• New Endovasular Revascularization Codes For 2011
• Durable Medical Equipment (DME) Competitive Bidding

• October 2010 CPT Assistant

• 2011 HCPCS annual update

• Payment policy for the technical component of pathology services provided to hospital inpatients and outpatients
• HCPCS modifier AZ for the Electronic Health Record incentive program

New Endovasular Revascularization Codes For 2011

   By Melody W. Mulaik, MSHS, RCC, PCS, FCS, CPC, CPC-H

For 2011, the familiar codes for lower extremity stent placement, angioplasty, and atherectomy have been replaced by a new series of endovascular revascularization codes. This article discusses the coding guidelines that were available for these new codes at the time this issue went to press.

The new revascularization codes will be used for: Balloon angioplasty (including cryoplasty or use of cutting balloons), Atherectomy (including rotational, directional, and laser atherectomy devices) and Stent placement (including bare metal stents and drug-eluting stents). One of the big changes for 2011 is that only one revascularization code is reported for each vessel that is treated. The coder will select the procedure code that represents the most intensive service that the physician performed.

Components of Revascularization

The revascularization codes include the following services, which should not be coded separately:

• Vascular access (percutaneous puncture or open exposure)
• Selective catheterization of the vessel
• Crossing the lesion
• Imaging guidance (radiological supervision and interpretation) for the intervention(s)
• Use of embolic protection (if used)
• Closure of the arteriotomy by any method
• Completion angiograms to check the results of the intervention(s)
• Use of moderate sedation

The revascularization codes do not include interventions other than angioplasty, atherectomy, and stent placement. For example, you can code separately for mechanical thrombectomy or thrombolytic infusion.

Diagnostic Angiograms

The revascularization codes do not include diagnostic angiograms that meet the CPT® criteria for separate reporting. You can find these criteria in the CPT manual just prior to the listing for code 75600.

For example, a patient is brought in for angiograms and possible intervention due to ultrasound evidence of stenosis of the right superficial femoral artery. The interventional radiologist performs an abdominal aortogram and bilateral lower extremity run-off (75625, 75716). This confirms the superficial femoral artery lesion, so the physician performs angioplasty and stent placement.

In this situation you can code the angiogram supervision and interpretation codes (75625, 75716), but not the catheter placement for the angiograms. The catheter placement for the diagnostic portion of the encounter is included in the revascularization code unless the angiograms are performed via a different access than the intervention.

Vascular Territories

The code selection for revascularization procedures depends on the anatomic area that was treated. CPT® 2011 recognizes three “vascular territories”: The iliac, femoral/popliteal, and tibial/peroneal. Each territory has its own codes and coding guidelines.

When the physician performs a single intervention to treat a lesion that extends from one vessel to another, or from one vascular territory into another, only one revascularization code should be assigned. For example, if the physician places a single stent to treat an area of stenosis at the junction of the common iliac and external iliac, you should code only one iliac stent placement even though the stent extends into two vessels.

When a lesion is located at a bifurcation and the physician has to perform interventions in two separate branches, you can assign two separate revascularization codes.

Iliac Territory

The iliac revascularization codes (37220-37223) are used to report iliac stent placement and angioplasty. These codes do not include atherectomy. New category III codes exist for reporting certain atherectomy procedures.

The iliac vascular territory consists of three vessels on each side—the common iliac, internal iliac, and external iliac. There are codes for revascularization of the initial vessel, as well as add-on codes for treatment of additional vessels on the same side.

Intervention	Initial	Vessel Each Additional Vessel (Max 2)
Angioplasty only	37220	+37222
Stent placement (with or without angioplasty)	37221	+37223

You should assign only one initial vessel code per side. If the physician placed a stent in one of the iliac vessels, assign the initial vessel code for stent placement (37221). This code includes any angioplasty that the physician performed in that vessel. On the other hand, if the physician performed angioplasty but did not place a stent on that side, assign the initial vessel code for angioplasty (37220).

Use the add-on codes to report treatment of additional vessels on the same side. Because CPT recognizes only three iliac vessels per side, you can report no more than three revascularization codes per side (one initial vessel code and two additional vessel codes).

Femoral/Popliteal Territory

The revascularization codes for the femoral/popliteal territory include angioplasty, atherectomy, and stent placement. Only one code is assigned per vessel. The code for angioplasty (37224) is assigned only if there is no stent placement or atherectomy. Angioplasty is included in all of the other intervention codes.

The left and right sides are coded separately. However, all of the vessels in the femoral/popliteal territory on a single side are considered a single vessel. This includes the common femoral artery, superficial femoral artery (SFA), deep femoral artery (profunda femoris), and popliteal artery. Because the entire territory is considered to be a single vessel, only one revascularization code can be assigned per side.

Intervention	Code
Angioplasty only	37224
Atherectomy (with or without angioplasty)	37225
Stent placement (with or without angioplasty)	37226
Stent placement and atherectomy (with or without angioplasty)	37227

Tibial/Peroneal Territory

The tibial/peroneal territory consists of three vessels on each side: the anterior tibial, the posterior tibial, and the peroneal. The tibioperoneal trunk is not counted as a separate vessel. For example, if the physician performs interventions in the tibioperoneal trunk and in the anterior tibial, you should code the procedure as though the physician performed both interventions in a single vessel.

Assign only one “initial vessel” code per side. Use the add-on codes to report interventions in additional vessels on the same side. Since there are only three recognized vessels on each side, a maximum of two add-on codes can be reported for each side.

Intervention	Initial Vessel	Each Additional Vessel (Max 2)
Angioplasty only	37228	+37232
Atherectomy (with or without angioplasty)	37229	+37233
Stent placement (with or without angioplasty)	37230	+37234
Stent placement and atherectomy (with or without angioplasty)	37231	+37235

Durable Medical Equipment (DME) Competitive Bidding

   By Patty Telgener, RN, MBA

The DMEPOS Competitive Bidding Program was mandated by Congress through the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). The statute requires that Medicare replace the current fee schedule payment methodology for selected Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) items with a competitive bidding process. CMS states the intent is to improve the effectiveness of the Medicare methodology for setting DMEPOS payment amounts, which will reduce beneficiary out-of-pocket expenses and save the Medicare program money while ensuring beneficiary access to quality items and services.

Round 1 Rebid will include the following product categories:

• Oxygen Supplies and Equipment
• Standard Power Wheelchairs, Scooters, and Related Accessories
• Complex Rehabilitative Power Wheelchairs and Related Accessories (Group 2)
• Mail-Order Replacement Diabetic Supplies
• Enteral Nutrients, Equipment and Supplies
• CPAP, RADs, and Related Supplies and Accessories
• Hospital Beds and Related Accessories
• Walkers and Related Accessories
• Support Surfaces (Group 2 mattresses and overlays) in Miami

Metropolitan Statistical Areas (MSAs) are areas that include major cities and the suburban areas surrounding them. Competitive Bidding Areas (CBAs) are defined by specific zip codes. Round 1 Rebid will occur in the following MSAs:

• Cincinnati – Middletown (Ohio, Kentucky and Indiana)
• Cleveland – Elyria – Mentor (Ohio)
• Charlotte – Gastonia – Concord (North Carolina and South Carolina)
• Dallas – Fort Worth – Arlington (Texas)
• Kansas City (Missouri and Kansas)
• Miami – Fort Lauderdale – Pompano Beach (Florida)
• Orlando (Florida)
• Pittsburgh (Pennsylvania)
• Riverside – San Bernardino – Ontario (California)

Under the program, companies/suppliers wanting to participate in competitive bidding for a particular Competitive Bidding Area (CBA) needed to submit a bid for the selected products as listed above. CMS outlined how bids were to be submitted electronically through a web-based application process and what additional documents were required for consideration. Bids are then evaluated based on the supplier’s eligibility, financial stability of the supplier and the bid price. CMS reports that contracts will be awarded to the Medicare suppliers who offer the best price and meet applicable quality and financial standards. Contract suppliers must agree to accept assignment on all claims for bid items and will be paid the bid price amount. The amount is derived from the median of all winning bids for an item.

The original date to release the names of the Round 1 rebid contract winners was September 2010. However, as of October 2010, CMS has not yet announced the companies that were chosen for Round 1 and no timeline to do so has been provided. Even still, it is still expected that CMS will move forward with implementation of the program January 1, 2011 without a delay.

CMS has published the single payment amounts for the products that will be included in Round 1 Rebid. The single payment amount will become the Medicare allowed payment amount for each competitively bid item for beneficiaries who reside in the CBAs. Consistent with current CMS practice, Medicare will pay 80 percent of the allowed amount and beneficiaries will be responsible for the remaining 20 percent.

Once competitive bidding is implemented in the assigned CBAs, companies that are not contract suppliers will not receive Medicare payment for competitively bid items. The only exception is if they choose to continue in the Medicare program as grandfathered suppliers for existing customers if they supply certain rented items or oxygen or oxygen equipment to Medicare beneficiaries. Suppliers that are not contract suppliers for this round of the DMEPOS competitive bidding program may bid in Round 2 in 2011 or in future rounds.

The current DMEPOS suppliers and Medicare fee schedule payment amounts will continue for beneficiaries who do not reside in the Round 1 Rebid CBAs and for items that are not subject to the Medicare DMEPOS Competitive Bidding Program.

Additional information, including the payment amounts can be found on the Competitive Bidding Implementation Contractor (CBIC) Web site at: http://www.dmecompetitivebid.com.

AMA Coding Guidance: