Current IR Audit – Renal and Peripheral Angiography

If there’s one thing we can count on to remain consistent in the world of IR coding, it’s that this time of year is full of change – potentially with a hint of chaos, and sometimes surprises.

One recent surprise that could leave your facility vulnerable is the approval of a recovery audit from the Centers for Medicare and Medicaid Services (CMS) targeting renal and peripheral angiography. Per the information released on the CMS website (which can be found HERE):

“renal and peripheral angiography procedures will be denied without documentation of a prior, inconclusive non-invasive study that supports the medical necessity for invasive angiography. Additionally, renal and peripheral angiography services will be reviewed for application and observance of correct coding guidelines.”

Well, that’s certainly broad.

Also note that this is a complex review, meaning recovery auditors will be requesting claims data from providers for review and that claims data can be requested as far back as three years.

What are they looking for?

The approved issue posted on the CMS website lists several codes that will be affected by this review. The affected codes are summarized below, with a few guideline reminders.

Selective Catheter Placement (36245-36248)

These codes are assigned for selective (the catheter is maneuvered from the access site into another vessel other than the aorta or vena cava) catheterization below the diaphragm – so the abdominal/visceral arteries, pelvic arteries and lower extremity arteries.

Within a single vascular family, one of these codes may be assigned for the most distal (farthest) selection, with 36248 assigned for additional 2^nd and 3^rd order, and beyond, branches. It is important to remember not to code for catheterization in vessels on the way to the final catheter placement. In other words, you can’t code for what you pass through to get to the destination.

Arterial S&I (75710, 75716 and 75726)

Codes 75710 and 75716 are assigned for unilateral (75710) or bilateral (75716) extremity angiography. These codes may be assigned for upper or lower extremity angiography and do not specify “selective,” so they may be assigned for selective or non-selective imaging, once per extremity. So, if both arms or both legs are imaged assign 75716. If arm(s) and leg(s) are both imaged, 75710 and/or 75716 would be assigned once for arm imaging and once for leg imaging with appropriate modifier(s) as required by your payer.

Code 75726 is assigned for visceral angiography – imaging of arteries leading to organs (other than renal) – commonly celiac, SMA and IMA angiography. 75726 should only be reported once per vascular family catheterized and includes an aortogram, if performed.

Abdominal Aortogram (75625, 75630)

How an aortogram is performed determines the way the procedure will be coded. Generally, the catheter is placed at or above the level of the renal arteries and contrast is injected. Because the aorta carries blood away from the heart, the flow will carry the contrast down to the lower part of the abdominal aorta and into the iliofemoral arteries (lower extremity run-off). 75625 is assigned for an abdominal aortogram with contrast injected at or above the renal arteries with documentation of imaging to the aortic bifurcation.

Code 75630 describes abdominal aortography with bilateral iliofemoral runoff from the initial high catheter position in the aorta – the abdominal aorta and bilateral lower extremities are imaged and documented without repositioning the catheter.

More commonly, the catheter will be repositioned to the lower part of the abdominal aorta for imaging of the iliofemoral arteries (run-off). When the catheter is moved to a lower position for imaging of the lower extremities, two codes would be assigned: 75625 and 75716 (bilateral lower extremities – 75710 for unilateral).

Complete Renal Angiography (36251-36254)

Renal angiography codes are complete codes that include all aspects of the exam: catheterization to one or more renal arteries, contrast injections, imaging, pressure measurements (if performed), and placement of a closure device. Abdominal aortography performed at the same session as a selective renal angiography is also included.

Code choices are unilateral 1^st order or 2^nd order or higher (36251, 36253), or bilateral 1^st order or 2^nd order or higher (36252, 36254). So, if both left and right main renal arteries are selected and imaged, 36252 would be the only code assigned.

Review, Validate and Remain Compliant

The coming of a new year is always a time for action. Reflecting, reviewing and preparation remain vital steps necessary to safeguard revenue and understand process gaps that could negatively impact your compliance and revenues. With these codes being targeted, which are often the bread and butter of vascular services, here’s a great place to start validating current practices and revisiting these codes (and their guidelines for use) to ensure compliance heading into the new year.