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Stent and PTA placements: Code them correctly

Radiology Administrator's Compliance and Reimbursement Insider, September 1, 2005

Having trouble coding for stents and percutaneous transluminal angioplasty (PTA) together in your facility? Susan Garrison, CPC, CHC, CCS-P, CPC-H, CPAR, vice president of Healthcare Consulting Services with Magnus Confidential in Atlanta, offers the following guidelines to help you code this challenging area of interventional radiology. We then follow up with a case study that puts these guidelines into practice.

Stent guidelines

Stent placement includes angiography for guidance and documentation, so do not code this procedure separately.

Only true diagnostic angiographies where it is not previously known whether the patients need a stent are captured in addition to the stenting, says Garrison.

Code catheter placement in addition to the stent placement. "But don't code catheter placement twice, unless there is an additional puncture site," Garrison says.

If the stent is performed through an existing access,

  • code diagnostic angiography even if it takes place on the same date. But do not code follow-up angiography.

  • code stents for each vessel separately treated. Code multiple lesions in a single vessel only once.

  • do not code inflation of a positioning balloon during stenting as balloon angioplasty. The only time you can code a stent and PTA of the same vessel is when "the angioplasty, if performed at the same time as a stent, was for therapeutic reasons and fails or doesn't give the level of flow necessary and the physician decides intraprocedure to insert a stent," says Garrison.

  • use radiology supervision and interpretation codes with both open and percutaneous stent codes.

  • do not separately code angioplasty performed as a method of stent deployment.

  • Conditions for coding stents, PTAs together

    Code both stents and PTAs if you meet one or more of the following conditions:

  • One fails and the other is used to treat the patient

  • If different treatment is provided for different sites (note: You can still code both if they are adjacent, provided the second site is documented as a different lesion)

  • If a stent complication is repaired via balloon

  • "At least one of those has to be documented in the operative report," Garrison says.

    "Let's say the intent of the physician when he or she starts the procedure is the angioplasty, but it does not succeed, and the physician takes a second reading and decides to place a stent," she explains. "If one fails and the other is used as treatment, you can code both and receive separate payment."

    Case study: Stent and PTA placement

    Indication: Stenosis brachiocephalic artery

    Title: Arch aortogram, right brachiocephalic arteriogram, angioplasty, and stent right brachiocephalic

    Details: The radiologist informed the patient of risks associated with the procedure, including stroke, and he or she agreed to the procedure. The patient's right groin underwent sterile preparation and was draped in the usual fashion.

    A 4Fr vascular sheath was inserted, via retrograde right femoral arterial approach. A 5Fr pigtail catheter was then advanced into the ascending aorta. The radiologist performed an arch aortogram in the left anterior oblique projection. A high-grade stenosis was demonstrated on the arch aortogram at the origin of the right brachiocephalic artery. A Simmons II catheter was inserted, and the catheter was reformed in the ascending aorta.

    The radiologist selectively catheterized the right brachiocephalic, advanced asupracore guide into the right subclavian artery, and positioned the catheter within the subclavian artery. The radiologist advanced the guide wire into the axillary artery. He or she removed the catheter and advanced a 7Fr shuttle sheath to the origin of the right brachiocephalic artery. He or she then inserted a 8 mm x 2 cm-long angioplasty balloon. The patient received 3,000 units of heparin intravenously. Then the radiologist balloon-dilated the area of stenosis.

    A repeat arteriogram demonstrated marked residual stenosis. The radiologist inserted a 12 mm x 30 mm-long Luminex stent and deployed it in the usual fashion across the area of stenosis. Then he or she inserted a 10 mm x 2 cm-long angioplasty balloon and the stent was further balloon-dilated to10 mm in diameter.

    A subsequent repeat arteriogram demonstrated good angiographic result with no significant residual stenosis identified. The radiologist removed the catheter and sheath and obtained hemostasis with a Perclose suture device.

    Impression: High-grade stenosis origin of the right greater cephalic artery. This was successfully angioplasted and stented to 10 mm in diameter as described above.

    Coding the case study

    Following are the codes that warrant assignment in the above case study and the lines from the documentation that support their use:

  • 75650 ("5Fr pigtail catheter was advanced into the ascending aorta. Arch aortogram was then performed")

  • 36216-RT ("right brachiocephalic artery was selectively catheterized")

  • 35475, 75962 ("8 mm x 2 cm-long angioplasty balloon was then inserted . . . the area of stenosis was then balloon-dilated")

  • 37205, 75960 ("A 12 mm x 30 mm-long Luminex stent was then inserted and deployed in the usual fashion across the area of stenosis")

  • Documentation do's and don'ts

    Although the Simmons II catheter was reformed in the ascending aorta, you cannot code for it because it's incidental to the procedure. Also, you cannot code for the Supracore guide wire. "However, the catheter positioned within the subclavian artery gives us that level of selectivity," Garrison says, and thus is an important piece of documentation to watch for.

    A key missing piece to the documentation is the line that reads, "A repeat arteriogram was obtained demonstrating marked residual stenosis." The physician must document how much stenosis remains, Garrison says.

    "The guideline is that 30% must remain before we can capture it with a code," she says. This percentage determines whether you can report codes 37205 and 75960.

    Finally, do not code the 10 mm x 2 cm-long angioplasty balloon because it was inserted to assist in the placement of the stent.

    Editor's note: The above article was adapted from the June 22 HCPro audioconference, "Interventional Radiology Coding: Solutions to Your Top Challenges." To order, go to www.hcmarketplace.com/Prod.cfm?id=3393, or call customer service at 877/727-1728.


    Ask the insider

    Q: Managing radiation exposure risks and mammography coding

    I know a dentist in private practice who treats multiple types of patients and frequently treats patients with dementia and disabilities. Taking x-rays of these patients is extremely difficult, if not impossible. When these patients require dental x-rays, he stands in the room with the patient. He doesn't wear a radiation badge and sometimes doesn't even wear a lead safety vest. How much danger is he putting himself in if he doesn't take x-rays of these patients very often? I know that any unnecessary exposure should be avoided, particularly in light of the recent study, reported in the August RACRI, which showed even exposure to small doses of radiation can increase the lifetime risk of cancer.

    A: The likelihood of anyone developing cancer from dental x-rays is as close to zero as one can get. First, the strength of x-rays used in dental work is minimal. Second, the x-rays are aimed at the patient's teeth. It is true that there is "scatter," which means that a tiny bit of radiation spills over to the immediate area, but this is minimal. Furthermore, the power of the x-ray drops with the square of the distance (e.g., the power at two ft. away is one-quarter [not one-half] of the power at one ft. The long and short of it is that there is no reason to worry about the dentist or any other bystander getting cancer from being near people who are x-rayed for dental purposes).

    That being said, let me say that we live in a world today where "minimal" and "close to zero" may not convince some people. Who is able to prove that there isn't one chance in a million that the dentist won't get cancer? Some people may think no one can. Most people have the perception they can get cancer from dental x-rays, despite my explanation above. Therefore, it would be advisable for the dentist to have a lead shield (in the form of a lead apron) not only for the patients and any bystander who may be adjacent to the dental chair, but even for himself. Even though I do not believe he is at any risk, I suggest that he might want to set an example of appearing careful and prudent not only to his patients, but to his employees as well.

    Insider sources

    Leonard Berlin, MD, chair, radiology department and professor of radiology at Rush Medical College, Chicago

    Melody Mulaik, MSHS, CPC; CPC-H, RCC, Coding Strategies Inc., Powder Springs, GA.