Lower Extremity Intravascular Lithotripsy

Question:

How do we code for lower extremity Intravascular Lithotripsy (IVL)? Can physicians use HCPCS codes C9764-C9767?

Answer:

There is currently no CPT code to represent physician coding for Intravascular Lithotripsy of the lower extremities. Physicians should not report the facility codes C9764-C9767, instead report these procedures with unlisted vascular CPT code 37799 and compare to an angioplasty code for the same vessel.

*This response is based on the best information available as of 10/31/24.

Collagen Dressings

Question:

Our physicians would like to start using and billing collagen dressings for all post-surgical patients in the global period to aid with healing and have the dressings shipped directly to the patient and used at the patient’s home. What are the coding and billing requirements for reporting the service?

Answer:

Thank you for your inquiry.  Several factors have to be considered.

First, using collagen dressings for routine dressing changes (e.g., all patients, as noted in the inquiry) during the global period would not meet the LCD requirements for payment consideration.

Routine dressing changes during the global period are included in the global surgical package per Medicare and, therefore, would not be separately reimbursable.

Per Medicare Claims Processing Manual, Chapter 12, Section 40.1

o   Miscellaneous Services - Items such as dressing changes; local incisional care; removal of the operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.

Second, suppose the clinic wants to utilize these collagen dressings for routine postoperative patients during the global. In that case, the clinic will need to either absorb the cost and provide it to the patient or obtain an ABN or waiver from the patient advising them it is a non-covered service and give them the option if this is an item they would like to pay for out of pocket.  Depending on medical necessity, the dressings may or may not be covered under a home health benefit.

Medicare has an LCD—Surgical Dressings (L33831), with specific medical necessity requirements for coverage and payment. As with all reported services, medical necessity and the required reporting criteria must be documented.

Per Medicare LCD L33831:

Collagen Dressing or Wound Filler (A6010, A6011, A6021 – A6024)

A collagen-based dressing or wound filler is covered for full-thickness wounds (e.g., stage 3 or 4 ulcers), wounds with light to moderate exudate or wounds that have stalled or not progressed toward a healing goal.  They can stay in place for up to 7 days.  Collagen-based dressings are not covered for wounds with heavy exudate, third-degree burns, or when active vasculitis is present.

To justify payment for DMEPOS items, suppliers must meet the following requirements:

• Standard Written Order Criteria (SWO)

• Medical Record Information (including continued need/use if applicable)

• Correct Coding

• Proof of Delivery

Medicare reimburses surgical dressings under the Surgical Dressings Benefit. This benefit only covers primary and secondary surgical dressings used on the skin of specified wound types.

Refer to the related Policy Article NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES for information about these statutory requirements.

LCD L33831 (Surgical Dressings) and Coverage Policy Article A54563 for complete details for reporting surgical dressings. 

https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33831

As with all reported services, medical necessity and the required reporting criteria must be documented. If all Medicare LCD requirements are not met, an ABN would need to be obtained. Check your private payor policies for coverage. KZA does not recommend billing the patient for Collagen dressings for routine wounds if medical necessity is not met (e.g., all postoperative patients).

*This response is based on the best information available as of 10/17/24.

Ultrasound Guidance for Vascular Access

Question:

What are the requirements to code 76937 for ultrasound guidance for vascular access? 

Answer:

CPT code 76937 requires documentation of the following: ultrasound evaluation of potential access sites, localization and documentation of vessel patency, and the permanent recording and report must be noted and stored. ​

*This response is based on the best information available as of 10/03/24.

Lower extremity revascularization

Question:

When coding lower extremity re-vascularization procedures, can the tibial-peroneal trunk, posterior tibial and anterior tibial arteries all be coded separately? 

Answer:

The tibial peroneal trunk (TPT) splits into the peroneal and posterior tibial (PT) arteries. The anterior tibial artery branches off the popliteal artery above the tibial peroneal trunk.  Therefore, when coding, the anterior tibial artery is considered separate from the TPT; however, the PT is considered a continuation of the TPT and not a separately coded vessel. So, if the anterior tibial, the posterior tibial, and the peroneal arteries are all treated, for example, with atherectomy, each may be separately reported.

*This response is based on the best information available as of 9/9/24.

Moderate Sedation

Question:

Can our vascular surgeon bill for moderate sedation if an RN was present to observe and monitor the patient?

Answer:

Yes; an RN has the knowledge and experience to observe and monitor the patients vital signs, including BP, oxygen levels, heart rate and level of consciousness under the direct supervision of the physician.

*This response is based on the best information available as of 7/11/24.

Can we Bill Co-surgeon if Called in to OR by Another Specialty for a Separate Procedure?

Question:

Our vascular surgeon was called into the OR by an orthopedic surgeon who was treating a patient for a traumatic injury of the lower left extremity as the result of an MVA.  While stabilizing an open tib-fib fracture the ortho surgeon identified a transected posterior tibial artery and called the vascular surgeon for an intra-operative consult.  The vascular surgeon quickly repaired the injured artery and then turned the patient back over to the ortho surgeon. Can we bill the vascular surgeon as co-surgeon?

Answer:

No; co-surgery involves both surgeons performing integral portions of the same procedure (CPT code). In this case, the vascular surgeon is the only one repairing the injured vessel so the vascular surgeon would document his/her own op note with the details of the vascular procedure and code accordingly (likely CPT code  35226).

*This response is based on the best information available as of 6/20/24.