LCDs and Vein Procedures: Should We Know About These?

Question:

We have an office-based vein center and have heard that something called LCDs should be followed before a procedure is performed. We’re not sure what these are or if they are important—if so, how do we integrate them into our office processes?

Answer:

An LCD is a Local Coverage Determination. These are medical coverage policies developed by regional Medicare carriers and Medicare Administrative Contractors (MAC) to determine whether there is medical necessity for a vein procedure. Every MAC and every private payor have published detailed criteria that must be met before veins can be considered symptomatic enough to justify interventions such as endovenous ablation. These criteria typically include conservative therapy requirements, vein size, number of ultrasounds performed, details of the ultrasounds, CEAP classification, and much more. If these criteria are not followed, payors can demand refunds upon case review. This can occur months or even years after the intervention is performed, even if it was pre-certified. We have seen significant refund demands from practices where policies were not followed, often because the practices were unaware that policies existed or were unsure of how to integrate them into daily practice.

Whether you are a “vein only” center or have vein procedure as part of a larger patient population, you cannot afford to ignore these payor policies.

To learn more about these coverage policies and how to integrate them as part of your EM, ultrasound, and procedure documentation, contact us to set up a telephone consultation.

Intraoperative ICG Dye Angiography

Question:

Can we bill the 92242 for the indocyanine green injection intraoperatively, for example to assess perfusion after a procedure? Can we bill for the injection using 15860?

Answer:

No, this service is included in primary surgery and not separately reported.

Wound Vac Billing

Question:

I’m a general surgeon. Some of my team are reporting the negative pressure wound therapy codes 97605 and 97606 when applying wound vacs after closing at the completion of their surgical cases. As a result, I am told by my coders that billing for these wound vacs is not appropriate, since there is a Medicare NCCI edit that bundles this with more comprehensive procedures at the same anatomic area.
The physicians and coders disagree about how to handle these edits. Some of the physicians believe the wound vacs are billable because they are applied to the skin which constitutes a different body system. The coders think the wound vacs are dressings which are included in the global surgical fee and would not billable. After multiple discussions with the physicians and coders, we are unable to provide a definitive answer. Could I please ask you for your advice regarding this issue? What is the right answer?

Answer:

The AMA published clarification on wound vac billing in the October 2021 CPT Assistant. Negative pressure wound therapy (97605-97606) is considered billable for both open and closed wounds. However, that does not mean that payors will reimburse separately for the service, so use caution and track results.

*This response is based on the best information available as of 04/27/22

Catheterization Codes in Vascular Coding

Question:

Are there any vascular CPT codes that still allow separate reporting of selective and non-selective catheterization codes?

Answer:

Yes, the following procedures still allow separate reporting of catheterization codes

• Non- lower extremely, stenting, angioplasty, for example subclavian or renal arteries
• Peripheral embolization, for example hypogastric artery embolization during EVAR or uterine fibroid embolization
• Thrombolysis and thrombectomy
• Diagnostic angiograms and venograms (with the exception of cervical/cerebral and renal angiograms)
• IVUS
• TEVAR

Renal Angiogram Coding

Question:

Is catheterization separately reported with renal angiograms?

Answer:

No. The renal angiogram codes, see table below, include all catheterization. The codes are selected by order of catheterization and as unilateral or bilateral. Also, remember that a flush aortogram is included in the renal angiogram codes and not separately reported.

CPT Code	Description
36251	Selective catheter placement (first-order), main renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; unilateral
36252	bilateral
36253	Supraselective catheter placement (one or more second order or higher renal artery branches) renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture, catheterization, fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; unilateral Do not report 36253 in conjunction with 36251 when performed for the same kidney.
36254	bilateral

Pelvic Angiograms

Question:

Is angiogram of the iliac arteries reported with the pelvic angiogram code, 75736?

Answer:

No, code 75736,Angiography, pelvis, selective or supraselectiveis only reported with selective or supraselective catheterization of the internal iliac arteries (hypogastric arteries) and interpretation of pelvic vasculature. For non-selective angiography of the common or external iliac arteries, use 75710 (unilateral) or 75716 (bilateral).