PCS and is recommended for this patient. PCS Symptoms [PATIENT NAME] is not alone in suffering with the symptoms of PCS. It has been estimated that almost 40% of all women will experience chronic pelvic pain during their lifetime and that 15% of all women between the ages of experience chronic pelvic pain. Of note, 15% of all hysterectomies and 35% of all diagnostic laparoscopies are performed due to chronic pelvic pain. Ovarian vein incompetence has been shown to occur in approximately 10% of women. This phenomenon can lead to PCS and its associated symptoms in 60% of these patients. Despite this incidence, PCS is significantly under-diagnosed. It typically results in pelvic pain that is often described as dull and aching. The pain is typically worse in an upright position and becomes more severe with walking and postural changes. It may be associated with dyspareunia or a postcoital ache. These symptoms of pelvic congestion syndrome (PCS) are typically caused by the development of varicosities in the infundibulopelvic and broad ligaments within the pelvis. The exact reason why these varicosities develop is unknown, but one important factor is the absence or incompetence of valves in the ovarian veins. It is felt that there is an anatomic component to this as well, since reflux occurs more often on the left than the right. This may be due to the fact that veins are absent more often on the left than the right, but is also likely due to the fact that the left ovarian vein drains into the left renal vein before draining into the inferior vena cava, while the right ovarian vein drains directly into the inferior vena cava. This is why

52 52 SAMPLE LETTERS symptoms are often more common or more severe on the left side than the right, which is what we are seeing with [PATIENT NAME]. A hormonal component is also felt to contribute to the development of PCS as well since it mainly affects premenopausal women. The pain associated with PCS has been directly attributed to the presence of these dilated veins within the pelvis. OVE Treatment Plan for PCS Once a patient such as [PATIENT NAME] has been diagnosed with PCS, it is important to direct treatment towards eliminating retrograde flow in the abnormal ovarian vein(s). This reduces pressure in the pelvic veins which eliminates the development of these varicosities and the pain that they cause. This can all be accomplished with the use of ovarian vein embolization (OVE), which is a percutaneous, catheter-based procedure that results in occlusion of the abnormal ovarian vein(s). For the past 15 years, this treatment has been associated with good clinical outcomes in most women suffering from the symptoms of PCS. Currently, this procedure is technically successful in almost 100% of patients. Symptomatic improvement tends to be seen in >80% of patients undergoing OVE. Specific data includes that reported in 2006 by Kim, et al who found an 83% success rate in 127 patients treated with OVE. This particular study reported results after 4-year follow-up. Kwon, et al also reported data in 2007 that described symptomatic improvement in 82% of 67 patients treated with OVE. In 2002, Venbrux, et al reported symptomatic improvement in 96% of the 56 patients 12 months after being treated with OVE. Other reports by Mowatt, et al, Capasso, et al, Sichlar, et al, Tarazov, et al, Maleux, et al, and Cordts, et al have reported similar data to the studies outlined above. The OVE treatment plan includes an ovarian venogram to confirm that retrograde flow is present in the ovarian veins. If reflux and retrograde flow is identified within the left and/or right ovarian vein, then one would

53 53 SAMPLE LETTERS proceed with embolization of the abnormal vein to eliminate this reflux and reduce the pressure within these pelvic varicosities. This procedure would be performed on an [OUTPATIENT/INPATIENT] basis. Patient s Medical History Consistent With Varicose Veins of the Lower Extremity(ies)/Pelvis Otherwise Known As PCS A review of [PATIENT NAME] s medical history finds that she had [LIST RELEVANT FINDINGS SPECIFIC TO THE PATIENT S HISTORY. FOR EXAMPLE: recurrent varicose veins following a vein stripping of her right leg. She had also developed labial varicosities with her first pregnancy and then with her second pregnancy the labial varicosities had markedly increased. She has also had increasing right varicose veins.] Patient s Current Symptoms Are Typical of Pelvic Congestion Syndrome [PATIENT NAME] s current symptoms are typical of PCS. The patient is experiencing extreme heaviness and discomfort in her pelvis with standing and also following sexual intercourse. Her pelvic discomfort is least in the morning and worsens during the day as she is standing. Her symptoms are very typical for ovarian vein reflux or potentially reflux into the internal iliac veins. PCS is initially caused by reflux into the ovarian vein, which then causes increased flow and pressure in the pelvic veins and causes severe pain in the pelvis. This is exactly the same as with varicoceles that are found in men. Body of Scientific Literature Supporting OVE As an Effective Treatment for PCS Attached is a comprehensive listing of the scientific literature available that supports OVE as an effective treatment for PCS (see Attachment A). Also

54 54 SAMPLE LETTERS enclosed is a table (see Attachment B) summarizing the scientific articles available supporting ovarian vein embolization as an effective treatment for PCS; many of these articles support that in many patients embolization of other pelvic veins may be required in addition to the OVE. To deny the existence of PCS contradicts these multiple articles. Tubal ovarian varices were described in the 1950s. The association between pelvic pain and varicosities was first described in 1928 and again in The association of these pelvic varicosities with PCS was described in In a 1984 study of laparoscopic and venographic studies in woman with unexplained chronic pelvic pain, 91% of them were found to have marked pelvic venous congestion. In 2002, a study examining incompetent ovarian veins demonstrated that with ligation of these veins 54% of them had resolution of their pelvic pain with improvement in 23%. There has been increasing recognition of this problem with multiple articles including a study from Korea where patients with documented pelvic congestion syndrome were randomized to hysterectomy (with either oopherectomy of ovary on the side of an incomplete gondal vein or bilateral oopherectomy) and OVE. OVE demonstrated significantly better results than surgery.to deny the existence of PCS contradicts these multiple articles. Tubal ovarian varices were described in the 1950s. The association between pelvic pain and varicosities was first described in 1928 and again in The association of these pelvic varicosities with PCS was described in In a 1984 study of laparoscopic and venographic studies in woman with unexplained chronic pelvic pain, 91% of them were found to have marked pelvic venous congestion. In 2002, a study examining incompetent ovarian veins demonstrated that with ligation of these veins 54% of them had resolution of their pelvic pain with improvement in 23%. There has been increasing recognition of this problem with multiple articles including a study from Korea where patients with documented pelvic congestion syndrome were randomized to hysterectomy (with either oopherectomy of

55 55 SAMPLE LETTERS ovary on the side of an incomplete gondal vein or bilateral oopherectomy) and OVE. OVE demonstrated significantly better results than surgery. Equitable Coverage Sought for Equivalent Treatments for Comparable Syndromes Found in Men and Women Varicose veins in the testicle of men is called varicoceles. Varicose veins of the uterus and pelvis of women is called pelvic congestion syndrome. These are comparable syndromes suffered by men and women. Your company will authorize coverage for testicular vein embolization to treat varicoceles in men. Yet, you are currently denying coverage for the equivalent treatment for the comparable syndrome (ovarian vein embolization for pelvic congestion syndrome) found in women. It is incomprehensible that men are allowed to undergo a procedure to cure their problem and that this same procedure, used to treat an equivalent syndrome, is denied for women. Your reversal of this inappropriate determination is respectfully requested. Please extend coverage [PATIENT NAME] for ovarian vein embolization to treat pelvic congestion syndrome. I hope that you will find this information helpful in reversing the previous denial [FOR PREAUTHORIZATION/OF COVERAGE]. Please feel free to contact me if you require any further information. Sincerely, [SIR/ACR MEMBER NAME], MD [SIR/ACR MEMBER TITLE] CC: [PATIENT NAME] [STATE INSURANCE COMMISSIONER]

56 56 SAMPLE LETTERS M R I O F T H E P E LV I S F O R U F E To Whom It May Concern: I am writing this letter to appeal your decision to deny coverage for an MRI of the pelvis for [PATIENT NAME], (DOB: [INSERT DATE OF BIRTH]; [PATIENT ID]) prior to a uterine artery embolization (UAE) procedure to treat symptomatic uterine fibroids. As you know, UAE is a uterine-sparing procedure that effectively treats the symptoms associated with uterine fibroids and reduces both uterine and fibroid volume due to fibroid infarction. Prior to UAE, the interventional radiologist performing the procedure needs to be certain that the procedure is being performed for an appropriate indication. When fibroids were treated exclusively with hysterectomy, pre-procedure imaging was not critical to gynecologists because the uterus, in its entirety, was being removed. As a result, a pathologic evaluation performed on the uterus after surgery was the primary means of determining the etiology of the presenting symptoms. Uterine artery embolization is different. Since the uterus is remaining in its anatomic position and the fibroids are not being removed, it becomes incumbent upon the physician responsible for performing this procedure to obtain definitive imaging of the pelvis prior to the procedure. The standard imaging modality used to evaluate patients with suspected uterine fibroids is ultrasound. In fact, almost all patients presenting in consultation for UAE have been evaluated previously with a pelvic ultrasound that has demonstrated fibroids. While ultrasound is certainly a good test to evaluate patients for fibroids, it is an operator-dependent imaging modality that has recognized limitations when it comes to evaluating patients specifically for UAE. Omary, et al (J Vasc Interv Radiol

57 57 SAMPLE LETTERS 2002; 13: ) evaluated the importance of imaging prior to UAE and recommended that MRI be considered in all patients prior to this procedure. They did this by evaluating the diagnostic confidence and anticipated treatment plan both before and after performance of a pelvic MRI. They found that MRI significantly increased diagnostic confidence. In addition, they found that MRI changed the initial diagnosis in 18% of patients and the immediate clinical management in 22% of patients. Overall, 19% of women who were anticipated to undergo UAE prior MRI did not undergo that procedure as a result of the findings on MRI, which most often included abnormalities other than fibroids. MRI has also been shown to potentially predict the response to UAE and can therefore be helpful with patient selection for this procedure. An MRI can accurately determine the location and size of fibroids within the uterus. As described by Cura, et al (Acta Radiol 2006; 47: ), UAE may not be the appropriate therapy if a patient s symptoms do not correlate with the size and location of their fibroids. For example, a small subserosal fibroid is not likely to be responsible for abnormal bleeding so UAE may not be indicated in this particular type of patient. In addition, MRI is helpful in differentiating degenerated fibroids from cellular fibroids, which is important since cellular fibroids typically have the best response to UAE. Cellular fibroids have characteristic MRI findings with high signal intensity on T2 weighted images and enhancement after contrast administration (Yamashita, et al, Radiology 1993; 189: ) so fibroids with these characteristics may be expected to respond best to UAE. This has been supported by Burn, et al (Radiology 2000; 214: ), who reported on the good response of fibroids with high signal intensity on T2-weighted images, and by Jha, et al (Radiology 2000; 217: ), who reported that hypervascular fibroids which enhanced after contrast administration had a greater response to UAE. Therefore, an MRI can help determine which patients are appropriate candidates for UAE on the basis of size, location,

58 58 SAMPLE LETTERS signal characteristics and degree of enhancement after contrast administration. The findings on MRI can also help determine if vessels other than the uterine arteries provide arterial supply to the fibroids. Kroencke, et al (Radiology 2006; 241: ) determined that contrast-enhanced MRI can help predict the presence of ovarian arterial supply to uterine fibroids. This information is important to have prior to UAE because if these vessels are not recognized, the ability of this procedure to induce infarction within the treated fibroids becomes significantly limited. In addition, knowing that ovarian arteries may need to be treated during a UAE procedure is something that is important to discuss with a patient prior to UAE since treating these vessels could increase the possibility of post-procedure amenorrhea. Finally, MRI is very helpful in determining if patients are potentially at risk for complications after UAE. For example, pedunculated submucosal fibroids are potentially at risk for transcervical expulsion or infection and pedunculated subserosal fibroids can potentially separate from the uterus and result in intraperitoneal complications. Pelvic MRI is able to define the morphology of pedunculated fibroids far better than ultrasound and therefore help determine which patients are potentially at risk for these complications. This was well described by Verma, et al (AJR 2008; 190: ) who reported on the utility of MRI in defining the interface between pedunculated submucosal fibroids and the endometrium. They found that this helps define the risk of fibroid migration into the endometrial cavity with subsequent transcervical expulsion after UAE. In summary, an MRI of the pelvis provides the information that is necessary for an interventional radiologist to determine if a patient with symptomatic uterine fibroids is a suitable candidate for uterine artery embolization. It can potentially provide information regarding the cellular morphology of

59 59 SAMPLE LETTERS fibroids, the presence or absence of other pathology that could explain a patient s symptoms, the contribution of other blood vessels responsible for the arterial supply of fibroids, and the potential risk of complications associated with pedunculated fibroids. As a result, MRI has been shown to potentially change the treatment plan in a significant number of patients, underscoring its importance as a pre-procedure imaging test. It is my hope that this information will help support a reversal of your decision to deny coverage to [PATIENT NAME] for an MRI of the pelvis prior to her planned uterine artery embolization procedure.

60 60 SAMPLE CHARGE SHEETS sample 2013 charge sheets Find the updated 2013 interventional radiology coding charge sheets at

61 VASCULAR CHARGE SHEET PATIENT: DATE: PROCEDURE: REFERRING PHYSICIAN: RADIOLOGIST: Catheterization and Imaging Separately Reportable Unless Specifically Noted Otherwise for ALL Therapeutic Procedures MCS-Moderate Conscious Sedation Do NOT additionally report Moderate Conscious Sedation codes in conjunction with these Valuation for codes in the MCS indicator column includes the physician work for conscious sedation. Procedure S&I Procedure S&I (x) MCS code Code (x) MCS Code Code THROMBOLYSIS AND INFUSION THERAPY DIALYSIS ACCESS INTERVENTIONS Transcatheter therapy, arterial infusion for thrombolysis other than coronary Clot removal any N/A Venous infusion for thrombolysis Dialysis N/A Continued thrombolytic infusions(s) on subsequent day(s) Add'l puncture (document in N/A Thrombolytic infusion(s) Final Day of therapy PTA, A-V fistula arterial Infusion, Non-Thrombolytic PTA, A-V fistula venous Infusion for Thrombolysis, cerebral Fistulogram with needles in N/A Intravascular stent Angio thru exist cath F/U embo/other than for thrombolysis N/A Insertion of tunneled intraperitoneal catheter (eg, dialysis) N/A MECHANICAL THROMBECTOMY includes imaging guidance Insertion of tunneled intraperitoneal catheter w/ subcutaneous po N/A Primary Arterial Mech Thromb - initial Peritoneal dialysis catheter placement open N/A Primary Arterial Mech Thromb Removal of tunneled intraperitoneal catheter N/A 2nd/and all subsequent vessel(s) Peritoneogram (Air &/or contrast) Secondary Mech Thromb- "rescue", suction, snare TRANSCATHETER THERAPY MISC. Venous Mech Throm - Day Foreign Body N/A Venous Mech Throm - repeat mech thrombectomy on IVC Filter subsequent day during a course of x IVC Filter IVC Filter Retrieval EMBOLIZATION (per surgical field) INTRAVASCULAR ULTRASOUND* Embolization (Non-Neuro, Non-UFE)* IVUS initial vessel imaging and Each additional vessel IVUS Cerebral Balloon Occlusion Test (BOT) includes PERCUTANEOUS ANGIOPLASTY imaging and catheterization of target vessel PTA, Renal or Visceral Embolization (CNS)* permanent PTA, Embolization (non-cns) Head or Neck PTA, Brachiocephalic F/U Angio study for transcatheter therapy, embolization or infusion, other than for thrombolysis N/A PTA, Add'l agent -prescribing, handling, and bolus administration PTA, Each add'l visceral x x chemotherapeutic agent PTA, Each add'l brachiocephalic x x radioactive agent PTA, Each additional x x TIPS (includes catheterization and associated imaging) INTRA-OPERATIVE (OPEN) ANGIOPLASTY TIPS PTA, Renal or Visceral Artery TIPS PTA, Aorta or PTA, Brachiocephalic vessels Embolization of varix* PTA, Venous INTRACRANIAL DILATION, ANGIOPLASTY, STENT includes selective catheterization and all imaging of target vessel *Note: Report selective catheterization codes in addition to embolization. MODERATE (CONSCIOUS) SEDATION Intracranial angioplasty provided by same physician performing the Dx-Tx service Intracranial angioplasty with stent Intraservice Start Time: End Time: Dilation of intracranial vasospam, initial vessel Conscious Sedation AGE 5 or OLDER first 30 min each add vessel same vascular family each additional 15 minutes x each add vessel different vascular family Conscious Sedation UNDER 5 first 30 min INTRAVASCULAR STENTS each additional 15 minutes x Intravascular Stents Non-Coronary/Non-Carotid/Non-Vertebral/Non-Intracranial OTHER Intravascular Stent, perc., initial Pseudoaneurysm TX Injection (Thrombin) Specific Intrasvascular Stent, perc., each add'l vessel Imaging Guidance for Needle Plcmnt (circle one) US fluoro CT MR Intravascular Stent, open, initial Closure Device G0269 Intrasvascular Stent, open, each add'l vessel CT, limited or localized follow-up Intravascular Stents Cervical Carotid US Guidance for Vascular Access includes all ipsilateral selective cath, ipsilateral cervical/cerebral angiography (required documentation on file) Intravascular Stent w/ distal embolic N/A UNLISTED IMAGING CODES Intravascular Stent w/out distal embolic N/A Unlisted, Fluoroscopic procedure Intravascular Stents Extracranial Vertebral/Intrathoracic Carotid Unlisted, CT procedure includes all ipsilateral selective cath, target vessel angiography Unlisted, MR procedure Intravascular Stent, perc; initial vessel 0075T N/A Unlisted, US procedure Intravascular Stent, perc; each addl. vessel 0076T N/A UNLISTED VASCULAR PROCEDURE Unlisted, vascular surgery Append Clinical Trial Modifier Service provided within FDA approved clinical trial (and device approved for use in the trial at the time the service was rendered.) -Q0 PRESENTING PROBLEM(S)/DIAGNOSIS Dx 1: ICD-9: IDE # Dx 2 : ICD-9: ATTACH REPORT CPT Only copyright 2012 American Medical Association. All Rights Reserved. Copyright 2012, Society of Interventional Radiology. All Rights Reserved.

62 VASCULAR CHARGE SHEET 2 PATIENT: DATE: REFERRING PHYSICIAN PROCEDURE: RADIOLOGIST ENDOVASCULAR VARICOSE VEIN TREATMENT includes imaging guidance catheterization is considered inherent to EVAT Radiofrequency - 1st vein treated. RFA - 2nd & subs. vein(s) Laser EVAT- includes imaging- 1st vein Laser - 2nd & subs. vein(s) OTHER VARICOSE VEIN TREATMENT Injections of sclerosing solutions (single/multiple), spider veins; face Injection of sclerosing solution- single vein Injection of sclerosing solution- multiple veins, same leg X MCS PROCEDURE CODE Injections of sclerosing solutions (single/multiple), spider veins; limb or trunk Stab phlebectomy of varicose veins, one extremity, incisions Stab phlebectomy of varicose veins, one extremity, more than 20 incisions MODERATE (CONSCIOUS) SEDATION provided by same physician performing the Dx-Tx service Intraservice Start Time: End Time: Conscious Sedation AGE 5 or OLDER first 30 min each additional 15 minutes Conscious Sedation UNDER 5 first 30 min each additional 15 minutes x x CPT Only copyright 2012 American Medical Association. All Rights Reserved. Copyright 2012 Society of Interventional Radiology All rights reserved

63 PATIENT: VASCULAR DIAGNOSTIC CHARGE SHEET DATE: PROCEDURE: designates moderate conscioius sedation included SELECTIVE VASCULAR CATHETERIZATIONS Each Add'l 2nd REFERRING PHYSICIAN: RADIOLOGIST: RADIOLOGICAL S&I For same session 1st 2nd 3rd or 3rd Order* DX and TX RS&I ARTERIAL VASCULAR FAMILY (X) Order (X) Order* (X) Order* (X) # of Vessels ARTERIOGRAPHY (X) CODE Append -59 Selective cath place thoracic or Brachiocephalic x Thoracic Aortogram Subclavian x Abdominal Aortogram initial 3rd oder of more selctive x Abd Aortogram w Run-Offs Additional 2nd/3rd x_ Brachial, Retrograde x Spinal, Selective, Each Vessel x x Extremity, Unilateral x Extremity, Bilateral Renal, Visceral w-w/o Flush, Each Vessel x -59 Renal, Adrenal, Unilateral IIiac, x Adrenal, Bilateral Common IIiac, x Pelvic, Each Vessel, Sel x -59 Common Femoral, x Pulmonary, Unilateral Common Femoral, N/A x Pulmonary, Bilateral Other Abdominal Aorta Vascular x Pulmonary, Nonselective Right Heart or Pulmonary Trunk Only N/A N/A N/A Internal Mammary Left Pulmonary (includes pressures) N/A x Each Add Vessel After Basic x -59 Right Pulmonary (includes pressures) N/A x AV Dialysis Shunt Existing Access st, 2nd VENOGRAPHY (X) CODE VENOUS VASCULAR FAMILY 1st 1st & 2nd & Each Add'l Extremity, Unilateral (X) Order* (X) Order* (X) 3rd Order* (X) 2nd or 3rd* Extremity, Bilateral Right Renal IVC Left Renal SVC Jugular Renal, Unilateral Left Adrenal NA Renal, Bilateral Right Adrenal Adrenal, Unilateral Selective Organ Blood Sampling (x #) x Adrenal, Bilateral Other Venous Vascular Family x x x x Sinus or Jugular Portal Venogram Superior Sagittal Sinus *CATHETERIZATION CODING CONVENTIONS Epidural ) Code multiple catheterizations in the same vascular family to the highest order 2) Use the "Each Additional" code for each Orbital additional second or third order vessel within the same vascular family 3) Code catheterizations of different vascular Hepatic w Hemodynamic Eval families separately Hepatic wedge pressures no Cervicocerebral Arch Angiography - Bilateral bilat diff territory Append -59 venogram -59 Non-selective cath thoracic/ aorta bilat/unil w/ imaging Hepatic w/o Hemodynamic Eval Selective unil carotid/innominate extracranial imaging Venous Sampling (E.G. renins) x -59 Selective unil carotid/innominate w/ipsil intracranial/extracranial LYMPHANGIOGRAPHY (X) CODE Selective unil internal carotid intra/exracranial imaging Extremity only, unilateral Selective unil subclavian/innom vertebral imaging Extremity only, bilateral Selective unil vertebral w/ipsil imaging Pelvic/abdominal, unilateral Selective unil external carotid w/ipsil carotid imaging Pelvic/abdominal, bilateral Selective internal carotid or * (MAX 2X PER SIDE) ea branch w/ imaging OTHER (X) CODE NON-SELECTIVE VASCULAR CATHETERIZATIONS (X) CODE Aorta, Catheter (Femoral, Brachial, Splenoportogram Extremity Artery, Needle/Intracatheter, Unilateral Radial artery catheter for pressures/monitoring Arteriovenous Dialysis Shunt including AV dialysis shunt additional access for therapeutic UNLISTED IMAGING CODES (X) Extremity Vein, Needle/Intracath, Uni (Including contrast Inj) Unlisted, Fluoroscopic procedure Attach Report Aorta, Translumbar Unlisted, CT procedure Attach Report Carotid/Vertebral, direct puncture Unlisted, MR procedure Attach Report Retrograde Brachial Unlisted, US procedure Attach Report Superior or Inferior Vena Cava, Catheter MODERATE (CONSCIOUS) SEDATION provided by same physician performing the Dx-Tx service (X) PRESENTING PROBLEM(S)/DIAGNOSIS Intraservice Start Time: End Time: Conscious Sedation AGE 5 or OLDER first 30 min Dx 1: ICD-9: each additional 15 minutes x Conscious Sedation UNDER 5 first 30 min Dx 2 : ICD-9: each additional 15 minutes x MISCELLANEOUS (X) Closure Device G0269 CT, limited or localized follow-up US Guidance for Vascular Access (Required documentation on file) CPT Only copyright 2012 American Medical Association, All Rights Reserve Copyright 2012, Society of Interventional Radiology. All Rights Reserved.

64 PATIENT: DATE: PROCEDURE: REFERRING PHYSICIAN: RADIOLOGIST: NONVASCULAR CHARGE SHEET MCS-Moderate Conscious Sedation Do NOT additionally report Moderate Conscious Sedation codes in conjunction with these services. Valuation for codes in the MCS indicator column includes the physician work for conscious sedation. GASTROINTESTINAL TRACT (X)MCS Procedure S & I DRAINAGE PROCEDURES (X) MCS Procedure S & I Perc. Transhepatic Cholangiogram Fistula or Sinus Tract Study Perc. Biliary Drainage (External) Thoracentesis needle or cath, w/out imaging N/A Perc. Biliary Drainage (Int. and Ext.) Thoracentesis needle or cath, with imaging N/A Abscess Drainage, Pleural (Empyema) w/out Injection, Cholangiography, Existing Cath., T-tube imaging N/A Abscess Drainage, Pleural (Empyema) w/ Change of Biliary Drainage imaging N/A Revise/Reinsert Transhepatic tube Abscess Drainage, Perc. Dil Biliary Stricture w/o Int. Stent Insertion, Indwelling Tunneled Pleural Perc. Dil Biliary Stricture with Int. Stent Removal of Indwelling Tunneled Cath w/ cuff N/A Cholangioscopy, perc., w/ or w/o brushing or wash N/A fibrinolysis via chest tube/catheter, agent initial N/A Cholangioscopy, perc., with biopsy N/A fibrinolysis viacatheter, agent subs N/A Cholangioscopy, perc., with calculus/calculi remova N/A Abscess Drainage, Biliary Stone Removal via T-Tube Abscess/Cyst Drainage, Intraoperative Cholangiogram Pancreatic Pseudocyst Intraoperative Cholangiogram Additional Abscess Drainage, Naso/oro gastric tube placement Abscess Drainage, G-tube placement under fluoro Abscess Drainage, J-tube placement under fluoro Paracentesis, Abdominal wo imaging guidance duodenostomy tube placement under fluoro Paracentesis, Abdominal w imaging guidance cecostomy/colonic tube placement under fluoro Change of Abscess Drain (inc. injection) G-J tube placement under fluoro Abscessogram (Tube Check) Conversion of previously placed G-tube to Pelvic, transvaginal or G-tube replacement under fluoro guidance Abscess Drainage, Renal or J-tube replacement under fluoro guidance duodenostomy tube replacement under fluoro guid BIOPSIES Muscle, Percutaneous by modality* G-J tube replacement under fluoro guidance Bone, Superficial, Percutaneous by modality* Mechanical removal obstructive material G-, J-, G- Bone Deep, Percutaneous by modality* J, C tube under fluoro guidance Pleura, Percutaneous by modality* Contrast Injection for G-, J-, G-J, C tube Lung, by modality* Perc. Cholecystostomy complete N/A Lymph Nodes, Sup., Percut by modality* Pneumoperitoneum Liver, Percutaneous, by modality* ** Liver, Percutaneous, w/ Other by modality* ERCP w/ ** Pancreas, Percutaneous by modality* ERCP for ** Abdomen/Retrop., Percutaneous by modality* ERCP calculus/calculi ** Renal, by modality* ERCP calculus/calculi ** Prostate by modality* ERCP Insert Nasobiliary/Nasopancreatic ** Thyroid, Percutaneous by modality* ERCP Biliary/Pancreatic ** Spinal Cord by modality* ERCP Stent Removal or ** Fine needle aspiration, w/out imaging guidance N/A ERCP Balloon ** Fine needle aspiration, w/ imaging guidance by modality* Esophagus *Imaging Guidance Modality Used (circle one) Esophageal Plastic Tube or ** **ERCP RS&I Fluoro US CT MR **ERCP Biliary Ducts RS&I OTHER (X)MCS Procedure S & I **ERCP Pancreatic Ducts RS&I Tracheal/Bronchial Stent N/A **ERCP Pancreatic and Biliary Ducts RS&I TRANSCATHETER BIOPSY (X)MCS Procedure S & I URINARY PROCEDURES (X) Procedure S & I Transjugular liver biopsy 37200/ Perc Antegrade Pyelogram (thru needle) ABLATION PROCEDURES (X) Procedure S & I Nephrostomy Percutaneous RFA, Liver by modality* Nephrostogram (thru existing catheter) Percutaneous Cryoablation, Liver Tumor(s) by modality* Nephrostomy Tube Change Percutaneous RFA, Renal by modality* Dilation of Nephrostomy Tract/Pyelostomy Percutaneous Cryoablation, Renal by modality* Ureterography Through Existing Catheter Percutaneous RFA Lung Tumor(s) by modality* Ureteral Dilation Percutaneous RFA Bone Tumor(s) URETERAL STENT includes CT Internally Dwelling Percutaneous RFA Breast Tumor(s) by modality* Placement through renal pelvis Percutaneous injection of ablative agent (i.e. - exchange, perc. approach includes alcohol or acetic acid), liver by modality* - removal, perc. approach includes Open RFA, Liver Tumor(s) using U/S guidance 47380** Transuretheral approach xchange, transurtheral approach includes Open Cryo, Renal Tumor(s) - removal, transurtheral approach includes includes US guidance 50250** Externally Dwellling (externally accesible transnephric ureteral stent/ **Use modifier -62 when service is provided by co-surgeons. -exchange, includes *Imaging Guidance/Monitoring Modality Used for Ablation (circle one) *** Considered inherent to E&M, report appropriate level of E&M provid -removal, includes imaging removal NOT requiring imaging*** 99XXX*** US FALLOPIAN DILATATION CT (X) MR Procedure S & I Change ureterostomy tube/ureteral stent via ileal Hysterosalpingogram Whitaker Test /74475 Hysterosonography, w/ or w/o color flow /74480 Fallopian Dilatation Nephrostolithotomy <2cm ** MODERATE (CONSCIOUS) SEDATION Nephrostolithotomy >2cm ** provided by same physician performing the Dx-Tx service Aspiration, Renal Cyst by Needle by modality* Intraservice Start Time: End Time: Contrast study of renal cyst Conscious Sedation AGE 5 or OLDER first 30 min Ileoconduit Injection each additional 15 minutes x Aspirate bladder (Diagnostic) by trocar/catheter by modality* Conscious Sedation UNDER 5 first 30 min Suprapubic Catheter (incl. Bladder aspiration) by modality* each additional 15 minutes x Cystogram Urethrocystogram, Voiding PRESENTING PROBLEM(S)/DIAGNOSIS Cystography/VCU w/chain Dx 1: ICD-9: Urethrocystogram, Retrograde Change Cystostomy Tube, Simple Change Cystostomy Tube, Complex Dx 2 : ICD-9: **use in lieu of if > 1 hr fluoro *Imaging Guidance Modality Used (circle one) US CT Fluoro MR CPT Only copyright 2012 American Medical Association. All Rights Reserved. Copyright 2013 Society of Interventional Radiology. All rights reserved

65 TRANSLUMINAL ANGIOPLASTY/STENT/ ATHERECTOMY CHARGE SHEET PATIENT: DATE: REFERRING PHYSICIAN PROCEDURE: RADIOLOGIST MCS-Moderate Conscious Sedation Do NOT additionally report Moderate Conscious Sedation codes in conjunction with these services. Valuation for codes in the MCS indicator column includes the physician work for conscious sedation. PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY/STENT/ATHERECTOMY* Procedure S&I Procedure S&I (x) MSC code Code (x) MCS Code Code PTA, Iliac Artery, N/A Stent, Iliac, with PTA when performed, N/A PTA, each add'l illiac vessel, N/A Stent, Iliac, with PTA when performed, each add'l vessel, N/A PTA, Femoral/Popliteal Arteries, N/A Atherectomy, Femoral/Popliteal, with PTA when performed, N/A Stent, Femoral/Popliteal, with PTA when performed, N/A N/A PTA, Tibial/Peroneal Artery, N/A Atherectomy, Tibial/Peroneal, with PTA when performed, N/A Stent, Tibial /Peroneal, y, with PTA when performed,, unilateral N/A N/A PTA, Tibial/Peroneal, each add'l vessel, N/A Atherectomy, Tibial/Peroneal, with PTA when performed, each add'l vessel,, unilateral, N/A N/A Stent and Atherectomy, Tibial/Peroneal, with PTA when performed, each add'l vessel, N/A Category III codes to describe transluminal atherectomy above Inguinal ligaments percutaneously and/or though open surgical exposure (includes RS&I) Renal artery 0234T N/A Visceral artery (except renal) each vessel 0235T N/A Abdominal aorta 0236T N/A Brachiocephalic trunk and branches, each vessel 0237T N/A Illicac artery, each vessel 0238T N/A Endovascular repair of iliac artery bifurcation using a bifurcated external and internal iliac artery 0254T 0255T Intravascular Stents Extracranial Vertebral/Intrathoracic Carotid includes all ipsilateral selective cath, target vessel angiography Intravascular Stent, perc; initial vessel 0075T N/A Intravascular Stent, perc; each addl. vessel 0076T N/A PRESENTING PROBLEM(S)/DIAGNOSIS Dx 1: ICD-9: Dx 2 : CPT Only copyright 2012 American Medical Association. All Rights Reserved. ICD-9: Copyright 2012 Society of Interventional Radiology

66 PATIENT: DOB IDENTIFICATION NUMBER: DATE: AAA-TA-IA ENDOVASCULAR REPAIR CHARGE SHEET Procedure Procedure REFERRING PHYSICIAN: EXPOSURE FOR ENDOPROSTHESIS Code Code Femoral Cutdown Bilat Fem-fem graft Physician #1 Iliac Retroperitoneal Exposure Bilat CATHETERIZATION: NON-SELECTIVE *Report cath codes in addition to exposure Physician #2 Aorta, Catheter (Femoral, Brachial, Axillary) Bilat Iliac, nonselective Bilat CATHETERIZATION: SELECTIVE --Circle code(s)-- 1st 1st & 2nd 1st, 2nd & or 3rd Orde Arterial Vascular Family**** Order Order 3rd Order # of Vessels Modifier(s) MODIFIER DEFINITIONS IIiac, Ipsilateral X Extended Services Common IIiac, Contralateral X Professional Component Common Femoral, Ipsilateral X Bilateral Procedure Common Femoral, Contralateral N/A X Multiple Procedures Common Iliac or Femoral, Axillary or Brachial Approach X Reduced Service Other Abdominal Aorta Vascular Family X Discountinued Service AAA ENDOPROTHESIS DEPLOYMENT Code Modifier(s) -58 Staged/Related Procedure AAA endo repr w/ aorto-aortic tube device / Distinct Procedural Service AAA endo repr w/ modular bifurcated device (1-limb) / Two Surgeons (Co-Surgeons) AAA endo repr w/ modular bifurcated device (2-limb) / Repeat Procedure, Same Physician AAA endo repr w/ unibody bifurcated device / Repeat Procedure, Different Physician AAA endo repair, aorto-uni-iliac/aorto-unifemoral device / Return for Related Procedure During Globa AAA endo repair w/ visceral branches using prosthesis 0078T 0080T - 62 / Unrelated Procedure, AAA EXTENSIONS/CUFFS DEPLOYMENT*** Imaging code billed per vesse -80 Assistant Surgeon initial vessel / -26 -RT Right-side each additional vessel / -26 -LT Left-side visceral extension prosthesis, ea visceral branch 0079T 0081T / -26 -Q0 FDA Approved IDE# TA ENDOPROTHESIS DEPLOYMENT Code Modifier(s) -GA Advanced Beneficiary Notice (ABN) on File TA endo repair w/ coverage of subclavian origin / -26 TA endo repair w/out coverage of subclavian origin / -26 CODING GUIDELINES: Open subclavian to carotid artery transposition performed in conjunction with TA endo repair, neck incision Graft with other than vein, transcervical retropharyngeal carotidcarotid performed in conjuncition with TAA TA EXTENSIONS/CUFFS DEPLOYMENT Proximal - initial * Stents placed inside the endoprosthesis treatment zone are not separately billable. ** Balloon dilatation of endoprosthesis is not separately billable. *** Multiple cuffs in the same vessel are not reportable beyond the first. ****Code caths of different vascular families separately per / -26 standard catheter coding conventions / -26 **** Code Multiple Caths in the Same Vascular Family to the Highest Order Delayed distal (not at time of initial repair) / -26 **** Use the "Each Additional" Code for Each Add/l 2nd or 3rd Order Vessel. IA ENDOPROSTHESIS DEPLOYMENT Endovasc iliac aneuryem repr / -26 OCCLUSION DEVICE (x) (x) Endovasc iliac occlusion device by by Procedure OPEN CONVERSION BYPASS #1 #2 Code Modifier(s) Open aortic tube prosth repr Fempop with vein Open aortoiliac prosth repr Fempop non vein Open aortofemor prosth repr THROMBOENDARTERECTOMY OTHER CONCOMMITANT SERVICES Code Code Modifier(s) Iliofemoral Sedation included in codes Femoral, common Perc TA, Renal or Visceral / -26 Femoral, deep Open TA, Renal or Visceral Artery / -26 EMBOLECTOMY THROMBECTOMY Perc TA, Aorta (within treatment zone NOT / -26 Fempop Open TA, Aorta (within treatment zone NOT reportable) / -26 Popliteal-tibio-peroneal Perc TA, Brachiocephalic / -26 ARTERIAL REPAIR Open TA, Brachiocephalic vessels / -26 Lower extremity, direct Perc TA, / -26 Lower extremity, vein graft Open TA, Venous / -26 Lower extremity, non vein graft Perc TA, Each add'l visceral x x / -26 Dx CODES Open TA, Each add'l visceral vessel x x / -26 Inclusion of a DX code is not meant to imply that payors have approved coverage. Please Perc TA, Each add'l brachiocephalic x x / -26 check with local payors for a list of approved DX codes for these services. Open TA, Each add'l brachiocephalic vessel x x / Malignant secondary renovascular hypertension INTRAVASCULAR ULTRASOUND Artherosclerosis, extremity w/ claud. IVUS initial vessel / Artherosclerosis, extremity w/ rst pain Each additional vessel IVUS / Artherosclerosis, extremity w/ ulcer INTRAVASCULAR STENTS* Artherosclerosis, extremity w/ gangrene Intravascular Stent, perc., initial / Dissection of abdominal aorta Intrasvascular Stent, perc., each add'l vessel / Abdominal aneurysm, ruptured Intravascular Stent, open, initial / Abdominal aneurysm without mention of rupture Intrasvascular Stent, open, each add'l vessel / Iliac artery aneurysm or pseudoaneurysm EMBOLIZATION *for embolization, follow up completion angio (75898) is separately reportable Aneurysm or pseudoaneurysm of subclavian artery / Lower extremity arterial embolism/thrombosis Embolization (Non-Neuro) / Chronic renal failure OTHER *Required documentation on file Iliac arteriovenous fistula US for Vascular Access* / Aortic arteriovenous fistula CT, limited or localized follow-up / Injury subclavian artery Placement of wireless sensor in sac during endo repair Aortic injury/trauma Noninvasive physiological study of implanted wireless sensor Not typically billable at the Injury iliac artery Additional Services--(please describe) Injury iliac vein Category III codes effective Jan 1, Iatrogenic rupture of vessel Endovascular repair of iliac artery bifurcation using a bifurcated external and internal iliac artery 0254T 0255T Other (please specify) CPT Only copyright 2012 American Medical Association. All Rights Reserved. Copyright 2012 Society of Interventional Radiology. All Rights Reserved

67 PATIENT: DATE: PROCEDURE: REFERRING PHYSICIAN: VENOUS ACCESS PROCEDURES CHARGE SHEET MCS-Moderate Conscious Sedation Do NOT additionally report Moderate Conscious Sedation codes in conjunction with these services. \Valuation for codes in the MCS indicator column includes the physician work for conscious sedation. CENTRALLY INSERTED DEVICE PERIPHERALLY INSERTED DEVICE Procedure Procedure (x)mcs Code (x)mcs Code Placement Centrally Inserted Placement Peripherally Inserted Non Tunneled child Non Tunneled PICC child Non Tunneled ( 5+ older) Non Tunneled PICC ( 5+ older) Tunneled child <5 no port, no PICC w/ port child Tunneled (5+ older) no port, no PICC w/ port ( Tunneled port child Tunneled port ( Repair PICC Tunneled PICC no port, no pump tunneled cath, 2 access sites (no port, no PICC w/ Two tunneled cath, two access sites, w/ Partial Replacement (Cath Only) Repair PICC w/ Non Tunneled no port, no pump, cent or per Tunneled no port, no pump, cent or periph Complete Replacement thru same vein access Tunneled port, cent or PICC Tunneled pump, cent or PICC w/ Two tunneled cath, two access sites (no port (X2)* Two tunneled cath, two access sites, w/ (X2)* Removal Non Tunneled no port, no pump 99XXX** Partial Replacement (Cath Only) PICC w/ Port, cent or Pump, cent or Two tunneled cath, two access sites, w/ (X2)* CENTRAL/PERIPHERAL CVA DEVICE MAINTENANCE Reposition central venous catheter Complete Replacement thru same venous access Thrombolytic declotting of vascular access N/A Non Tunneled CVA maintenance fibrin stripping (sep access) Tunneled, no port no CVA maintenance through lumen (brus Tunneled Non-Selective Catheter Plcmnt- superio Tunneled Selective Catheter Plcmnt- venous 1st Two tunneled cath, two access sites (no (X2)* Selective Catheter Plcmnt- venous 2nd Two tunneled cath, two access sites, w/ (X2)* Radiological Catheter Evaluation MODERATE (CONSCIOUS) SEDATION Removal provided by same physician performing the Dx-Tx service Non Tunneled no port, no pump 99XXX** (Do NOT report withcodes marked Tunneled no port, no pump Intraservice Start Time: End Time: Tunneled Conscious Sedation AGE 5 or OLDER first 30 min Tunneled pump Two tunneled cath, two access sites (no (X2) each additional 15 minutes Conscious Sedation UNDER 5 first 30 min x Two tunneled cath, two access sites (X2) each additional 15 minutes x IMAGING for Central/Peripheral Device Procedures Fluoro guidance replacement, partial or complete Fluoro guidance removal US guidance for vascular access (required documentation on file) CT, limited or localized follow-up Fluoro only - no archived image SVC gram IVC gram Extremity venogram CPT Only copyright 2012 American Medical Association. All Rights Reserved. * For multi-catheter devices use the appropriate repair, ** Removal of a non-tunneled device is considered inherent to E&M, report Copyright 2012, Society of Interventional Radiology. All Rights Reserved.

68 PATIENT: PROCEDURE: DATE: REFERRING PHYSICIAN: RADIOLOGIST NONVASCULAR CHARGE SHEET 2 BREAST Aspiration Breast Cyst each additional cyst Fine Needle Aspiration, w/ imaging guidance Breast, Perc. Core Bx, Image Guided (per lesion) Breast, Perc Bx. vacuum assisted/rotating device (per lesion) Plcmnt each Localizing Clip (use w/ 19102/19103) RFA Breast Tumor(s) Breast Wire Localization each additional localization Galactogram, Single Duct Galactogram, Multiple Ducts Sentinel Node Injection (X) CS Procedure S & I by modality* x by modality* by modality* see above ablation procedures x x x x by modality* *Guidance Modalities for Breast Procedures Stereotactic Guidance, each lesion x Mammographic Guidance, each lesion x Ultrasound Guidance for needle placement x CT Guidance for needle placement x Fluoroscopy Guidance needle placement x MR Guidance for needle placement x Specimen Services (X) Breast Specimen X-ray x MISCELLANEOUS (X) Closure Device G0269 CT, limited or localized follow-up US Guidance for Vascular Access (required documentation on file) PRESENTING PROBLEM(S)/DIAGNOSIS Dx 1: ICD-9: x by modality* x by modality* x by modality* Dx 2 : ICD-9: CPT Only copyright 2012 American Medical Association. All Rights ReservCopyright 2012 Society of Interventional Radiology. All Rights Reserved

69 PATIENT: PROCEDURE: DATE: REFERRING PHYSICIAN: RADIOLOGIST: MR ANGIOGRAPHY (X) CODE CT ANGIOGRAPHY (X) CODE MRA Head w/out contrast CTA Head w/out & w/ contrast MRA Head w/ contrast CTA Neck w/out & w/ contrast MRA Head w/out & w/ contrast CTA Chest w/out & w/ contrast MRA Neck w/out contrast CTA Pelvis w/out & w/ contrast MRA Neck w/ contrast CTA Upper Ext w/out & w/ contrast MRA Neck w/out & w/ contrast CTA Lower Ext w/out & w/ contrast CTA Abdomen/Pelvis w/contrast & wo/contrast when performed MRA Chest w/ or w/out contrast CTA Abdomen w/out & w/ contrast MRA Spinal Canal w/ or w/out contrast CTA Heart, coronary arteries & bypass grafts w/contrast MRA Pelvis w/out & w/ contrast CTA Aorta w/ Run-offs w/out & w/ contrast MRA Upper Ext w/ or w/out contrast MRA Lower Ext w/ or w/out contrast CARDIAC MRI (X) CODE MRA Abdomen w/ or w/out contrast Cardiac MRI for morphology and function without contrast MRA - Abdominal Aorta including iliacs w/ bilateral runoff RT CT/MR Angiography - Cardiac MRI Charge Sheet with stress imaging Cardiac MRI for morphology and function with and without contrast with stress imaging Cardiac MRI for velocity flow mapping LT 3-D RENDERING with interpretation and report under concurrent supervision use in addition to base imaging code (X) CODE MRA - Thoracic and Abdominal Aorta including iliacs w/ bilateral runoff RT NOT requiring postprocessing on an independent workstation LT REQUIRING postprocessing on an independent workstation MODERATE (CONSCIOUS) SEDATION* Do NOT report 3-D rendering, 76376/76377 in conjunction with codes for which provided by same physician performing the Dx-Tx service postprocessing is considered inherent including: 31627, 70496, 70498, , Intraservice Time Start Time: (X) 71275, 71555, 72159, 72191, 72198, 73206, 73225, 73706, 73725, 74174, 74175, 74185, AGE 5 or OLDER - first 30 min , 75557, 75559, 75561, 75563, 75565, , 75635, 78012, each additional 15 minutes x 78013, , 0159T. UNDER 5 YRS of AGE- first 30 min INJECTION (X) CODE each additional 15 minutes x C1-C2 puncture with injection for DX/Treatment *Requires midpoint of time be reached in order to assign code. Lumbar puncture, for myelogram OTHER (X) CODE (Valuation for code includes conscious sedation Do NOT additionally report ) US guidance for vascular access (required documentation on file) PRESENTING PROBLEM(S)/DIAGNOSIS Dx 1: Dx 2 : ICD-9: ICD-9: CPT Only copyright 2013 American Medical Association. All Rights Reserved. Copyright 2012, Society of Interventional Radiology. All Rights Reserved.

70 ONCOLOGY CHARGE SHEET PATIENT: PROCEDURE: DATE: REFERRING PHYSICIAN: RADIOLOGIST: MCS-Moderate Conscious Sedation Do NOT additionally report Moderate Conscious Sedation codes in conjunction with these services. Valuation for codes in the MCS indicator column includes the physician work for conscious sedation. BIOPSY (X) MCS Procedure S & I ABLATION PROCEDURES (X) MCS Procedure S & I Muscle, Percutaneous by modality* Percutaneous RFA, Liver by modality* Bone, Superficial, Percutaneous by modality* Percutaneous Cryoablation, Liver Tumor(s) by modality* Bone Deep, Percutaneous by modality* Percutaneous RFA, Renal by modality* Pleura, Percutaneous by modality* Percutaneous Cryoablation, Renal by modality* Lung, by modality* Percutaneous RFA Lung Tumor(s) by modality* Lymph Nodes, Sup., Percut by modality* Percutaneous RFA Bone Tumor(s) Liver, Percutaneous, by modality* includes CT Liver, Percutaneous, w/ Other by modality* Percutaneous RFA Breast Tumor(s) by modality* Pancreas, Percutaneous by modality* Percutaneous injection of ablative Abdomen/Retrop., Percutaneous by modality* agent (i.e. alcohol or acetic acid), liver by modality* Renal, by modality* Open RFA, Liver Tumor(s) using U/S guidance 47380** Prostate by modality* Open Cryo, Renal Tumor(s) Thyroid, Percutaneous by modality* includes US guidance 50250** Spinal Cord by modality* **Use modifier -62 when service is provided by co-surgeons. Fine needle aspiration, w/out imaging N/A *Imaging Guidance/Monitoring Modality Used for Ablation (circle one) Fine needle aspiration, w/ imaging gu by modality* *Imaging Guidance Modality Used (circle one) TRANSCATHETER BIOPSY (X) Procedure S & I HEPATIC EMBOLIZATION Transjugular liver biopsy 37200/ Selective Catheterization 3rd Cytohistologic study of specimen Additional Selective Catheterization x Selective Catheterization 2nd Percutaneous placement of an Selective Catheterization 1st interstitial device(s),fiducial Dx Angio- visceral selective (if indicated) or dosimeter for radiation therapy Percutaneous placement of an Dx Angio- selective add'l vessel beyond basic exam interstitial device(s), such as fiducial Embolization (Non-Neuro)* marker or dosimeter for radiation REPORT ONLY ONCE PER SURGICA Placement of interstitial device(s) for F/U Angio study for transcatheter rad therapy guidance, prostate therapy, embolization or infusion, other Add'l agent -prescribing, handling, and bolus administration chemotherapeutic agent radioactive agent MISCELLANEOUS (X) Yttirum-90 Closure Device G0269 Selective Catheterization 3rd CT, limited or localized follow-up Additional Selective Catheterization x US Guidance Vascular Access (required documentation on file) US CT Fluoro MR MODERATE (CONSCIOUS) SEDATION - requires midpoint of time be reached in order provided by same physician performing the Dx-Tx service Selective Catheterization 2nd order US CT MR Selective Catheterization 1st Dx Angio- visceral selective (if indicated) Dx Angio- selective add'l vessel beyond basic exam Embolization (Non-Neuro)* REPORT ONLY ONCE PER SURGICA F/U Angio study for transcatheter therapy, embolization or infusion, other than for thrombolysis Intraservice Start Time: End Time: Conscious Sedation AGE 5 or OLDER first 30 min Yttirum- 90 Radiopharmaceutical therapy, by intra-arterial particulate administration each additional 15 minutes x Radiation therapy planning Conscious Sedation UNDER 5 first 30 min each additional 15 minutes x Radiation therapy dose plan Radiation handling PRESENTING PROBLEM(S)/DIAGNOSIS Dx 1: ICD-9: Dx 2 : ICD-9: CPT Only copyright 2012 American Medical Association. All RiCopyright 2012 Society of Interventional Radiology

71 PATIENT: PROCEDURE: DATE: REFERRING PHYSICIAN: 21 Prolonged E/M Services 22 Extended Services 24 Unrelated E/M During Global 25 Separate E/M Same Day of Procedure 26 Professional Component 50 Bilateral Procedure 51 Multiple Procedures 52 Reduced Service 53 Discountinued Service 57 Decision to Operate 58 Staged/Related Proc., During Global, Same MD 59 Distinct Procedural Service 62 Two Surgeons (Co-Surgeons) 76 Repeat Procedure, Same Physician 77 Repeat Procedure, Different Physician 78 Return for Related Procedure During Global 79 Unrelated Procedure, Same Physician During Global 99 Multiple Modifiers RT Right-side LT Left-side PRESENTING PROBLEM(S)/DIAGNOSIS Dx 1: MUSCULOSKELETAL CHARGE SHEET ICD-9: RADIOLOGIST: SPINE (X) Procedure S & I* VERTEBROPLASTY unilat or bilat procedur (X) Procedure S & I MYELOGRAM Thoracic one vertebral body w/bone by modality* Lumbar puncture, for myelogram see Lumbar one vertebral (Valuation for code includes moderate myelogram body w/bone bx (conscious) sedation - Do NOT separately report.) by modality* Each add'l T or L vertebral x by modality* see sacroplasty unilat injection 0200T by modality* Cervical puncture, for myelogram myelogram sacroplasty bilat injection 0201T by modality* codes KYPHOPLASTY unilat or bilat injection(s) Cervical Myelogram Thoracic Myelogram Thoracic one vertebral body by modality* Lumbar Myelogram Lumbar one vertebral body by modality* Spinal Canal Myelogram two or more regions Each add'l T or L vertebral body x by modality* Lumbar puncture, Tx for drainage *Guidance Modalities for Vertebroplasty Cervical puncture, w/o injection Puncture Shunt Tubing Fluoroscopic guidance, per vert. body x NEUROLYTIC INJECTION/INFUSION CT guidance, per vertebral body x Subarachnoid * BIOPSIES Cervical or Thoracic Epidural * Bone, Superficial, Percutaneous by modality* Lumbar, Single Epidural * Bone Deep, Percutaneous by modality* NON-NEUROLYTIC INJECTION Spinal Cord by modality* Dx/Tx, Cerv or Thoracic, Epi/Subara., * *Bx Imaging Guidance Modality Used (circle one) Dx/Tx., Lumb or Sac., Epi/Subara., * Fluoro CT MR Cont. Infusion OR Intermittent Cerv or Thoracic, Epi/Subara * RADIOFREQUENCY ABLATION Cont. Infusion Lumb or Sac., Epi/Subara * Percutaneous RFA Bone Tumor(s) Injection, epidural, of blood or clot patch (Valuation for code includes * moderate (conscious) sedation - Do NOT FACET JOINT INJECTION per joint level Inject Anesthesia, cervical or thoracic; single joint level N/A OTHER (X) Procedure S&I Code second level N/A Perc. Aspiration of Nucleus Pulposus third and any additional level(s) N/A Sinogram, Therapeutic Inject Anesthesia Lumbar/Sacral, single joint level N/A Sinogram, Diagnostic second level N/A Aspiration &/or Injection Small Joint third and any additional level(s) N/A Arthrocentesis Medium Joint by modality FACET JOINT NERVE DESTRUCTION BY NEUROLYTIC INJECTION per nerve level Arthrocentesis Large Joint by modality Cervical/thoracic, single nerve level w/guidance Sacroiliac Joint Injection w/o imaging cervical/thoracic, each additional nerve level ARTHROGRAPHY Lumbar/sacral, single nerve level w/guidance (X) Procedure Radiographic S&I* CT S&I** MR S&I** lumbar/sacral, each additional nerve level Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) Arthrogram, TMJ with ultrasound guidance, cervical or thoracic; single level T US only second [cervical/thoracic] level T US only or or Arthrogram, Shoulder third and any additional [cervical/thoracic] level(s) 0215T US only Injection(s), diagnostic or therapeutic agent, paravertebral fac 0216T US only Arthrogram, Elbow or or second [lumbar or sacral] level (s) T US only third and any additional [lumbar or sacral] level(s) 0218T US only or or Arthrogram, Wrist ANESTHETIC/STEROID INJECTION TRANSFORMINAL EPIDURAL Cervical/thoracic, single level N/A Arthrogram, Hip or or cervical/thoracic, each additional level x N/A without anesthesia Lumbar, single level N/A Arthrogram, Hip or or lumbar, each additional level x N/A with anesthesia Arthrogram, Sacroiliac Joint (incl's imaging) *Use instead of if formal epidurography is also done. Report or ONCE per each spinal region Codes OR are to be coded ONCE per each spinal REGION MODIFIERS Arthrogram, Knee or or or or Arthrogram, Ankle **Flouroscopic Guided Inj for CT/MR *Do not additionally report in conjunction with radiographic arthrography S&I codes. MODERATE (CONSCIOUS) SEDATION provided by same physician performing the Dx-Tx service Intraservice Time Start Time: End Time: (X) Conscious Sedation AGE 5 or OLDER first each additional 15 minutes x Conscious Sedation UNDER 5 first 30 min each additional 15 minutes x MISC (X) CT, limited or localized follow-up US Guidance for Vascular AcAccess (require documentation in file) Codes 64622, 64623, 64626, are to be coded per NERVE LEVEL. NOTE: Reporting of associated RS&I/imaging guidance code72275/ has been limited to once per each spinal REGION. Dx 2 : ICD-9: CPT Only copyright 2012 American Medical Association. All Rights Reserved. Copyright 2012 Society of Interventional Radiology. All Rights Reserved

72 OFFICE WITH ULTRASOUND CAPABILITY CHARGE SHEET PATIENT: DATE: EVALUATION & MANAGEMENT SERVICES OFFICE VISIT CONSULTATION Office/Outpatient NEW OR ESTABLISHED PATIENT (x) NEW PATIENT History and Examinatio n Problem focused Problem focused Straightforward Straightforward (x) ESTABLISHED PATIENT (x) History and Examination Problem focused Expanded Expanded Low Detailed Low Detailed Moderate Comprehensive Moderate Comprehen sive High Comprehensive High Referring Physician: ENDOVASCULAR VARICOSE VEIN THERAPY Presenting Problem(s)/Diagnosis (x) VARICOSE VEIN IMAGING DX/FOLLOW-UP Dx 1: ICD-9: Non-invasive physiological study extremity veins, complete Dx 2: ICD-9: bilateral study (Doppler) Dx 3: ICD-9: Complexity of Medical Decision Making Duplex scan of extremity veins - Bilat Duplex scan of extremity veins - unilat/limited study Common Presenting Problem(s)/Diagnosis for Varicose Vein TX (x) ENDOVASCULAR VARICOSE VEIN TREATMENT Varicose vein of lower extremities with ulcer Radiofrequency EVAT- includes imaging- 1st vein Varicose vein of lower extremities with inflammation Radiofrequency - 2nd & subs. vein(s) Varicose vein of lower extremities with ulcer and inflammation Laser EVAT- includes imaging- 1st vein Varicose vein of lower extremities with other complications Laser - 2nd & subs. vein(s) Varicose vein of lower extremities asymptomatic varicose vein (x) OTHER VARICOSE VEIN TREATMENT Venous (peripheral) insufficiency, unspecified Injections of sclerosing solutions (single/multiple), spider Other venous embolism and thrombosis of other specified veins veins; limb or trunk Superficial thrombophlebitis Injections of sclerosing solutions (single/multiple), spider veins; face Injection of sclerosing solution- single vein Injection of sclerosing solution- multiple veins, same leg Presenting Problem(s)/Diagnosis Not Listed Stab phlebectomy of varicose veins, one extremity, Stab phlebectomy of varicose veins, one extremity, more Dx 2: ICD-9: incisions than 20 incisions Dx 1: ICD-9: ULTRASOUND GUIDED BIOPSY Common Presenting Problem(s)/Diagnosis for BX (x) BIOPSY muscle (limb) lump Muscle, Percutaneous localized superficial swelling, mass, lump Pleura, Percutaneous head and neck swelling, mass, lump Lung, Percutaneous chest/lung swelling, mass, or lump Lymph Nodes, Sup., Percut abdominal/pelvic swelling, mass, or lump 789.3X Liver, Percutaneous, Separate (5th digit required) Liver, Percutaneous, w/ Other Procedure unspecified site Pancreas, Percutaneous right upper quadrant Abdomen/Retrop., Percutaneous left upper quadrant Prostate right lower quadrant Thyroid, Percutaneous left lower quadrant Fine needle aspiration, w/out imaging guidance periumbilic Fine needle aspiration, w/ imaging guidance epigastric (x) ULTRASOUND IMAGING GUIDANCE generalized US guidance needle placement other unspecified- multiple site Presenting Problem(s)/Diagnosis Not Listed RADIOLOGIST: Dx 1: ICD-9: Dx 2: ICD-9: CPT Only copyright 2012 American Medical Association, All Rights Reserved. Copyright 2012 Society of Interventional Radiology Complexity of Medical Decision Making Straightforward Straightforward