Billing and Coding: Double-Check Your Chemoembolization Coding
Melody W. Mulaik, MSHS, CRA, FAHRA, RCC, CPC, CPC-H
Radiology Today
Vol. 19 No. 3 P. 10

Chemoembolization is a treatment for inoperable liver cancer that is used as an alternative to conventional or intra-arterial chemotherapy. It is also called transcatheter arterial chemoembolization or hepatic arterial chemoembolization. The procedure is performed on a frequent basis and has become a standard of sorts for many interventional practices. This article will address the proper coding guidelines to ensure that you are not overcoding or undercoding for this very valuable procedure.

Normal liver tissue receives most of its blood supply from the portal vein, but liver tumors receive most of their blood supply from the hepatic artery. By introducing chemotherapy agents and embolic agents into the hepatic artery, the physician can kill the cancer cells and block the blood flow to the tumor without killing off normal liver tissue.

The physician will perform one or more visceral arteriograms to determine which vessels are supplying the tumor. Then, these vessels are embolized using chemotherapy drugs such as doxorubicin or cisplatin, mixed with iodized poppy seed oil. Typically, one-half of the liver is treated in a single session via either the right or left hepatic artery. Once the chemoembolic agent has been delivered, the artery is embolized further with a standard embolic agent such as gelatin sponge or polyvinyl alcohol particles. The techniques vary, but these variations should not impact procedure code assignment. The procedure may be performed as a single course of treatment or multiple times. Immediately prior to chemoembolization, the physician may embolize other vessels, such as the gastroduodenal artery, that are at risk of being occluded during the chemoembolization. After the embolization, follow-up arteriograms may be performed to evaluate the vascular anatomy.

While the procedure itself sounds straightforward enough, there are several coding questions that arise: How many embolization codes may be assigned? Can the initial diagnostic arteriogram be billed? How many units of selective arteriograms may be billed? It is useful to break down the coding based on the key steps of the procedure.

It is appropriate to bill for all catheter placements performed during the procedure. Remember that only one primary catheterization code may be assigned within a vascular family and, since the hepatic vessels are all off the celiac family, you may assign only one unit of 36247, Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family. Any additional second or third order catheterizations should be coded as 36248, Selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch, within a vascular family. There is a Medically Unlikely Edit (MUE) outpatient facility limit of two for 36248 so you will need to list the first units of 36248 on one line item of the claim and any additional units on a separate line item with a modifier. Interestingly, the practitioner MUE limit is six for 36248 so the physician should have an easier time getting reimbursement for additional selective catheter placements.

Diagnostic Arteriograms
It is not an automatic assumption that you can bill separately for the initial diagnostic arteriograms performed prior to chemoembolization. The CPT manual states that diagnostic angiography/venography codes should not be used with interventional procedures to represent contrast injections, angiography/venography, roadmapping, and/or fluoroscopic guidance for the intervention. Diagnostic angiography/venography performed at the time of an interventional procedure is separately reportable under the following conditions:

• no prior catheter-based angiographic/venographic study is available and a full diagnostic study is performed, and the decision to intervene is based on the diagnostic study; or

• a prior study is available, but the following is documented in the medical record:

o the patient's condition with respect to the clinical indication has changed since the prior study; or

o there is inadequate visualization of the anatomy and/or pathology; or

o there is a clinical change during the procedure that requires new evaluation outside the target area of intervention.

In other words, as long as diagnostic angiography is not included in the intervention code, which it is not for embolization, it is appropriate to report the diagnostic angiogram supervision and interpretation (S&I) codes, provided that a true diagnostic study was performed and the above criteria are met. Modifier 59 or XU must be appended to the diagnostic angiogram S&I codes in this situation. For chemoembolization cases, there must be clear documentation of the medical necessity for and performance of the diagnostic arteriogram, especially in cases where it is a subsequent treatment encounter.

Chapter 9 of the National Correct Coding Initiative (CCI) Policy Manual states that providers can report a diagnostic angiogram together with an intervention, using a modifier to bypass the CCI edit, if the service satisfies CPT manual guidelines, national Medicare guidelines, and local Medicare Administrative Contractor guidelines.

According to the CCI manual, "If a diagnostic angiogram (fluoroscopic or computed tomographic) was performed prior to the date of the percutaneous intravascular interventional procedure, a second diagnostic angiogram cannot be reported on the date of the percutaneous intravascular interventional procedure unless it is medically reasonable and necessary to repeat the study to further define the anatomy and pathology. Report the repeat angiogram with modifier 59."

So if the criteria for billing a diagnostic arteriogram are met, code 75726, Angiography, visceral, selective, or supraselective (with or without flush aortogram), radiological supervision and interpretation, should be assigned for the study. Any additional selective diagnostic studies—not roadmapping—should be assigned the add-on code 75774, Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation (list separately in addition to code for primary procedure). Code 75774 has an MUE limit of seven, and it would be unlikely that greater than seven selective studies would be performed and billed. Because this is a date of service edit, any units over seven will be denied and only potentially paid upon appeal.

The embolization portion of the chemoembolization procedure is reported with code 37243 (tumor embolization). Code 37243 includes the following services, which should not be reported separately: Radiological supervision and interpretation, guidance and roadmapping, and completion angiograms.

In those cases where the interventional physician determines the chemotherapy dose, writes the prescription, and personally administers the chemotherapeutic agent in conjunction with the embolic agent, procedure code 96420, Chemotherapy administration, intra-arterial; push technique, may be assigned in addition to the embolization codes. However, Medicare will not pay physicians for code 96420 in the hospital setting. This code has PC/TC indicator 5 in the Medicare Physician Fee Schedule, meaning that it is considered a staff service rather than a physician service.

Immediately prior to chemoembolization, the physician may embolize other vessels, such as the gastroduodenal artery, that are at risk of being occluded during the chemoembolization. In this situation, only one embolization code should be assigned—code 37243 for the tumor embolization. It is not appropriate to also assign code 37242 for the embolization of the at-risk vessels, since they are part of the same surgical field. However, catheterization of these vessels should be coded separately.

The embolization codes 37241–37244 may only be reported once per surgical field. The CPT manual defines the surgical field as "the area immediately surrounding and directly involved in a treatment/procedure." Per CPT Assistant, November 2013, when both the left and right lobes of the liver are treated during the same session, it is appropriate to assign two units of 37243. Medicare does not recognize codes 37241–37244 as eligible for modifier 50, so if bilateral embolizations are performed in separate surgical fields, the second embolization should be reported with modifier XS (Separate structure), 76, or 59, or as instructed by the payer. Under the Medicare MUEs, code 37243 has a limit of one unit as a date of service edit so the codes will need to be listed on separate lines and may require an appeal to ensure payment.

While chemoembolization has been around for a number of years, the coding guidelines have changed, and it is important that you ensure that you are following the most up-to-date authoritative guidelines. Accurate coding is a dynamic and sometimes challenging process that requires research, diligence, and patience.

— Melody W. Mulaik, MSHS, CRA, FAHRA, RCC, CPC, CPC-H, is the president of Coding Strategies, Inc & Revenue Cycle, Inc.