Article - Billing and Coding: Endovascular Repair of Aortic and/or Iliac Aneurysms (A53124)

CMS National Coverage PolicyN/AArticle TextCoding GuidelinesThe Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not take precedence over NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.Endovascular repair of aortic aneurysms requires the combined effort of radiologists and vascular surgeons. These procedures have several key components:Preservice planning and sizingTreatment Zone definedOpen exposure of the artery to allow delivery of the endovascular prosthesisReporting Bilateral Aneurysm RepairIntroduction of guidewires and cathetersImaging in conjunction with endovascular repairPlacement of the prosthesisReporting ExtensionsEndovascular repair with rupture or for other than rupture repairPreservice Planning and SizingPreprocedure sizing of the aneurysm and selection of the appropriate type of endograft are part of the preservice work included in the endograft CPT codes34701-34708. The preservice planning and sizing should not be reported separately.Treatment Zone DefinedThe CPT Manual defines the treatment zone as the vessels(s) in which an endografts(s), including the main body, docking limb(s), and/or extension(s), is deployed during an operative session. For reporting purposes, the treatment zone for endovascular repair of abdominal aorta and/or iliac arteries extends the entire length of the vessel treated even if the device used does not cover the entire vessel.Services included in the endovascular repair codes include angioplasty and stenting performed within the treatment zone, placing and securing endografts, placement of extensions in the aorta from the renal arteries to the iliac bifurcation, nonselective catheterization, and radiological supervision and interpretation. These services are not to be reported separately.Artery ExposureOpen arterial exposure is performed during endovascular repair of abdominal aorta and/or iliac arteries procedures when a vessel is too small in diameter to accommodate the endograft. As of 2018, the open exposure codes are add-on codes. To report the open exposure of the artery use add-on CPT codes 34812, 34820, 34833, 34834, 34714, 34715, or 34716 dependent upon the artery used. When the same open arterial exposure is used bilaterally, report the open exposure add-on code twice with appropriate anatomical modifier.When reporting surgical exposure of the artery by the same physician who performed the primary endovascular aortic aneurysm repair, use the CPT code specific to the artery (e.g., femoral: 34812, iliac: 34820) and append the -51 modifier (multiple procedures).If an extensive repair or replacement of the exposed artery is required, this should be billed withCPT code 35266 or 35286.Reporting Bilateral Aneurysm RepairReport simultaneous bilateral iliac artery aneurysm repairs with aorto-bi-iliac endograft with CPT code 34705 or 34706.If bilateral iliac artery aneurysms are treated, report with CPT code 34707 or 34708 with -50 modifier.Introduction of Guidewires and CathetersNonselective catheterization is inherent for CPT codes 34701-34708 and is not separately reportable. Selective catheterization of the hypogastric artery(ies), renal artery(ies), and/or arterial families outside the treatment zone of the endograft may be separately reported.Selective catheter introduction should be reported using the appropriate catheterization codes as follows:For repair of a descending thoracic aneurysm use CPT codes 36140, 36200-36218 as appropriate.For repair of an abdominal aortic aneurysm use CPT codes 36200, 36245-36248, and 36140 as appropriate.As above, when reporting catheterization by the same physician who performed the endovascular AAA repair, append the -51 modifier to the appropriate catheterization code.Imaging in Conjunction with Endovascular RepairAs of 2018, separate CPT codes for supervision and interpretation of endograft services have been deleted. Most imaging services related to endovascular repair codes are included in the new endograft codes. Services not separately reportable with 34701-34708 include the following, please note: this list may not be all inclusive:Radiological supervision and interpretation,Intraprocedural and completion angiography (e.g., confirm position, detect endoleak, etc.),All intraprocedural imaging (e.g., angiography, rotational CT, etc.) of the aorta and its branches prior to deployment of the endovascular device, andFluoroscopic guidance and mapping used to deliver endovascular components.For repair of a descending thoracic aneurysm use CPT codes 75956-75959 as appropriate.Placement of the ProsthesisSeveral codes may be used when repairing an abdominal aortic and/or iliac artery aneurysm. Use CPT codes 34701, 34702, 34703, 34704, 34705, 34706, 34707, or 34708 for the repair of an abdominal aortic/iliac artery aneurysm (with or without rupture) with an endovascular prosthesis.CPT code 34717 and 34718 describe endovascular repair of the iliac artery using an iliac branched endograft. CPT 34717 is an add on code and is reported in conjunction with CPT codes 34703, 34704, 34705 or 34706. CPT 34718 is a stand alone code and should not be reported with 34703, 34704, 34705 or 34706.Code 34717 may only be reported once per side. For bilateral procedures, report 34717 twice. Do not report modifier 50 in conjunction with 34717.Code 34718 - for bilateral placement of an iliac branched endograft, report modifier 50.For the replacement of the descending thoracic aneurysm with an endovascular prosthesis use CPT codes 33880-33891.If an iliac artery occlusion device is required CPT code 34808 may be applicable when performed during the same operative setting as the endovascular repair.CPT code 34813 is used if a femoral-femoral prosthetic graft is required during the endovascular repair of the abdominal aortic aneurysm.When the abdominal aortic aneurysm cannot be repaired via an endovascular approach and an open approach must be used to complete the procedure, use CPT codes 34830, 34831, or 34832.Reporting ExtensionsReporting extensions is dependent on the procedure performed rather than the specific device placed. CPT code 34709 is an add-on code for CPT codes 34701-34708 and is reported once per vessel treated regardless of the number of extension modules necessary to complete the procedure. Extensionprosthesis(es) may not be reported separately when placed in the treatment zone. Docking limbs are considered part of the endograft procedure and are not reported separately even when the docking limb used to complete the procedure extends into the external iliac artery. Otherwise, CPT code 34709 is reportable once per vessel when extension of a prosthesis(es) is required in any of the following cases:Above the renal arteries (CPT codes 34701, 34702)Above the renal arteries or below the iliac bifurcation(s) (CPT codes 34703, 34704, 34705, 34706)Below the iliac bifurcation (CPT codes 34707, 34708)CPT codes 34710 and 34711 are used for delayed placement of the extension prosthesis(es) not performed at the same operative session as CPT codes 34701-34709.Endovascular repair with rupture or for other than ruptureEndovascular repair in the aortic or iliac arteries for acute rupture is reported using CPT codes 34702, 34704, 34706, or 34708. When reporting these codes, rupture is defined in the CPT manual as clinical and/or radiographic evidence of acute hemorrhage. Contained/stable ruptures or chronic ruptures (also referred to as pseudoaneurysms) are repaired using CPT codes 34701, 34703, 34705, or 34707.Other Billing ConsiderationsOther interventional procedures performed at the time of endovascular abdominal aortic aneurysm repair may be additionally reported (e.g., renal transluminal angioplasty, arterial embolization, intravascular ultrasound, balloon angioplasty of native artery[ies] outside the graft [e.g., aortic or iliac] before and after deployment of the endoprosthesis). The treatment zone includes the entire vessel treated even if the device does not cover the entire vessel. Any stenting performed in the treatment zone of the endograft before, during, or after placement of the endograft is included with the work of endograft placement. There are; however, indications for placement of separate vascular stents outside the treatment zone of the endograft (e.g., iliac, renal arteries). These stent placements are to be coded using CPT codes 37236-37239. Please note CPT codes 37236-32739 include radiological supervision and interpretation.Endovascular repair codes are not to be used to report for treatment of atherosclerotic occlusive disease in the iliac artery(ies).When the endovascular repair of AAA is performed by cooperating physicians, each participant should report the appropriate repair codes and append modifier -62 (co-surgeons) or modifier -80 (assistant surgeon).In situations in which a cardiologist, for example, bills for the supervision (the "S") of the S&I code, and a radiologist bills for the interpretation (the "I") of the code, both physicians should use a -52 modifier indicating a reduced service, e.g., the interpretation only. When a -52 modifier is reported, Novitas recommends submitting supporting documentation or explanation with the claim submission. For additional information on the use of modifier -52, please see our website at Novitas-solutions.com.