Significant changes in Current Procedural Terminology (CPT)* coding will be implemented in 2018. Notably, considerable changes have been made to codes for reporting endovascular repair of abdominal aorta and/or iliac arteries. This article provides reporting information about the codes that are relevant to general surgery and its related specialties.
Code 15732, Muscle, myocutaneous, or fasciocutaneous flap; head and neck (i.e., temporalis, masseter muscle, sternocleidomastoid, levator scapulae), was deleted and replaced with new code 15733 to more clearly describe a muscle, myocutaneous, or fasciocutaneous flap that involves one of six different named vascular pedicles. In addition, new code 15730 was established to describe a midface flap that does not involve a named vascular pedicle. The two new codes, along with one related code, include the following (● = new code for 2018):
●15730, Midface flap (i.e., zygomaticofacial flap) with preservation of vascular pedicle(s)
15731, Forehead flap with preservation of vascular pedicle (i.e., axial pattern flap, paramedian forehead flap)
●15733, Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (i.e., buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae)
Code 17250 was identified by the American Medical Association (AMA)/Specialty Society Relative Value Scale Update Committee (RUC) as potentially misvalued through a screen of codes that had high utilization growth; Medicare utilization grew from 50,368 in 2006 to 150,342 in 2015 for code 17250. Upon review of detailed specialty utilization data and place of service data, it was determined that the code did not clearly define the intended use, leading to misreporting. Therefore, the code descriptor was revised to remove the terminology “sinus or fistula” from the parenthetical instructions and to clearly define the intended use of the code term “proud flesh” as follows (▲ = revised code for 2018):
▲17250, Chemical cauterization of granulation tissue (i.e., proud flesh)
New exclusionary parentheticals were added to this code that direct reporting for this service, including an instruction regarding exclusion of reporting 17250 for chemical cauterization for wound hemostasis and excluding use in conjunction with active wound care management services (97597, 97598, 97602).
Code 29582, Application of multilayer compression system; thigh and leg, including ankle and foot, when performed, was deleted from the CPT code set for 2018 because it was determined that 29582 was being misreported in conjunction with codes for sclerotherapy, endovenous ablation, and vascular embolization/occlusion. These codes already include compression stockings as inherent practice expense supplies, and therefore, a multilayer compression system may not be additionally reported. Separately, several surgical society CPT advisors, including representatives from the American College of Surgeons (ACS) and the Society for Vascular Surgery, argued that to be effective, compression would always need to begin at the toes, as described by code 29581, Application of multilayer compression system; leg (below knee), including ankle and foot, which is included in the 2018 CPT code set.
Code 29583, Application of multilayer compression system; upper arm and forearm, was deleted from the CPT code set for 2018 due to unusual Medicare reporting for this very low-volume code, including 20 percent reporting by dermatologists. To be effective, compression would need to begin at the fingers, as described by code 29584, Application of multilayer compression system; upper arm, forearm, hand, and fingers, which is included in the 2018 CPT code set.
Endovascular repair of abdominal aorta and/or iliac arteries
For 2018, endovascular repair of abdominal aorta and/or iliac arteries codes (34800–34806, 34825, 34826, and 34900) have been deleted; 16 new codes (34701–34716) have been added; and four related codes (34812, 34820, 34833, and 34834) have been revised. A substantial number of new guidelines have been added and parenthetical notes have been added, deleted, and revised to assist with correct reporting of these services. These changes were prompted by identification of code pairs as potentially misvalued by a RUC screen for services frequently billed together.
Codes 34701–34708 are structured based on the vascular anatomy involved (i.e., infrarenal aorta and/or iliac arteries) and the type of endograft deployed. The new codes also distinguish between endovascular repair “with rupture” and for “other than rupture.” This distinction is based on evidence that repair of a ruptured vessel will involve more complexity, intensity, and physician work, including placement of a temporary aortic and/or iliac occlusion balloon when necessary. This balloon would be inflated in the event the patient goes into hemorrhagic shock.
Many services have been bundled into 34701–34708, including angioplasty and stenting performed within the treatment zone, placement of endografts, placement of extensions in the aorta from the renal arteries to the iliac bifurcation, and nonselective catheterization. Codes 34701–34708 also include the time-intensive preoperative work of sizing the aneurysm and selecting the appropriate type of endograft to be deployed. Codes 75952–75954, which describe radiological supervision and interpretation for endovascular repair of abdominal aorta and/or iliac arteries, have been deleted, as this work also has been bundled into 34701–34708.
For 2018, the new guidelines for endovascular repair of abdominal aorta and/or iliac arteries include a definition of “treatment zone” as the vessel(s) in which an endograft(s)—including the main body, docking limb(s), and/or extension(s)—is deployed. Procedures performed outside of the treatment zone, such as angioplasty or embolization, may be reported separately. For example, when an endograft terminates in the common iliac artery, any additional treatment performed in that artery is not reported separately; however, treatment that is performed in the external or internal iliac artery may be reported separately.
Add-on code 34709, which describes placement of an extension prosthesis(es) distal to the common iliac artery(ies) or proximal to the renal artery(ies), may be reported in conjunction with codes 34701–34708. However, endograft extension(s) that terminate(s) within the common iliac arteries are included in codes 34703–34708 and are not reported separately.
Codes 34710 and 34711 describe delayed placement of an extension prosthesis(es).
Code 34712 describes delivery of an enhanced fixation device(s) to an endograft, such as an anchor, screw, or tack. It is reported once per operative session, regardless of the number of fixation devices deployed, and includes radiological supervision and interpretation.
Add-on code 34713 describes percutaneous access and closure of the femoral artery for delivery of an endograft through a sheath size 12 French or larger. Code 34713 may be reported with endovascular repair of the descending thoracic aorta codes 33880–33886, endovascular repair of abdominal aorta and/or iliac arteries codes 34701–34708, or endovascular fenestrated repair of the visceral aorta/infrarenal abdominal aorta codes 34841–34848, as appropriate. Code 34713 is not reported separately if a sheath smaller than 12 French is used.
Open arterial exposure is performed during endovascular repair of abdominal aorta and/or iliac artery procedures when a vessel is too small in diameter to accommodate passage of the endograft. Before 2018, the open arterial exposure codes were standalone codes with a global period. For 2018, the arterial exposure codes (34812, 34820, 34833, 34834) have been revised to be add-on codes because they will never be performed as standalone procedures. In addition, new add-on codes have been established to describe open exposure of the femoral artery (34714) and axillary/subclavian artery (34715 and 34716). Codes 34833, 34714, and 34716 also describe exposure for establishment of cardiopulmonary bypass.
Add-on codes 34812, 34820, 34833, 34834, 34714, 34715, and 34716 are for unilateral procedures. Until 2018, bilateral arterial exposure was reported by appending modifier 50 to the appropriate code. For 2018, coders are instructed to report the open exposure add-on code with two units when performed bilaterally.
Table 1 lists codes related to endovascular repair of abdominal aorta and/or iliac arteries. Codes are displayed as they appear in the CPT codebook, which may not be in numerical sequence. It is important to review the code descriptors, guidelines, and parenthetical notes in the CPT codebook carefully before determining the appropriate code(s) to report for the services performed.
Table 1. Endovascular repair of abdominal aorta and/or iliac arteries codes
Introduction of a needle or intracatheter
With the new 2017 dialysis access code family, and because of changing clinical practice, code 36120, Introduction of needle or intracatheter; retrograde brachial artery, and code 75658, Angiography, brachial, retrograde, radiological supervision and interpretation, were deleted as these services are more appropriately reported with other existing upper extremity angiography codes. As a result of these deletions, code 36140 has been revised to specify upper or lower extremity artery as follows:
▲36140, Introduction of needle or intracatheter, upper or lower extremity artery
Treatment of incompetent veins
An array of procedures can be used to treat varicose veins and, specifically, incompetence of the great and small saphenous vein. CPT codes exist to report many, but not all, of these treatments, including direct puncture sclerotherapy (36468–36471), mechanochemical endovenous ablation (36473, 36474), laser ablation (36478, 36479), radiofrequency ablation (36475, 36476), ligation/stripping (i.e., 37718, 37722), and stab phlebectomy (37765, 37766). For 2018, three codes have been revised to support correct coding and four codes have been added to describe newer treatments involving the use of chemical adhesive and non-compounded foam sclerosant as follows:
▲36468, Injection(s) of sclerosant for spider veins (telangiectasia), limb or trunk
▲36470, Injection of sclerosant; single incompetent vein (other than telangiectasia)
▲36471, Injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg
●36465, Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; single incompetent extremity truncal vein (i.e., great saphenous vein, accessory saphenous vein)
●36466, Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; multiple incompetent truncal veins (i.e., great saphenous vein, accessory saphenous vein), same leg
●36482, Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (i.e., cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; first vein treated
●36483, Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (i.e., cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)
It is important to note that codes 36465 and 36466 describe injection(s) of a “non-compounded” foam sclerosant into an extremity truncal vein. The sclerosant described in these codes is one that is not compounded by a physician or other qualified health care professional. Compounding is the process of combining, mixing, or altering the ingredients of a drug by a physician or other qualified health care professional to tailor the needs of an individual patient. When a compounded sclerosant foam is injected for treatment of an incompetent extremity truncal vein, codes 36470 and 36471 should be reported. Codes 36465 and 36466 include compression maneuvers that are performed under ultrasound guidance to control the dispersion of the foam sclerosant and to ensure that the sclerosant reaches the intended treatment area. The ultrasound guidance and monitoring are included in codes 36465 and 36466 and not reported separately.
Accurate coding is the responsibility of the provider. This summary is intended only to serve as a resource to assist in the billing process. The ACS sponsors coding workshops for surgeons and/or their coding staff in different cities throughout the year. For more information or to sign up for one of the 2018 ACS General Surgery Coding Workshops, visit the ACS website.