ZHealth Penumbra Webinar Jan 28 2025

Overview

Subject: Coding for Percutaneous Thrombectomy Procedures in Cardiology, Interventional Radiology (IR), and Vascular LabsPresented by: David Zielske, MD, with support from Penumbra.

Aim: To comprehensively discuss the following aspects of coding related to percutaneous thrombectomy procedures:

• Catheter placements: This includes detailed discussions on venous, pulmonary, and arterial placements relevant to various medical situations.

• Procedural CPT codes: An in-depth examination of the CPT codes associated with thrombectomy, thrombolysis, and revascularization procedures to ensure clarity in billing and coding.

• Specific codes: Focused review on codes applicable specifically for Deep Vein Thrombosis (DVT) and Venous Thromboembolism (VTE), highlighting the significance of accurate coding for these conditions.

• ICD 10-PCS codes: Review of the codes used for Computer-Assisted Vacuum Thrombectomy, emphasizing their importance in correctly documenting procedures.

• Thrombectomy for acute arterial ischemia: Exploring the coding implications and procedural details involved in acute arterial ischemia thrombectomy.

Catheter Placement Coding Rules

• Understanding vascular families: These categories help in the accurate coding and classification of vascular systems involved in the procedures, focusing on vessels branching off the aorta or arising from the access site.

• Coding Guidelines consist of crucial principles for accurate reporting:

  • Code based on the specific location of the catheter's tip to ensure precision.

  • When coding for catheter placement in the aorta, code 36200 should be prioritized over 36140, which is used for non-selective placements.

  • Ensure that selective codes are reported before non-selective codes when applicable, as this affects billing.

  • Each vascular system (arterial, venous, portal, pulmonary) must be coded separately to maintain clarity and avoid inaccuracies.

  • Modifiers are essential for distinguishing between different vessels and access sites when coding procedures.

Non-Selective Catheter Placement Codes

Common Codes:

• 36005: Injection for extremity venography.

• 36010: Catheter placement into the vena cava.

• 36013: Placement into the main pulmonary artery.

• 36140: Placement into extremity artery.

• 36200: Placement into the aorta.

• 36481: Placement into the portal vein.

• 36901: Placement with imaging of arteriovenous dialysis shunt/fistula.

Selective Catheter Placement Codes

Above the Diaphragm Codes:

• 36215: First order selective catheterization.

• 36216: Second order selective catheterization.

• 36217: Third order or higher selective catheterization.

• 36218: Additional second order or higher selective catheterization.

Below the Diaphragm Codes:

• 36245: First order selective catheterization.

• 36246: Second order selective catheterization.

• 36247: Third order or higher selective catheterization.

• 36248: Additional second order or higher selective catheterization.

Selective Venous Catheter Placement Codes

Venous System Codes:

• 36011: First order selective catheterization.

• 36012: Second order or higher selective catheterization.

Pulmonary Artery Catheter Placement Codes

Codes (Radiology only):

• 36013: Right heart or main pulmonary artery.

• 36014: Left or right pulmonary artery.

• 36015: Segmental or subsegmental artery (additional branches).

Imaging Codes:

• 93568: Right heart/pulmonary artery imaging.

• 93569: Left or right selective imaging.

• 93573: Left and right selective imaging including branches.

Thrombolysis Non-Coronary and Non-Dialysis Circuit Codes

Therapy Codes:

• 37211: Catheter directed intra-arterial thrombolysis (initial day).

• 37212: Catheter directed intravenous thrombolysis (initial day).

• 37213: Each additional day of thrombolysis.

• 37214: Final day of therapy (includes closure).

Important Note: It is critical not to report the final day and the initial/additional day of therapy concurrently on the same day, as it may lead to billing inaccuracies.

Thrombectomy Devices

Types of Devices:

• Fogarty Catheter: This device is primarily used to aspirate clots, although it might necessitate additional methods for efficient removal of all clots.

• Other various thrombectomy devices include:

  • FlowTriever

  • Solitaire Stent Retriever

  • AngioVac

  • Angiojet

  • Penumbra products

Procedural Codes for Percutaneous Thrombectomy

Arterial Codes:

• 37184: Primary mechanical thrombectomy.

• +37185: Additional vessels within the same vascular family.

• 37187: Initial day of venous thrombectomy.

• 37188: Repeat treatment on a subsequent day.

Cardiac and Dialysis Circuit Codes:

• +92973: Mechanical coronary artery thrombectomy.

• 61645: Endovascular revascularization for cerebral vessels.

Case Examples

• Case 1 - IVUS with Stenosis, No Thrombus:

  • Access via left popliteal vein.

  • Catheter effects on Inferior Vena Cava (IVC).

  • Successful stent placement with documented measurements and imaging support.

• Case 2 - IVUS with Thrombus, No Stenosis:

  • Access via ultrasound guidance resulted in effective thrombus removal.

  • Utilization of Lightning Flash catheter with Computer Assisted Vacuum Thrombectomy (CAVT) enabling successful aspiration and restoration of flow.

• Case 3 - IVUS with Thrombus and Stenosis:

  • Severe DVT treated with multiple stents and thrombectomy.

  • Continuous monitoring and follow-up required due to complexity of case.

Risks and Awareness

Statistics:

• Approximately 900,000 individuals experience VTE annually, showcasing the urgent need for effective management due to the significant mortality rates associated with pulmonary embolism (PE).

Risks with Non-Standard Care:

• Delays in treatment and low rates of intervention among PE patients can lead to adverse outcomes and increased healthcare costs, emphasizing the necessity for timely intervention and diligent follow-up care.

Conclusion

Need for Awareness:

• Emphasis on timely intervention and accurate coding is crucial to improving patient outcomes and reducing costs in VTE management.

• Final Note: It is essential to diligently refer to complete product indications and regulatory codifications throughout all discussions on these intricate medical procedures to ensure compliance and accuracy.