Hello, and welcome to the MedAxiom Academy. In this session, we will be covering Venus Basic Diagnostic and Interventional CPT Coding. My name is Jolene Bruder, and I'm a Revenue Cycle Solutions Consultant for MedAxiom, an ACC company. Before we get started, I'd like to go over our disclaimer, and basically it states that this is for informational purposes only and does not constitute legal, reimbursement, coding, business, or other advice. You should always check with your local Medicare carrier and consult with your practice's legal counsel for coding and reimbursement advice. My next disclaimer is the CPT, all of the codes listed in this webcast, came from the CPT coding book. All right, so let's get started. So we're going to talk about some Venus conditions first. So if you see here, we have normal blood flow, and as you recall, the veins take the blood back to the heart. So in this picture, it shows as a calf muscle relaxes, the blood flows through, and then as it contracts, it pushes the blood back. So that's normal how that's supposed to happen. However, you can develop varicose veins. In some of these pictures, it shows, like this one, they have spider veins. The second one, the veins are getting a little worse, and you can see little nodes popping up here. In the third picture, not only do we have the veins popping out, but the patient also has edema of the lower leg. And then finally, on the fourth picture, if that gets bad enough, you can develop ulcers, eczema, things like that. Now normally, varicose veins, for cosmetic reasons, is not going to be payable by Medicare or most of your carriers. When you get to areas like this, where you have the ulcers, this is no longer just a cosmetic problem. Now you have medical issues. So again, we have some chronic venous insufficiency here, and as you can see on this picture, you have, again, that normal blood flow. But then here, we've got issues. The valves are not closing properly, so the blood's just kind of starting to accumulate in these veins. And some of these can get very, very severe. So it's not something that you just want to let go if you do develop these. So how do we treat varicose veins? Years ago, they used to do what was called vein stripping. And although that's still available, it's usually not done this day and age, because they found better ways of treating these. And one of the ways is what's called a STAB plebectomy. Now what happens here is they'll puncture through the skin and grab the vein with this hook. It kind of reminds me of those of you that have ever done latch hook. It's kind of the same type of device. And what they'll do is they'll pull that vein up, and then they cut it out. So what they have for the codes, they're split up between one and 10 incisions, and then more than 20. If you happen to have less than 10, then we have to use what's called an unlisted code, because there is no code for less than 10. And sometimes you will see that, where they may only do four or five. So in that case, you do have to use that unlisted code. Another way to treat veins is through sclerotherapy. Now note the 36468, which is that injection for spider veins, is not covered by Medicare. In 36470, they actually do injection of a single incompetent vein. And then 36471 is multiple incompetent veins with the same leg. So what they do is they inject this drug, and they put it into that vein, and it causes that vein to collapse. Now if you didn't know this, your body will recreate veins. So if you're wondering, well, if they're taking all these out as incompetent, how's the blood getting back to the body? Well, the body will reproduce veins. So sclerotherapy continued. We have code 36465, and that's where they inject a non-compounded foam, and they use ultrasound guidance, and they will inject that agent into those veins. For 36466, you have multiple veins, same leg. So always keep in mind, most of these procedures are going to be per leg, per extremity. So another way that's more popular is vein ablation itself. So in this, they do, in this particular code, the 36473, they're going to use a mechanical chemical ablation. So they'll inject a chemical into the, they'll run this wire through here, and they inject a chemical, and that will render the vein incompetent. Now they can treat multiple veins in the same leg, and you can build separately, but it does have to have a separate access site. So if they treat all these veins through the same access site, you cannot charge that additional code. Another method is to use radiofrequency ablation, or you'll hear it called RFA. Again, same rule. To treat multiple veins in the same leg, you have to have separate access sites. And then this shows, they run a catheter through here, and then the vein heats and collapses, and then they withdraw that vein. That's probably one of the most popular ways of doing this now is the radiofrequency. They can also use a laser ablation, or you'll see it called ELA. And again, same principles where the first vein treated is coded with the 36478, and then any subsequent in that same leg has to be done through a separate access. And that is with all the ablation, the rule. And finally, this method is by delivering a chemical adhesive. So on this one, they thread that catheter through the vein, and then they use an application that allows glue to be injected. Now this wouldn't be Elmer's glue, but it is a glue, and it actually will harden and collapse that vein. And then the procedure is actually repeated at five centimeter intervals to seal that vein. All right, so now we're going to talk about diagnostic venous procedures, and we're going to start with the vena cava. Now the vena cava is a complement to the aorta. So the aorta supplies the body with blood, and the vena cava is what brings the blood back up into the lungs and the heart. So most of your arteries will have a complementary vein with them, your major arteries. So this shows, here we have the iliac veins. Now remember again, veins bring the blood back. So remember that veins are in blue because the blood is not oxygenated like it is coming out of the aorta. That's why your arteries are red and your veins are blue. So basically what we have here is you have the common iliac, and then this is the inferior vena cava. And then as you get up higher towards the heart, that's called the superior vena cava. So the codes that we can do for this, we have 36010, which is the introduction of that catheter into the superior or the inferior. So once they place that catheter in here, just like on the aorta, only this time we're in the vena cava. There are codes for this, you have 75825, it's for the inferior portion. And then you have 75827, which is the superior portion. Now in order to charge for that superior, there has to be full and complete diagnostic study. So it's not enough just to come up here a little bit and say, yes, I imaged the superior. They have to do the whole gamut in order to code for that. So if you recall, when we talked about the artery section and the aorta, when you did your renal arteries in the aorta, you were not allowed to bill for the aortagram. That's different with the vena cava, this was a different rule. So you can bill the 75825 and the 75827 along with your venous codes. So the 75831 is venography of the renal, and that's unilateral, and the 75833 is for bilateral. So always keep in mind that this is separately billable when you have the vena cava with your renals, unlike the arteries. So what are actually bundled with the 75825 and the 75827? Well we do not report that when we do an inferior vena cava filter. We don't report it with dialysis circuit codes. And the dialysis circuit is where they're establishing an arterial venous fistula. And that's what they create that circuit so a patient can receive dialysis. You also would not report them when the vena cava is being done for sampling, for venous sampling procedure. All right, next we're going to talk about the extremities. So next we're going to talk about the venous catheter codes. As you can see, there's only three cath placements versus the arteries where we have several different catheter codes. So for the venous side, you have selective cath placement that's outside of the vena cava. You can have the non-selective, which is where they puncture the vein and then do an injection. And then that code is billed unilaterally. So if they have a puncture in the right leg and the left leg and do venography, you can bill that with a 50 modifier. Once we get into order cath, your selective cath, so you would have to cross the vena cava. So if you're in the left leg and they puncture, say the femoral vein, and they move that catheter up across the vena cava and then go down the other leg. So now we'd be on the right side if we started on the left. You can have selective cath placements with 36011, which is first order. And then second or higher cath placement is 36012. Now these are the same whether you're in the arms or the legs. So for the upper extremity, selective cath placement is second order from the subclavian vein from a transfemoral approach. If they do an ipsilateral approach, the cath placement is considered non-selective, which would be your 36005 code. For the lower extremity from a transfemoral approach, once you cross the vena cava, the common iliac on the contralateral side is first order. Then all the veins from the external iliac down to the foot are second order. So you have to cross that vena cava in order for those to be selective in the legs just like you would in the arteries. So we have our extremity imaging, which we have venography unilateral, and that's a 75820. That also includes those pelvic veins. In 75822, we have bilateral venography, and again, that also includes the pelvic veins. So what happens when we deal with the upper and lower extremity venography studies that are on the same day at the same session? Well, there's a couple of things. If you're doing unilateral on both upper and lower, you would report the 75820 venography, which is for one side, twice. So what that means is if they do, let's say they do the right arm and the right leg, you would still report the 75820 twice. Or even if they did the left arm and the right leg, it doesn't matter. It's just if they do one arm and one leg, you're going to report the single extremity twice. If they happen to do bilateral on both arms and legs, you would report the 75822 twice. You will more than likely need either a 59 modifier or an XS modifier to code that. So that lets Medicare know that, hey, we know what we're doing. We did not accidentally report this code twice. So for diagnostic venous visceral procedures, we're going to talk about some things here. So again, all of these have arteries that match them. So like we're talking about the mesenteric vein, the superior mesenteric vein. So remember, there's arteries that go along with that. And these are all in your abdominal area. But they are considered the visceral venous system. So for the visceral venous, you have to have selected calf placement and it needs to be in a vein that supplies a visceral organ. So it would have to supply one of the organs in the visceral area, which would be like the liver, the spleen, things like that. That's all in your visceral area. The access also must be from a peripheral access. So that can come from the femoral vein. The brachial vein or the jugular vein. So calf placement for your visceral, you have first order, which is the 36011. Now some of these codes, you're going to want to make notes in your book or keep the slide because there's different rules depending on where you're at. So for unilateral and bilateral selective renal, you would use the 50 modifier on the 36011. If they do the right testicular venography, that would not include the renal. There's also right ovarian venography for the females. And that is with or without the renal. And then you have right adrenal venography or hepatic venography with or without hemodynamics. So this is all for your first order calf placement in the visceral. Now as you get further into those veins, you can also hit second order. So for 36012, your calf placement would be for additional renal venography after that basic venography on the renal. So you'd have your, you know, your first, when you first hit the renals and then these would be veins coming off of those. Now for this slide, left testicular venography without the renal is actually second order. And then for the females, left ovarian venography is with or without renal. And then again, you have left adrenal venography and then hepatic venography wedged with or without hemodynamics. I will say for cardiology, you're probably not going to get into too much of this. But if you, if you have a physician that does, or if you have vascular surgeons, they will get into this. So you want to be sure that you keep all this straight on what your calf placements are. So for our imaging for the viscerals, 75831 is used for either a renal or ovarian venography or left gonadal venography, unilateral. For 75833, this would all be bilateral. You only use these once per session. So if renal and ovarian are done, you would only code the venography once. Hepatic venography is used for testicular, either unilateral or bilateral, and then the unilateral code includes the right gonadal vein. So selective iliac venography, if it's not mentioned, you will have to reduce that with a 52 modifier. So they have to talk about selective iliac venography when it comes down to the testicular venography. So keep that in mind. So some more imaging, we have 75840 for adrenal, and then 75842, which is adrenal that is bilateral. 75889 is hepatic venography with hemodynamics, and 75891 is without the hemodynamics. Also, with the arteries, as you know, we have the 75774. For the veins, you can possibly bill 76946, which would be an additional study after the basic exam, but you need to check with your carrier. That is not an automatic code that they will cover. So for venous sampling, we have venous cath for selective organ blood sampling, and this would be coded with the 36500 and then the 75893. So this would be the code for the cath and then the 75893 for the imaging. And then keep in mind that this is coded per organ studied, not per vessel. So again, you would have to, they would have to sample the liver, the spleen, the kidneys, all those types of things would have to be done. It'd be separate organ, not separate vessel. It does have what's called a medically unlikely edit of four, and that means you can only report this four times. So if they did five samplings, you could only report four. So let's talk about some diagnostic venous head and neck procedures. So here we have a picture of the veins going up from the head and neck. You mainly have your jugulars. Those are probably the most popular that would be done. As you get higher up, you have your temporals and your orbitals. Those all are up here in the head. Now again, most of your cardiologists are not going to venture up there. And to be quite honest, most of your vascular surgeons aren't. So for calf placement for head and neck, so this is actually very easy compared to the arteries. We have one calf placement, and this is the 36012. And that is because when you come from a transfemoral approach, so they're coming from the femoral vein all the way up to the head and neck, all of those veins are considered second order or greater. Now, if they do a direct puncture into the jugular and that is used, you have to code that as an unlisted vascular injection. So keep that in mind. But for the most part, it's pretty common to go through the leg and then thread that catheter up through the vena cava. And then wherever they select off of the vena cava in the head and neck, those are all second order calf placements. So what goes along with the venography with these? Well, we have jugular venography, which is a 75860. We have the superior sagittal sinus, or also known as transverse sinus. That's with 75870. If they happen to do epidural venography, it's 75872. Orbital venography is 75880. And again, we have that 76946, which would be your additional venography after that basic exam. But again, you're going to want to check with your carrier. So let's talk about some interventions with Ardenas procedures. So just like the arteries, we have balloons and we have stents. So this would be a balloon placed in the vein. And then here we have a stent. It's probably going to be threaded with a balloon. And then once that balloon is inflated, and that stent pops out, then they'll pull it back. So this, you can see there's disease here. And then this is how we open that up to have better blood flow. So for diagnostic venography, it is separately billable with intervention. And this is the same rule, whether we were talking about the heart or the arteries. And now it's the same with the veins. So there cannot be a prior catheter-based venographic study. If there has been one, then as documented in the medical record, either the patient's condition needs to have changed since the prior study, or there is inadequate visualization of the prior study, or there's a clinical change during the procedure that requires a new evaluation, and that would have to be outside the target area where they are working. So for our interventions in the veins, again, like I said, we have balloons and stents. So we have the 37248, which is angioplasty or balloon. And then this would be for the initial vein, and the 37249 is each additional vein. Now again, you're going to want to check your MUEs on this to see how many times you can actually bill that add-on code. For the stent, we have 37238. And again, that's going to include any angioplasty that's performed, and it's broke out by the initial vein. And then with the 37239, that's each additional vein. Now keep in mind, this is not multiple stents in the same vein. This would be, it doesn't matter how many stents you do in one vein. You only code the 37238. And then with the 37239, it's each additional vein. Same with the angioplasty. So what's actually separately billable with these interventions? Well again, that diagnostic venography, if you have met the requirements, non-selective and or selective cath placement is separately reportable. Now remember, that's different than the arteries and the legs. Because any intervention you do in the arteries and the leg, that cath placement is bundled. That's not the case with the veins. So as similar as veins and arteries are, the rules are not necessarily. So again, you have to keep in mind that you're working on the venous side of the house, not the arterial. If they use IBIS or that intravascular ultrasound, those are coded with 37252 for the initial vein and 37253 for the additional. Also mechanical thrombectomy can be performed and that is coded with 37187 and 37188. If they do ultrasound guidance and you meet the requirements for the 76937, that is also billable. Keep in mind that 76937 does require documentation of vessel patency. It requires real-time visualization of needle entry and it also requires that permanent images are kept on file. If those are not met, you cannot bill those codes. So next we're going to talk about thrombectomy and thrombolysis. As you can see, this is the patient has a clot here and they're treating that clot and I'm going to, we're going to talk about how they do that. So for the mechanical thrombectomy with the veins, we have the 37187. So they thread that catheter through and they can do a pharmacological injection. They can also pull that clot out. That is coded with 37187. Also notice that vein is plural here. So you have the vein or veins. So what that means, that's pertaining to one leg. If two legs are treated, you can use the 50 modifier or some carriers like the LTRT modifier to distinguish between left and right, but some like the 50. So it just depends on what they want to code. Anyway, that is one leg. So it doesn't matter how many veins they do that thrombectomy in, in the same leg, you will only report to 37187 once. 37188 is for repeat treatment on the subsequent day. So this would be the next day. If they have to go in and pull out more clot, then you would code the 37188. So next we're going to talk about what is separately billable with those thrombectomy. Well, again, we have non-selective and or selective cath placement, other interventions such as your balloons or your stents, thrombolytic therapy, which we will talk about in depth here in the next slide. And that those are codes 37212 through 37214. And then again, you can build that diagnostic venography if the requirements are met. So what is transcatheter thrombolytic infusion? Well, in this procedure, what they do is they place the catheter, they infuse thrombolysis, usually it's going to be overnight. But they'll leave that catheter in and let the patient, they have a drip, and it drips that thrombolysis trying to break up that clot. So it doesn't matter what method is done. The supervision and interpretation are included. And this is billed on the initial treatment day. So this will be the first day, the 37212. Now, if they come back and they do more imaging, you're not allowed to bill your extremity venography imaging, because that's included in this 37213. So what they do is come back and look at that and see if it's broke up enough. If it's not, and they continue that thrombolysis, then you would code the 37213. Now, let's say they come back and look at it. Again, you cannot bill that venography separately. But let's say they come back and look and they figure out that, hey, it's worked, we don't need to do this anymore. So they're going to stop the thrombolysis, then you would code the 37214. If they happen to do initial and succession on the same day, you would only code the initial treatment. So some of the additional services that we can bill with the thrombolysis, if it is done bilaterally, you can use modifier 50. Now, keep in mind that does require separate access sites. So if they place that catheter in the vena cava, let's say they're trying to break up clots in both the right and left leg, and they place that cath in the vena cava and allow that thrombolysis to just go down both legs, you cannot bill that as bilateral. That would just be a single code. Now, if they puncture in the left leg, and they put in the thrombolysis catheter there, and then they also puncture the right leg and put in a different thrombolysis catheter, then you could bill both of those. So it would be separate access site, you cannot go through the same site. Cath placements, again, are separately billable. Diagnostic studies, those would be separate diagnostic studies that have nothing to do with the thrombolysis itself. So make note of that, that that is not just your regular vena cava study or your extremity studies, that would have to be something separate. So if they were treating the left leg, and then the patient started complaining about their right leg, and then they went and did a diagnostic study of the right leg, you could bill that one. But in general, if it's any diagnostic study in the leg or arm that's being treated, then you cannot bill for that. Other interventions, such as stents and balloons, are separately billable. That ultrasound, if the requirements are met, is separately billable. And if the physician also performs an E&M that same day, it is separately reportable with the 25 modifier. However, keep in mind, it can't just be to talk about the thrombolysis. There has to be other things going on that makes it a significant and separately identifiable service. So always keep that in mind with E&M. You're probably going to see, you know, some ways, if the patient comes through the ER, and they do an E&M and decide to do the thrombolysis, then that would definitely be a reason to code that with a 25 modifier. But as far as your subsequent days, you better be treating something else in order to bill that E&M code. Right. So for our final section, we're going to talk about intravascular vena cava filters. That's this little guy here that kind of looks like a spider, or some people call it an umbrella. And what this little guy does, it's placed in the inferior vena cava, and it's put there to catch any blood clots before they travel to the heart or lung. So this is something that is necessary, and they will treat people that either have pulmonary emboli, or they'll use it for deep vein thrombosis. And that's to keep that clot from going to the heart, the head, anything like that. So we're going to talk a little more about that filter. So the 37191 is actually the insertion of the vena cava filter. It is an endovascular approach. It does include vascular access, vessel selection, and any of that imaging. Now if they happen to do an open approach, so if they cut open the vein to get that threaded up and placed into the inferior vena cava, you would have to use an unlisted code because this is percutaneous approach only. For the 37192, that is for repositioning of the filter. Now that cannot be done at the same session as insertion. So let's say they insert it, and the patient goes back to their room, and they come out for whatever reason and check and see that it's migrated, or that it's moved, or that it's not where they want it. And they take the patient back to the cath lab or the OR, depending on where they're at, and they reposition that filter. That's fine. But you cannot bill for it at the same session that they're actually inserting it because they're going to move it around several times to get it in the optimum area. So that is not what this is for. This could be same day or subsequent days or three weeks later. It just cannot be the same session. For 37193, this is retrieval of that filter. So again, if they decide that it's not going to work and they're going to retrieve it as the same day or same session as that initial placement, you would not code this. This would be after the fact. Keep in mind the thing about these filters, normally if they're not removed within six months, they will not remove them because what happens when you have a foreign body placed in your body, your body constantly fights it and wants to get rid of it. So vessels and fat and all kinds of things start to grow in and around that filter. So the longer it's in, the harder it would be to take out. So like I said, normally in time frame six months, I've never really seen any removed after that. Sometimes they'll be removed sooner. But the longer it's in there, the more vessels and tissue and body structure attached to it. So they won't take it out after it's been in a long time. Okay, so for some final thoughts, keep in mind that VENUS rules are different than arterial, but some remain the same. One of the things that remains the same is the diagnostic angiography is bundled with the interventions, but it is allowable to be billed if that criteria is met. So it cannot be for road mapping. It has to be a true diagnostic study. Cath placements do not differ above or below the diaphragm when it comes to the VENUS side. And then cath placements are allowed with interventions unlike the arteries. So I want to thank you for joining us for this session. This is our email address if you have any additional questions about this particular presentation, and it will go to myself, Jamie Quimby, and Nicole Knight, and one of us will be happy to answer your questions. Remember that's revenuescyclesolutions at medaxium.com. Thank you so much for attending this presentation.

Venus Basic Diagnostic

Interventional CPT Coding

varicose veins

chronic venous insufficiency

thrombosis

vein stripping

STAB plebectomy

MedAxiom Academy

sclerotherapy