Vascular Coding Questions and Answers

Overview 

Coding is a complicated aspect of all medical fields. To help vascular surgery professionals better understand the ins and outs of coding, the SVS will be posting frequently asked questions and their answers on this webpage. Please note that this information is provided for educational purposes only, based on regulations at a particular point in time. Final decisions on how to code are ultimately up to the provider.  If you have questions of your own, they can be submitted via the form below

Frequently Asked Questions

Topic Question/Answer Category

Lesion Crossing Two Territories

Q: Our vascular surgeon did a single intervention on a lesion that was at the juncture of the femoral/popliteal and tibial/peritoneal territories. Can we charge for two interventions?

A: Lesions that extend across the margins of one vessel vascular territory into another, but can be treated with a single therapy are reported with a single intervention code.

Answer created in April 2023.

Cerebrovascular Disease

Billing for Multiple Embolectomies

Q: How do we code multiple embolectomies of the aorta when using 34201? Do we code units by the number removed?

A: 34201, Embolectomy or thrombectomy, with or without catheter; femoropopliteal, aortoiliac artery, by leg incision, is billed once per leg incision no matter how many emboli are removed from each incision. If this is performed bilaterally (two leg incisions), then bill 34201 with mod -50.

Answer created in October 2023.

Venous Disease
Coding Carotid Stents at Different Operative Sessions 

Q: The physician performed right and then left carotid stent insertion with embolic protection. The right carotid stent was done first and then 6 weeks later the left side was done.  Which modifier should be used on the second carotid stent? 

A: The second carotid stent is an unrelated procedure performed during the global period.  Append a modifier 79 to code 37215 to indicate this unrelated procedure.  Even though these are the same procedures reported with the same CPT code, they are performed at different anatomic locations and therefore are unrelated. 

Answer created in January 2024.

Venous Disease

 

Topic Question/Answer Category

Venogram and Catheterization

Q: During catheterization, the surgeon performed a venogram. I don’t see that these procedures are bundled, is that correct?

A: Venous catheterization codes are separately reported with venograms unless they are performed at the same session with an intervention that includes catheterization.

Answer created in April 2023.

Vascular Procedures

Nonselective or Selective

Q: When does a nonselective catheterization become a selective catheterization?

A: If the catheter (not just the wire) is manipulated into another vessel beyond the puncture site or beyond the aorta, then it is coded as a selective catheterization.

Answer created in April 2023.

Vascular Procedures

Pelvic Angiograms

Q: Is an angiogram of the iliac arteries reported with the pelvic angiogram code, 75736?

A: No, code 75736, Angiography, pelvis, selective or supraselective is only reported with selective or supraselective catheterization of the internal iliac arteries (hypogastric arteries) and interpretation of pelvic vasculature.

Answer created in November 2023.

Vascular Procedures

 

Topic Question/Answer Category

Catheterization and Intervention Billing

Q: Does TEVAR allow for billing of catheterization and intervention? Would a 59 modifier be needed?

A: Yes, billing for catheterization in addition to the TEVAR is allowed. And no, a modifier 59 is not needed as these two codes do not bundle.

Answer created in April 2023.

Aneurysm

Renal Angiogram Coding

Q: Is catheterization separately reported with renal angiograms?

A: No. The renal angiogram codes, see table below, include all catheterization. The codes are selected by order of catheterization and as unilateral or bilateral. Also, remember that a flush aortogram is included in the renal angiogram codes and not separately reported.

CPT Code Description
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 bilateral
36253

Supraselective 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

  • Do not report 36253 in conjunction with 36251 when performed for the same kidney.
36254 bilateral

Answer created in November 2023.

Aneurysm
Iliac Artery Aneurysm Treatment

Q: How do I code for an isolated iliac artery aneurysm treated endovascularly with an iliac endograft?

A: These codes were revised in 2018 to include either ruptured or unruptured iliac aneurysms. In addition, non-selective catheterization and radiological supervision and interpretation are now inclusive. Refer to the CPT codebook for detailed guidelines on the use of these codes. Here are the full code descriptions.

34707

Endovascular repair of iliac artery by deployment of an ilio-iliac tube endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and all endograft extension(s) proximally to the aortic bifurcation and distally to the iliac bifurcation, and treatment zone angioplasty/stenting, when performed, unilateral; for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation)

34708

Endovascular repair of iliac artery by deployment of an ilio-iliac tube endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and all endograft extension(s) proximally to the aortic bifurcation and distally to the iliac bifurcation, and treatment zone angioplasty/stenting, when performed, unilateral; for rupture including temporary aortic and/or iliac balloon occlusion, when performed (eg, for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation, traumatic disruption)

Note: For bifurcated iliac endografts, refer to codes 34717 and 34718.

Answer created in November 2023.

Aneurysm

 

Topic Question/Answer Category

Providing Exposure for a Neurosurgeon

Q: A neurosurgeon asked my vascular surgeon to perform the exposure for an anterior spine procedure. Does he report an exploratory lap his work?

A: No. Providing the exposure for a neurosurgeon for an anterior spine procedure is co-surgery, since code 22558 Arthrodesis, anterior interbody technique includes both the exposure/approach and the work on the spine. Both surgeons append the co-surgery modifier 62 to code 22558.

Answer created in October 2023.

Surgical Exposure/techniques

 

Topic Question/Answer Category

Angiogram Billing for All Vessels Viewed

Q: Can we bill for all vessels mentioned if they are documented within the angiogram?

A: No. You should only bill for vessels that are targeted and are medically necessary. Documentation alone doesn’t mean that procedures are always separately billable.

Answer created in April 2023.

Practice Management

Co-Surgery Due to Complex Procedure

Q: I have 2 vascular surgeons from the same practice that want to bill co-surgery for a complex open abdominal aneurysm repair. They both performed the same code but say that it should be co-surgery because it was complex and needed both surgeons. Can we bill with modifier -62?

A: The surgery described does not support the definition of a co-surgery (each surgeon performs distinct work described within the same code) and should be billed as a primary and assistant surgeon. Co-surgery implies two surgeons with a different skill set, i.e. different specialties, each provider performing distinct portions of the case, and each documenting their portion in separate operative reports. Also, Medicare and other payors may require that surgeons be of different specialties when billing for co-surgery. Note that the federal Office of Inspector General (OIG) has identified co-surgery as an area of potential overpayment/incorrect payment, making this an audit target. For more information go to the link below:

https://oig.hhs.gov/oas/reports/region1/12000503.asp

Answer created in April 2023.

Practice Management
Time Calculation for E/M services

Q: I heard that I can now count the time I spend documenting in the patient’s EHR when I bill by Time, is that true?

A: Yes, it is true. Time for documenting clinical information in the electronic or other health record (for the E/M only) is allowed to count for total time. Time spent documenting in the medical record for other billed services is not counted toward the time spent on the E/M office visit.

Answer created in October 2023.

Practice Management
Same Day Observation Services

Q: Can a physician bill for same day observation codes if she only sees the patient once during the day?

A: No. Codes 99234, 99235, 99236 require two or more encounters on the same date of which one of these encounters is an initial admission encounter and another encounter being a discharge encounter.

Answer created in October 2023.

Practice Management
Approved Telehealth Platforms

Q: Now that the public health emergency is over and telehealth flexibilities have been extended, can we use any app or platform to conduct a telemedicine visit?

A: No. Some telehealth flexibilities are in place until December 31, 2024. However, as of May 11, 2023, HIPAA approved telehealth platforms are once again required for conducting audio and video telehealth visits. Skype, FaceTime, Facebook Messenger Chat, and Google Hangouts video are no longer approved platforms.

Answer created in December 2023.

Practice Management
LCDs and Vein Procedures: Should We Know About These?

Q: We have an office-based vein center and have heard that something called LCDs should be followed before a procedure is performed. What are these and how do we integrate them into our office processes?

A: An LCD is a Local Coverage Determination. These are medical coverage policies developed by regional Medicare carriers and Medicare Administrative Contractors (MAC) to determine whether there is medical necessity for a vein procedure. Every MAC and every private payor have published detailed criteria that must be met before veins can be considered symptomatic enough to justify interventions such as endovenous ablation. These criteria typically include conservative therapy requirements, vein size, number of ultrasounds performed, details of the ultrasounds, CEAP classification, and much more.

If these criteria are not followed, payors can demand refunds upon case review. This can occur months or even years after the intervention is performed, even if it was pre-certified. Whether you are a “vein only” center or have vein procedure as part of a larger patient population, you cannot afford to ignore these payor policies.

Answer created in December 2023.

Practice Management
MDM Credit for Comorbidities

Q: Can we give the physician credit for Problems Addressed if comorbidities are simply listed within the Assessment and Plan?

A: Comorbidities and underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are specifically addressed by the provider. Documentation should indicate the comorbidity’s impact on the condition treated.

Answer created in January 2024.

Practice Management
Prolonged Service Code for Medicare 

Q: Can we use 99417 and 99418 for prolonged services with Medicare? 

A: No. Medicare has developed G codes for reporting prolonged services. G2212 for office outpatient and G0316 for inpatient /observation. 

Answer created in January 2024.

Practice Management

 

Topic Question/Answer Category

Modifier 52 VS 53

Q: We are confused about the difference between modifier 52 and 53. What is the difference?

The physicians and coders disagree about how to handle these edits. Some of the physicians believe the wound vacs are billable because they are applied to the skin which constitutes a different body system. The coders think the wound vacs are dressings which are included in the global surgical fee and would not billable. After multiple discussions with the physicians and coders, we are unable to provide a definitive answer. Could I please ask you for your advice regarding this issue? What is the right answer?

A: Modifier 52 Reduced Services is used when the procedure or surgery is partially reduced or eliminated by the physician. This is used when a procedure has an existing CPT code, but not all of the components of the code were performed. Modifier 52 is not used for unlisted procedures (where there is no existing CPT code to describe the procedure that was performed).

Modifier 53 Discontinued Procedure is used when a procedure is discontinued due to extenuating clinical circumstances or those that threaten the well-being of the patient. An example is during a fem-pop bypass a patient develops an arrhythmia and the procedure is discontinued.

Answer created in April 2023.

All other

(e.g. modifiers, E/M, wound care)

Wound Vac Billing

Q: I’m a vascular surgeon. Some of my team are reporting the negative pressure wound therapy codes 97605 and 97606 when applying wound vacs after closing at the completion of their surgical cases. As a result, I am told by my coders that billing for these wound vacs is not appropriate, since there is a Medicare NCCI edit that bundles this with more comprehensive procedures at the same anatomic area.

The physicians and coders disagree about how to handle these edits. Some of the physicians believe the wound vacs are billable because they are applied to the skin which constitutes a different body system. The coders think the wound vacs are dressings which are included in the global surgical fee and would not billable. After multiple discussions with the physicians and coders, we are unable to provide a definitive answer. Could I please ask you for your advice regarding this issue? What is the right answer?

A: The AMA published clarification on wound vac billing in the October 2021 CPT Assistant. Negative pressure wound therapy (97605-97606) is considered billable for both open and closed wounds. However, that does not mean that payors will reimburse separately for the service, so use caution and track results.

Answer created in April 2023.

All other

(e.g. modifiers, E/M, wound care)

Emergency Department Services

Q: I don’t see Time listed for codes 99282-99285; can Time be used with these codes?

A: Time is not a descriptive component for the emergency department levels of E/M services because emergency department services are typically provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period of time.

Answer created in November 2023.

All other

(e.g. modifiers, E/M, wound care)

After Hours Emergency Department Visit

Q: A patient arrived at the clinic as it was closing and told to go to the Emergency Department and physician would meet them there. Does this qualify as an ED visit in this case (99282-99285)?

A: No. If a patient is seen in the emergency department for the convenience of a physician or other qualified health care professional and not out of medical necessity, use office or other outpatient services codes (99202-99215).

Answer created in December 2023.

All other

(e.g. modifiers, E/M, wound care)

Intraoperative ICG Angiography 

Q: Can we bill the 92242 for the indocyanine green injection intraoperatively, for example, to assess perfusion after a procedure?  Can we bill for the injection of the dye using 15860? 

A: No, this service is included in primary surgery and not separately reported. 

Answer created in January 2024.

All Other

(e.g. modifiers, E/M, wound care)

 

This Non-CME Activity is supported through an educational grant provided by CVRx.

 

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