E/M Coding for Emergency Surgery

Question:

Under the revised 2023 EM guidelines what E/M code would be supported for seeing a patient in the the ED for a ruptured abdominal aorta aneurysm (AAA) and taking them emergently to surgery for repair?

Answer:

This scenario would support , 99223, the highest level of Initial hospital care. Based on:

• High Problem-Acute or chronic illness or injury that poses a threat to life or bodily function and,
• High Risk- Emergency surgery

Remember, only 2 of the 3 medical decision-making elements are needed to support a level of E/M.

Coding for TCAR

Question:

How is the TCAR procedure reported?

Answer:

Transcarotid Artery Revascularization (TCAR) is a minimally invasive procedure that can clear blockages and open a narrowed cervical carotid artery. The surgeon makes an incision over the common carotid artery to perform the repair. During the TCAR procedure, the surgical team reverses blood flow in the area of the blockage.

TCAR is reported with the same code as a carotid stent, 37215,Transcatheter placement of intravascular stent(s), cervical carotid artery, open or percutaneous, including angioplasty, when performed, and radiological supervision and interpretation; with distal embolic protection.

Medicare High Risk Criteria in Carotid Stenting

Question:

What does Medicare consider high risk to support a stent instead of a carotid endarterectomy (CEA)?

Answer:

Patients at high risk for CEA are defined as having significant comorbidities and/or anatomic risk factors (i.e., recurrent stenosis and/or previous radical neck dissection) and would be poor candidates for CEA in the opinion of a surgeon. Significant comorbid conditions include but are not limited to:

• congestive heart failure (CHF) class III/IV;
• left ventricular ejection fraction (LVEF) < 30%;
• unstable angina.
• contralateral carotid occlusion;
• recent myocardial infarction (MI);
• previous CEA with recurrent stenosis ;
• prior radiation treatment to the neck; and
• other conditions that were used to determine patients at high risk for CEA in the prior carotid artery stenting trials and studies, such as ARCHER, CABERNET, SAPPHIRE, BEACH, and MAVERIC

Billing FEVAR with a Physician-Modified Endovascular Graft ( PMEG)

Question:

We use a Physician-Modified Endovascular Graft (PMEG) for our FEVAR procedures. Do we have to bill this with an unlisted code?

Answer:

No, use of a PMEG does not require billing as an unlisted code. Use the existing FEVAR codes based on endograft coverage and number of fenestrations.

Billing Diagnostic Angiograms with Lower Extremity Interventions

Question:

Are diagnostic angiogram billable with a lower extremity intervention, such as an atherectomy or stent? I’ve been told they are bundled.

Answer:

That is a common misunderstanding. Diagnostic angiograms are separately billable during a lower extremity intervention such as an atherectomy or stent intervention if no prior adequate diagnostic angiogram is available to the physician. For example,

• no previous angiogram is available,
• the prior angiogram is not adequate to diagnose the disease or
• the patient’s condition changed either since the last angiogram or during the procedure.

Document if any of these situations exists and code the diagnostic angiogram(s) with a 59 modifier (or XU) to indicate that there was no adequate diagnostic angiogram available. And remember Medicare considers a CTA to be equivalent to a catheter-based angiogram. So if a Medicare patient had a CTA that met the physician’s diagnostic purposes, a diagnostic angiogram would not be billable in addition to an intervention.

Documenting Assistant Surgeon

Question:

When acting as an assistant surgeon, should I dictate a separate operative note?

Answer:

No. In a scenario with a primary and assistant surgeon, only the primary surgical dictates the operative note. Importantly, in that note, the specific role of the assistant must be documented. This should be more specific then, Dr. Jones assisted in a complex surgery. The specific activities performed must be documented. For example, Dr. Jones assisted with the exposure, vessel clamping , anastomoses of the inflow and outflow vessels.