When it Comes to Coding for Endovascular Aortic/Iliac Aneurysm Repair, Details Matter!

Illustration: Lee Sauer

My favorite topic in the whole wide world is endovascular aortic aneurysm (EVAR) repair procedures. Some of you may think I’m crazy, but back in 2005, I was invited to witness an EVAR with the cardiothoracic surgeon I worked for and an interventional radiologist. I was absolutely fascinated by the procedure and saw what a great benefit it was for the patient - less invasive equals quicker recovery. After that experience I was hooked. When it comes to coding these procedures though, often it is not a walk in the park. However, with time and experience they do become easier. Below, I give tips to providers on their documentation and to coders on what to look for.

Break Down of Procedures

I’m going to break down each procedure because although they are similar, the rules are different for each type.   

EVAR: These are covered stent grafts and may be called endovascular graft, endoprosthesis, endograft or stent graft. The devices used may be an aorto-aorto tube graft, a bifurcated unibody device, a modular bifurcated docking system, or an aorto-uni-iliac device. To properly document and code these procedures we need to establish where the treatment zone is. CPT states, “The treatment zone for endovascular procedures is defined by those vessels that contain endograft(s), main body, docking limb(s) and/or extension(s) deployed during that operative procedure.” 

Let’s go over the steps for coding and documentation:

Step 1

• Physicians: Document if the aneurysm was ruptured.
• Coders: Ensure you are choosing the correct repair code if it’s ruptured or non-ruptured.

Step 2

• Physicians: Document access. Where and how are you accessing to deploy the graft? Is it percutaneous or open? Where is the access (femoral, brachial, etc.)? Was a conduit required to aid the graft deployment? Was a larger than 12 French sheath used in percutaneous access? Was ultrasound guidance used and if so, was vessel patency captured and permanent recordings maintained in the chart and real-time visualization of the needle entering the vessel captured? Was an extensive repair to an access artery required?
• Coders: Code the proper access, if cutdowns are used, code the vessel where the cutdown occurred. If a conduit was used with a cutdown be sure you capture the correct code.  If percutaneous access was done and ultrasound guidance was used, code the ultrasound guidance.  If a 12 French or larger sheath was used for percutaneous access, drop the ultrasound guidance and only code the 12 French or larger sheath. If an extensive repair is required, drop the cut down code and bill for the repair.

Step 3

• Physicians: Identify the treatment zone by documenting where the graft landed and where it terminated. Document the type of graft, aorto-aorto tube graft, or aorto-uni-iliac or aorto-bi-iliac. If extensions are used, where did they terminate? Extensions are billable that are distal to the common iliac or proximal to the renal arteries.
• Coders: Choose the appropriate code by what vessels were involved (i.e., aorto-bi-iliac graft) and whether the aneurysm is ruptured. Capture extensions that do not terminate in the common iliac or are proximal to the renal arteries. It’s important to note, if the docking limbs of the main body are long and terminate in the external iliac, these are not considered extensions. Also, extensions are coded once per vessel treated. All imaging is included in the graft deployment.

Step 4

• Physicians: Document other interventions that are performed outside of the treatment zone. For example, stents in the renals, coil embolization in the internal iliac, etc. Document selective cath placements, and other services such as fem-fem bypass, IVUS and enhanced fixation devices (anchors).
• Coders: Capture all interventions outside of the treatment zone. Capture selective cath placements (outside of treatment zone such as renals or internal iliacs.) Capture the vessels where IVUS was performed, but be cautious if it’s a pullback as you should only code one. For anchors, remember you only code once no matter how many are used. Use the fem-fem add-on code with EVAR, not the regular fem-fem bypass codes.

Step 5

• Physicians: Be sure documentation is clear if an iliac branched endoprosthesis (IBE) is used.
• Coders: Ensure you use the add-on code for the IBE when it’s done in conjunction with an EVAR.

Step 6

• Physicians: Clearly document whether a co-surgeon or an assistant was involved.
• Coders: Use the appropriate modifier, whether it be for a co-surgeon (62) or an assistant (80) for physician and (AS) for a physician assistant. Medicare does require co-surgeons to be of different specialties.

Endovascular Repair of Iliac Artery: Iliac Aneurysm Repair can be accomplished with an ilio-iliac tube or an IBE.

Step 1

• Physicians: Be sure you document where the graft is placed and where it terminates. Again, procedures outside of the treatment zone are separately billable and should be well documented.
• Coders: Ensure you code the procedure correctly. Is it an ilio-iliac tube graft or an IBE graft? If the IBE is done in conjunction with an EVAR, you need to choose the add-on code for IBE. If done by itself, choose the primary code. Also, code other procedures outside the treatment zone.

Fenestrated Endovascular Repair of the Visceral and Infrarenal Aorta (FEVAR): Fenestrated aortic repair is based on the extent of the aorta treated; the proximal portion of the graft span from the visceral aorta to one, two, three or four visceral artery origins; and the distal portion of the graft terminates in the infrarenal aorta. These devices do not extend to the iliac arteries.  Or, the distal portion includes the infrarenal aorta into the common iliac artery(ies.) These grafts can be a bifurcated unibody or a modular bifurcated docking system with docking limbs, or an aorto-uni-iliac device. FEVAR procedures follow the same rules as EVAR with the noted exceptions below:

Step 1

• Physicians: Unlike EVAR procedures, the planning you put into the FEVAR graft does have a billable code since these are patient specific. You need to document the planning and sizing for the patient specific graft. A minimum of 90 minutes must be documented to code this. According to CPT, “The planning includes review of high-resolution cross-sectional images (i.e., CT, CTA, MRI) utilization of 3D software for iterative, modeling of the aorta and device in multiplanar views and centerline of flow analysis.” The planning time does not have to be continuous and should be clearly documented in the patient record. This service is reported once the planning is complete and does not include time spent the day before or day of graft implantation.
• Coders: Ensure you are capturing this code and reporting once the planning is complete.

Step 2

• Physicians: It is critical that you document what type of graft you are using and which vessels are involved. You can really sell yourself short if this is not clear. It is vital to note which visceral vessels are involved and if the graft terminates in the aorta or extends to the iliac(s).
• Coders: Ensure you are capturing the correct codes and counting the correct number of visceral vessels involved.

Step 3

• Physicians: Clearly document the use of extensions.
• Coders: With FEVAR, extension rules are a little different than EVAR. Proximal aorta extensions and distal extensions that terminate in the aorta or the common iliac arteries are not separately billable. Extensions that terminate in the internal iliac, external iliac or femorals are billable.

Step 4

• Physicians: Clearly document your cath placements.
• Coders: Only cath placements outside of the aorta, viscerals or renals are coded.

Step 5

• Physicians/Coders: IBEs are not billable with FEVAR grafts.

Endovascular Repair of Descending Thoracic Aorta (TEVAR): TEVARs are grafts that are used in the descending aorta. Access for these procedures is the same as EVAR as well as intervention outside the treatment zone. However, there are some significant differences in these procedures compared to the other endovascular grafts.

Step 1

• Physicians: For the deployment of these grafts, it is imperative that you document whether the graft involved is covering the subclavian. If it is not well documented, then the assumption is that the subclavian was not covered. No one in coding likes to make assumptions.
• Coders: If the physician fails to document status of coverage of the subclavian, do not assume and ask the physician for clarification. This way you can ensure you are capturing the correct code.

Step 2

• Physicians: Document your cath placements clearly.
• Coders: Cath placements are coded no matter where the occur (aorta, carotid etc.). Just ensure you are coding the farthest cath placement and noting selective cath placement over nonselective.

Step 3

• Physicians: For extensions, only the proximal extensions are coded. Keep in mind you must document if those proximal extensions end up covering the subclavian artery.
• Coders: Count each proximal extension. Code the primary code for the first one and then code the add-on code for each additional (up to 2). You also need to pay attention as to whether the subclavian gets covered by the extensions. If it does, you change your primary code to involving coverage of the subclavian and drop the other primary code and all extensions.

Step 4

• Physicians: Remember to document if you perform an open subclavian to carotid artery transposition in conjunction with a TEVAR or if you perform a bypass other than vein carotid-carotid.
• Coders: Use the proper code in the TEVAR section to code these. Do not use regular transposition or bypass codes.

Hopefully, by reading this blog, you learned some important tips for coding endovascular aortic/iliac aneurysm repair procedures. To the physicians, remember for these procedures we need details, details, details. It will help your coder so much when it comes to billing these properly. And for my fellow coders, I also hope you found this information valuable. My advice is to keep your CPT books handy when coding these, especially if you’re new to this area.   Maybe someday you will love these procedures as much as I do! 

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