Compliance with changes for the coding of interventional radiology procedures made by the American Medical Association (AMA) and the U.S. Centers for Medicare and Medicaid Services (CMS) for 2016 may be a challenge for some radiologists and coding professionals.
This is especially true for a few new and revised instructions "hiding" in documents such as the January 2016 edition of the National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services, as well as those not hiding but not obvious at first glance. Examples of several such changes -- as well as clarifications on new coding and billing requirements -- are provided below.
Postprocedure mammograms
Medicare's policy on post-procedure mammography has changed yearly since 2013 -- from not allowing it at all, to allowing it with stereotactic, ultrasound, and MR-guided procedures; and then to allowing it only with ultrasound and procedures guided by MRI. The 2016 NCCI Policy Manual has reverted back to the 2014 policy statement that allows separate coding of a postprocedure mammogram with all but the mammogram-guided localization.
Chapter 9 of the policy manual includes the following statement:
11. If a breast biopsy, needle localization wire, metallic localization clip, or other breast procedure is performed with mammographic guidance (e.g., 19281, 19282), the physician should not separately report a postprocedure mammography code (e.g., 77051, 77052, 77055-77057, G0202-G0206) for the same patient encounter. The radiologic guidance codes include all imaging by the defined modality required to perform the procedure.
Soft-tissue marker
Occasionally, an interventional radiologist is asked to place a marker in a lesion in a location other than the breast prior to open biopsy or other surgery. Until now, an unlisted code had to be reported for these procedures. AMA added the following codes to the 2016 CPT book for the placement of soft-tissue markers such as clips, pellets, needle/wire, or radioactive seeds:
- 10035: Placement of soft-tissue localization device(s) (e.g., clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, including imaging guidance; first lesion
- 10036: Placement of soft-tissue localization device(s) (e.g., clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, including imaging guidance; each additional lesion (list separately in addition to code for primary procedure)
The most common use for the above codes would be to mark lymph nodes in the axilla and groin, although there may be other situations as well. Guidelines include the following:
- Report 10035 for the first lesion marked.
- If a second lesion is also marked, report add-on code 10036.
- Report codes 10035 and 10036 only once per lesion regardless of the number of markers used.
- Do not also assign code 76942, 77002, 77012, or 77021 since imaging guidance of any kind is included in the above.
Percutaneous sclerotherapy
In 2016, the following new code was introduced for sclerosis of a (nonvascular) fluid cavity:
- 49185: Sclerotherapy of a fluid collection (e.g., lymphocele, cyst, or seroma), percutaneous, including contrast injection(s), sclerosant injection(s), diagnostic study, imaging guidance (e.g., ultrasound, fluoroscopy), and radiological supervision and interpretation when performed
This code includes any diagnostic injection of contrast and imaging to evaluate the cavity prior to sclerotherapy. The code also includes imaging guidance for the sclerosing procedure, injection of the sclerosant, and supervision and interpretation.
Code 49185 does not include access into the cavity, nor does it include drainage prior to sclerotherapy, if performed. Access and drainage codes such as 10160, 50390, 10030, 49405-49407, and 50390 may be reported in addition to 49185 when appropriate.
Coding tips include the following:
- Do not also report 49424 and 76080 in addition to 49185.
- Report 49185 once per day for each fluid cavity sclerosed through separate catheters. If multiple cavities are treated through the same catheter, report 49185 only once.
- When a previously placed drainage catheter is replaced before or after sclerotherapy, codes 49423 and 75984 may be separately coded.
- Use code 49185 for sclerotherapy of a lymphocele, but report embolization code 37241 for sclerotherapy of a lymphatic malformation.
Thoracic paravertebral block
Three new codes have been introduced for thoracic paraspinous blocks and infusion for pain management. These blocks may be performed instead of an epidural or subarachnoid injection for patients undergoing thoracic, breast, or upper abdominal surgery:
- 64461: Paravertebral block (PVB) (paraspinous block), thoracic; single injection site (includes imaging guidance, when performed)
- 64462: Paravertebral block (PVB) (paraspinous block), thoracic; second and any additional injection site(s) (includes imaging guidance, when performed) (list separately in addition to code for primary procedure)
- 64463: Paravertebral block (PVB) (paraspinous block), thoracic; continuous infusion by catheter (includes imaging guidance, when performed)
All of the above codes include imaging guidance, when performed; do not also assign one of the modality-specific guidance codes.
Coding tips include the following:
- Code 64461 is reported for a single injection at any thoracic level.
- Code 64462 is reported when additional injections are performed at other thoracic levels, or on the opposite side as the initial injection. Only report code 64462 once per day, regardless of how many additional injections are performed.
- Report 64463 when a catheter is placed into the paravertebral space and left in place for continuous infusion of an anesthetic, usually for postoperative pain management.
- Do not report the above codes with epidural, transforaminal epidural, intercostal, or facet joint injections in the thoracic area.
Biliary system code changes
Codes for percutaneous procedures in the biliary system underwent significant revision for 2016. Most of the existing codes for procedures in the biliary system were deleted and new codes were added. Most of these new codes bundle diagnostic exams and therapeutic procedures when performed at the same session. Injections of contrast and imaging necessary to perform the therapeutic procedure should not be separately coded.
Pay careful attention to code descriptions and guidelines within the CPT book to determine when multiple codes may be assigned.
Donna Richmond is a senior healthcare consultant, clinical consulting services, for Panacea Healthcare Solutions. In addition to her coding hotline responsibilities for Panacea, she performs a variety of radiology and cardiology audits and contributes to several webcasts and publications, including MedLearn Publishing's new Basics of Interventional Radiology Coding book.
