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    Coding Q&A: Coding for Renal PTA/Stenting and Dx Renal Angiography: Clear Documentation Essential

    June 01, 2012

    Question:

    Can renal PTA (percutaneous transluminal angioplasty) be reported in conjunction with renal stent placement? Is preceding diagnostic angiography additionally reportable?

    Answer:

    This is an important and timely question because renal PTA has landed in the crosshairs for revaluation by the Centers for Medicare and Medicaid Centers (CMS) and the RVS Update Committee (RUC). SCAI’s CPT and RUC representatives, Arthur Lee, M.D., FSCAI, and Clifford Kavinsky, M.D., FSCAI, are collaborating with other members of the cardiovascular CPT and RUC coalition to seek a reprieve in dealing with restructuring these codes until the 2014 CPT cycle. In the interim, it is imperative that SCAI members code these services correctly, particularly those for renal PTA. SCAI encourages all members to share this column with their billing staff and take steps to ensure their practices are properly reporting these services.

    The key point to remember is this: When the intended intervention is primary stenting, PTA performed to predilate or as the method for stent deployment is NEVER a separately coded service. However, PTA is additionally reportable with stent placement when –

    • the intention was to perform angioplasty as the primary intervention, AND
    • the stent placement was performed only after failed or suboptimal results from the angioplasty.

    To bill both renal PTA and stent interventions of the same vessel, the patient record must clearly establish angioplasty as the intended intervention. Most experts agree orificial lesions (the most common lesions involving the renal arteries)  should be treated by primary stenting; therefore, renal PTA would not be expected to be commonly reported in conjunction with renal stenting procedures.

    Renal PTA and stenting are still currently component coded, with catheterization, intervention, and supervision and interpretation all separately reportable.

    Renal Catheterization

    Renal catheterization should be reported using the applicable catheterization code(s), as follows:

    36245 — Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family

    36246 — Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family

    36247 — Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family

    36248 — Selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriate)

    Therapeutic Renal PTA

    The codes to report therapeutic* renal PTA are ––

    35471 — Transluminal balloon angioplasty, percutaneous; renal or visceral artery

    75966 –– Transluminal balloon angioplasty, renal or other visceral artery, radiological supervision and interpretation

    *Codes 35471 and 75966 may NOT be used when the intended intervention was to stent.

    Renal Stenting

    The codes to report renal stenting are ––

    37205 — Transcatheter placement of an intravascular stent(s) (except coronary, carotid, vertebral, iliac, and lower extremity arteries), percutaneous; initial vessel

    75960 — Transcatheter introduction of intravascular stent(s) (except coronary, carotid, vertebral, iliac, and lower extremity artery), percutaneous and/or open, radiological supervision and interpretation, each vessel

    PTA and stent placement codes are assigned per vessel, not per dilation or by the number of stents deployed. Follow-up radiological studies to check the results of angioplasty or stent placement are not separately coded.

    CMS has instructed, “It is appropriate for a provider to bill for both a diagnostic angiogram/venogram RS&I and an interventional therapeutic vascular RS&I when the decision to perform the interventional therapeutic vascular procedure is based on the results of the preceding diagnostic angiogram/ venogram. Providers may bill both codes utilizing an NCCI associated modifier.”

    The coding guidelines for diagnostic angiography performed at the time of an interventional procedure require that ––

    No prior catheter-based angiography/venographic study is available and a full diagnostic study is performed and the decision to intervene is based on the diagnostic study

    – OR –

    If a prior study is available, the medical record must document:

    • The patient’s condition with respect to the clinical indication has changed since the prior study, OR
    • There is inadequate visualization of the anatomy and/or pathology, OR
    • There is a clinical change during the procedure that requires new evaluation outside the target area of intervention

    One important requirement is that modifier 59 must be appended to the diagnostic imaging code(s) when the above criterion is met.

    Diagnostic Renal Angiography

    Diagnostic renal angiography performed from a nonselective catheter position is considered inherent to abdominal angiography and not separately reportable. In contrast, renal angiography performed from a selective catheter position is reportable using one of the following applicable codes:

    36251 — Selective catheter placement (first-order), main renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; unilateral

    36252 –– Selective catheter placement (first-order), main renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; bilateral

    36254 — Superselective catheter placement (one or more second order or higher renal artery branches) renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture, catheterization, fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; bilateral

    36253 — Superselective catheter placement (one or more second order or higher renal artery branches) renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture, catheterization, fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; unilateral

     


     

    Please note: SCAI is committed to making every reasonable effort to provide accurate information regarding the use of CPT®, and the rules and regulations set forth by CMS for the Medicare program. However, this information is subject to change by CMS and does not dictate coverage and reimbursement policy as determined by local Medicare contractors or any other payor. SCAI assumes no liability, legal, financial, or otherwise, for physicians or other entities who utilize this information in a manner inconsistent with the policies of any payors or Medicare carriers with which the physician or other entity has a contractual obligation. CPT codes and their descriptors are copyright 2012 by the American Medical Association.