EVAR
CPT Reporting for IBE with Main Aortic Trunk
Question: What CPT® code should be reported for placement of an iliac branched (bifurcated) endograft when EVAR includes both a main trunk and an iliac branched endograft during the same surgical session?
Answer: Code +34717 should be reported: Endovascular repair of iliac artery at the time of aorto-iliac artery endograft placement by deployment of an iliac branched endograft including pre-procedure sizing and device selection, all ipsilateral selective iliac artery catheterization(s), all associated radiological supervision and interpretation, and all endograft extension(s) proximally to the aortic bifurcation and distally in the internal iliac, external iliac, and common femoral artery(ies), and treatment zone angioplasty/stenting, when performed, for rupture or other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation, penetrating ulcer, traumatic disruption), unilateral (List separately in addition to code for primary procedure).
+34717 was new for 2020 and replaced Category III code 0254T. It is reported as an add-on code in addition to the primary procedure code for EVAR (34703, 34704, 34705, 34706). It is reported once per side. If a bilateral procedure is performed, report 34717 twice without appending modifier 50.
CPT Reporting for IBE without Main Aortic Trunk
Question: What CPT® code should be reported for placement of an iliac branch endograft when EVAR includes only the iliac branch endograft during a surgical session?
Answer: Code 34718 should be reported: Endovascular repair of iliac artery, not associated with placement of an aorto-iliac artery endograft at the same session, by deployment of an iliac branched endograft, including pre-procedure sizing and device selection, all ipsilateral selective iliac artery catheterization(s), all associated radiological supervision and interpretation, and all endograft extension(s) proximally to the aortic bifurcation and distally in the internal iliac, external iliac, and common femoral artery(ies), and treatment zone angioplasty/stenting, when performed, for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation, penetrating ulcer), unilateral
34718 was new for 2020 and replaced Category III code 0254T. It is reported as a stand-alone code for placement of an iliac branched endograft. As such, it cannot be reported with 34701, 34702, 34703, 34704, 34705, 34706, 34707, 34708, 34709 or 34717. It can be reported bilaterally by appending modifier 50.
Cuffs
Question: Would code 34709 (Placement of extension prosthesis(es) distal to the common iliac artery(ies) or proximal to the renal artery(ies) for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, penetrating ulcer, including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and treatment zone angioplasty/stenting, when performed, per vessel treated) be appropriate to report when cuffs are placed in conjunction with an EVAR endoprosthesis?
Answer: No. Cuffs are placed in conjunction with an endoprosthesis to ensure the proper seal, typically in the proximal aorta. From a coding perspective, this is not considered an extension prosthesis. Therefore, the appropriate code for the EVAR procedure should be reported and no additional codes are reported for the cuff.
Docking Limbs
Question: Would code 34709 (Placement of extension prosthesis(es) distal to the common iliac artery(ies) or proximal to the renal artery(ies) for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, penetrating ulcer, including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and treatment zone angioplasty/stenting, when performed, per vessel treated) be appropriate to report when docking limbs are placed in conjunction with an EVAR endoprosthesis?
Answer: No. Per CPT® guidelines, the treatment zone is defined as “treatment as the vessel(s) in which an endograft(s), including the main body, docking limb(s), and/or extension(s) is deployed.” Placement of the docking limb(s) is integral to insertion of a modular endoprosthesis and is not reported separately. The specific treatment zones are defined by the primary procedure code (34701-34708, 34717, 34718) in the CPT® guidelines.
Delayed Distal or Proximal Extension(s)
Question: What is the appropriate CPT® code for a delayed placement of a distal or proximal extension for endoleak or endograft migration after an EVAR?
Answer: Codes 34710 (Delayed placement of distal or proximal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, endoleak, or endograft migration, including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and treatment zone angioplasty/stenting, when performed; initial vessel treated) and 34711 (…each additional vessel treated) are used for delayed treatment. Please note: if this procedure is a return to the operating room during the global period of the original EVAR procedure, modifier -78 should be appended to code(s) 34710/34711 to report “an unplanned return to the Operating/Procedure Room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period”.
Hybrid Procedure
Question: What is a HYBRID EVAR procedure and how is it coded?
Answer: Hybrid endovascular abdominal aortic aneurysm repair (EVAR) with standard open surgery for repair of common iliac aneurysms is typically performed on patients who are not candidates for iliac branched endograft (IBE) devices or in situations where the IBE is not available. This procedure combines EVAR with an open unilateral external to internal iliac bypass to help preserve pelvic arterial flow.
From a coding perspective, there will be at least two codes for reporting:
- EVAR – 34701-34708 (based on the vessels treated and type of endograft); and
- Ilioiliac Bypass – 35563 (using vein) or 35663 (other than vein).
Iliac Branched Endograft (IBE)
Question: What is the definition of an iliac branched endograft?
Answer: According to CPT® guidelines, an iliac branched endograft is a multi-piece system consisting of a bifurcated device that is placed in the common iliac artery and then additional extension(s) are placed into both the internal iliac artery and external iliac/common femoral arteries, as needed as well as proximal extension that overlaps with an aorto-iliac endograft, when performed.
IBE for Rupture
Question: What code should be reported for placement of an isolated iliac branch endograft for rupture?
Answer: According to CPT® guidelines, report unlisted procedure code 37799 for this service. Because the code description for 34718 specifically excludes rupture, this code cannot be reported for treatment of rupture:34718 – Endovascular repair of iliac artery, not associated with placement of an aorto-iliac artery endograft at the same session, by deployment of an iliac branched endograft, including pre-procedure sizing and device selection, all ipsilateral selective iliac artery catheterization(s), all associated radiological supervision and interpretation, and all endograft extension(s) proximally to the aortic bifurcation and distally in the internal iliac, external iliac, and common femoral artery(ies), and treatment zone angioplasty/stenting, when performed, for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation, penetrating ulcer), unilateral.
Inpatient Reporting for EVAR with IBE
Question: From an inpatient coding perspective, when a AAA repair is performed with an aortic endoprosthesis and an IBE, how would these procedures be sequenced in order to group to the appropriate MS-DRG?
Answer: While both procedures should be reported,the PCS code for the AAA repair with aortic endoprosthesis (04V03DZ) would be considered the principal procedure in this case. Treatment in the iliac artery(ies) with an IBE (04VC0EZ, 04VC3EZ, 04VC4EZ, 04VD0EZ, 04VD3EZ or 04VD4EZ) would be considered a secondary procedure. The principal procedure groups the surgical MS-DRG with the diagnoses also impacting MS-DRG assignment. Therefore, the AAA repair code would be sequenced first, followed by the IBE.
Stenting of Renal Artery
Question: What code is reported for endograft placement into a renal artery that is being covered by a proximal extension during an endovascular aneurysm repair?
Answer: According to CPT® guidelines, codes 37236 and 37237 are used to report renal artery endograft placement in this scenario:
37236 – Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; initial artery
37237 – Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; each additional artery (List separately in addition to code for primary procedure)
Ultrasound Guidance with Percutaneous Access
Question: Can ultrasound guidance (code +76937) be reported in conjunction with code +34713 (Percutaneous access and closure of femoral artery for delivery of endograft through a large sheath (12 French or larger), including ultrasound guidance, when performed, unilateral (List separately in addition to code for primary procedure)?
Answer: According to CPT® guidelines, code +76937 cannot be reported with add-on code +34713 for the same percutaneous access. NCCI edits follow suit, as 76937 is bundled into 34713 and a modifier is not allowed to bypass the edit.
