Coding Basics
ASDIN Coding Committee
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CPT Codes
• CPT stands for Current Procedural Terminology
• Current Procedural Terminology refers to a listing of
descriptive terms and identifying 5 digit codes for
reporting medical services and procedures
performed by physicians
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CPT
• CPT codes and their descriptors are created by the
AMA CPT Editorial Panel assisted by the AMA CPT
Advisory Committee
• The CPT codes are owned by the AMA
• They have been adopted as a standard by CMS
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CPT Advisory Committee
• This committee plays a very important role in the
creation and description of CPT codes
• It is made up of representatives of all of the
appropriate speciality societies
• The RPA represents interventional nephrologists on
this committee
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Requirements for Representation
• Representation on the CPT advisory committee is
critically important
• In order to have representation on the committee,
at least 50% of RPA members must be members of
the AMA
• In order for RPA to represent interest of ASDIN, at
least 50% of our members must be members of RPA
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RBRVS
• RBRVS stands for Resource-Based Relative Value Scale
• This is a schema used to determine how much medical
providers should be paid by CMS for any given code
• RBRVS assigns procedures relative value units (RVU)
which are adjusted by geographic region
• This value is then multiplied by a fixed conversion factor,
which changes annually, to determine the amount of
payment
• RBRVS determines prices based on three separate
factors:
– physician work (52%)
– practice expense (44%), and
– malpractice expense (4%)
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• CMS is mandated to make appropriate adjustments
to the RBRVS in response to the Omnibus Budget
Reconciliation Act of 1989 to account for changes in
medical practice coding and new data and
procedures
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RUC Committee
• RUC stands for AMA/Specialty Society Relative Value
Scale Update Committee (RUC)
• This committee acts as an expert panel in developing
RVS update recommendations to CMS in making
adjustments to the RBRVS
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Make-Up of RUC Committee
• The committee has 31 members
• The AMA Board of Trustees selects the RUC chair
and also the AMA representative to the RUC
• The individual RUC members are nominated by the
specialty societies and are approved by the AMA
• Nephrology representation on this committee is
through an Internal Medicine representative
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CPT Codes
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CPT Codes
• Each code is unique and consists of 5 digits
• The first digit of each code is determined by its
category
– 3 XXXX indicates a surgical (or procedural) code
– 7XXXX indicates a radiological code
– 9XXXX indicates a medical code
• However, any of these codes can be used by any
type of physician, they are not restricted to a
speciality
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Component Coding
• This is a process by which multiple codes (a list) are
used for a single patient encounter
• This list may differ somewhat from one encounter to
another based upon what was actually done
• For example in performing a thrombectomy, there
are a few basic codes that are always used, but in an
individual case something additional might be
required resulting in an additional code being added
to the list
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Documentation
• Documentation is an important part of the coding of
a procedure
• It is critical that what was done be documented in a
manner that can be easily understood by another
person who might have a reason to read the
operative report
• If the documentary evidence does not support the
coding, it is problematic
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Add-On Codes
• Add-on codes enable separate identification of a service
that is performed in certain situations as an additional
component or as a commonly performed supplemental
service to the primary service/procedure that was
performed
• For example if an access is cannulated, the basic code is
36147. However, at times it is necessary to cannulate a
second time. This warrants a second code + 36148. In
this situation the second cannulation is an add-on code
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More on Add-On Codes
• CPT designates the codes that are considered add-on
codes
• These codes are identified with a “+” sign (+36148)
• In addition, the code descriptors contain some variation
of the phrase “List separately in addition to code for
primary procedure.”
• An add-on code is not a stand-alone code, it can not be
used except with the primary code
• They are exempt to the depreciated value that occurs
when multiple procedures
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NCII Edits
• NCII stands for the National Correct Coding Initiative
• NCII edits are published from time to time to clarify
how certain codes are to be applied
• A series of NCII edits has been published dealing
with pairs of codes when used together:
– Column 1/Column2 edits
– Medically unlikely edits
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Column 1/Column 2 Edits
• These edits get their name from the table in which
the code-pairs appear
• The CPT code appearing in Column 1 is the payable
service
• The code in Column 2 is the non-payable code
(unless it is qualifies for an appropriate modifier)
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• In effect, the edit bundles the Column 2 service into
the Column 1 service when either:
– The Column 2 procedure is an integral part of Column 1
(comprehensive), or when
– The Column 1 and Column 2 procedures could not
reasonably, based on medical necessity, be provided to
the same patient on the same day by the same physician
• However, in some cases the Column 2 code can be
used with a modifier
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• In the printed version of these edits there are 6
columns
• Only 3 are of importance to us
– Column 1 is the payable code in the edit pair
– Column 2 is the non-payable code in the edit pair
– Column 6 shows whether exceptions are allowed for
billing the code pair (the use of a modifier)
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• Column 6 will have either a “0” or a “1”
– “0” – indicates that the two are mutually exclusive, the
column 2 code can not be used with the Column 1 code
– “1” – indicates that the Column 2 code can be used with
Column 1 but only with an appropriate modifier attached
• The modifier most frequently applied is 59
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Examples
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• It should be noted that the same code can be a
column 1 code when paired with one code and a
column 2 code when paired with a different code
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Medically Unlikely Edits (MUE)
• An MUE for a CPT code sets the maximum number of
units that a physician can report under most
circumstances for a single patient on a single date of
service
• These are ordinarily based upon the natural anatomic
limits
• If the MUE is “2,” no more than 2 units of that code can
be used for a single patient on a single date of service
• It should be noted that not all CPT codes have MUEs
associated with them
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Example
• 35476 (venous angioplasty) has an MUE of 2 for a
dialysis access case
• This means that this code can only be used 2 times
for each individual patient on a single day of service
• However, 35476 can only be used 1 time within the
access (MUE of 1) and 1 time within the central
veins (MUE of 1)
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Use of Dx and Tx RS&I Codes Together
• Vascular diagnostic and therapeutic procedures
often are performed at the same encounter
• Each of these may be associated with a radiological
supervision and interpretation code (RS&I)
• When a diagnostic RS&I code is used in association
with a therapeutic RS&I code, a -59 modifier should
be attached to the diagnostic RS&I code
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Example
• Procedure - embolization coil followed by a post-coil
angiogram via catheter
• Codes for the coil placement - 37204 and 75894
– 75894 is a therapeutic RS&I
• Code for the angiogram - 75898-59
– 75898 is a diagnostic RS&I
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Lower Extremity Revascularization (LER) Codes
• In most instances, the coding guidelines for the
upper and lower extremity are the same
• An exception to this rule occurs when arterial work
is performed in the lower extremity
• In this instance the LER rules apply
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Global Period
• A number of the procedures that are performed have
global periods
• This is a period of time following a procedure during
which services provided by the physician related to the
original procedure are considered to be included in the
reimbursement and cannot be separately reported
• For our purposes, this means that if the same procedure
is repeated during this period, it is not covered
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Global Period Examples
•
•
•
•
•
•
36870 (thrombectomy) - 90 days
36565 (tunneled catheter placement) – 10 days
36581 (tunneled catheter exchange) – 10 days
36589 (tunneled catheter removal) – 10 days
49421 (insertion of peritoneal catheter) – 90 days
49422 (removal of peritoneal catheter) – 10 days
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Definitions
• The definition of what constitutes a repeat
procedure is important
• Examine the following two scenarios:
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Scenario 1
Day 1 - A patient had a thrombectomy - flow was restored
Day 2 – At dialysis, the access was found to have thrombosed
again. The patient returned to the center where it is found
that a stenotic lesion had been missed and that a clot had
formed distal to the lesion. A repeat thrombectomy was
performed
This procedure should not be reported, it is a continuation of
the original which was incomplete – it is within the global
period.
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Scenario 2
Day 1 - A patient had a thrombectomy - flow was restored
Day 4 –The access thrombosed again following a prolonged period
of hypotension. The patient returned to the center and a
thrombectomy was performed. There was no evidence of stenosis
present. The only apparent cause for the event was the
hypotension.
The procedure can be reported. This is not a continuation of the
previous procedure, but a new event related to the hypotension.
The global period would not apply.
36870 should be reported with a 79 modifier to indicate that this is
an unrelated procedure
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Professional and Technical Services
• Some radiology services (7xxxx codes) are eligible for
the separate payment of professional and technical
components
– Applies only to hospital, not ASC or office site of service
– Used if physician does not own or is not employed by the
facility
• Modifier
– 26 Physician services only
– TC Technical component only
• No modifier (Global designation)
– Used if the physician owns or is employed by the facility
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Place of Service
• Codes are utilized on professional claims to specify
the entity where service(s) were rendered
• Applicable codes to vascular access procedures
– 11
– 22
– 24
– 21
office
outpatient hospital
ambulatory surgery center
inpatient hospital
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Physician Office Based Procedures
• Paid according to the CMS Physician Fee Schedule (PFS)
– Updated annually
• Facility
– Includes only the physician’s professional service (work) payment
assuming that the procedure is being performed in a facility which
the physician does not own (Hospital, ASC)
• Non-facility
– The payment for physicians who are performing procedures in
their own office facility
– This higher reimbursement is intended to reimburse both the
physician’s professional work and the facility costs related to the
procedure.
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Ambulatory Surgery Center Procedures
• Physician paid using CMS Physician Fee Schedule (PFS)
according to the facility rate
• ASC paid using CMS Ambulatory Surgery Center
Schedule
– List of reimbursable procedures published annually
– Some procedures used for vascular access not reimbursable in
this place of service
• e.g. Currently no reimbursement for radiologic 7xxxx codes
– Expanded number of surgical procedures reimbursed
compared to office place of service
• e.g. Many open surgical procedures have no “non-facility”
reimbursement
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Important Note
• This document is for informational purposes only and
should serve as a guideline for appropriate coding.
• The ultimate responsibility for correct coding
/documentation remains with the provider of service.
• ASDIN makes no representation, warranty, or guarantee
that this compilation of information is error-free, nor
that the use of this guide will prevent differences of
opinion or disputes with CMS or any other carrier.
• ASDIN will bear no responsibility or liability for the
results or consequences that may grow out of the use of
this guidance.
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