ACR Radiology Coding Source™ September-October 2009 Q and A

Q: As of January 1, 2010, will HCPCS Level II codes G0392 and G0393 be used to report arterial and venous percutaneous transluminal angioplasty for maintenance of a hemodialysis access, arteriovenous fistula or graft? It is my understanding that the Centers for Medicare and Medicaid Services are proposing to delete these two codes.

A: The Centers for Medicare and Medicaid Services, through the Hospital Out-Patient Prospective Payment System Proposed Rule, is recommending the deletion of HCPCS Level II percutaneous transluminal angioplasty codes G0392 (AV fistula or graft arterial) and G0393 (AV fistula or graft venous) and the designation of CPT code 35475 (Repair arterial blockage) and 35476 (Repair, venous blockage) as covered surgical procedures in the Ambulatory Surgical Center (ASC) setting for CY 2010. If approved, ASCs will be able to use CPT 35475 and 35476 to report the AV fistula or graft angioplasty procedures currently reported by G0392 and G0393.

Prior to the establishment of the G codes in 2007, a percutaneous transluminal angioplasty of an arterial AV fistula or graft was reported with 35475 for the procedure and 75962 for the imaging. When a venous AV fistula or graft angioplasty was performed it was reported with code 35476 for the procedure and 75978 for the imaging.

It will not be known until the final rule is published in early November 2009 whether these proposed changes will be made. The ACR will be posting comments on the Final Rule in November to keep its members up to date.

Q: There are CCI edits on the MR with contrast code pairs 70552 (MRI, brain with contrast) and 70553 (MRI, brain without contrast, followed by with contrast material) reported in conjunction with the injection codes 36000 and 96372. However, a modifier indicator of “1” is listed, which denotes a modifier can be used to override the edit. Would it be appropriate to append a modifier -59 to code 36000 or 96372 in order to designate a separate encounter, as this portion of the procedure is performed 10-15 minutes before the actual with contrast study (70552 or 70553) procedure is performed?

A: No, it is not appropriate to add modifier 59 to code 36000 (Introduction of needle or intracatheter, vein) or 96372 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular) to override the Correct Coding Initiative (CCI) edits in order to report an injection for a contrast-enhanced magnetic resonance imaging (MRI) study that is given 10-15 minutes prior to the study. The injection performed 10-15 minutes prior to the study is part of the same study. A contrast-enhanced magnetic resonance imaging (MRI) study includes the professional component for injecting contrast, and reporting a separate code for the injection is unwarranted. It is only appropriate to add the 59 modifier to one of these codes when the with contrast code is reported on the same day by the same physician for the same patient when the injection is performed for a separate procedure, i.e., the injection code is not reported for the injection of contrast for the MRI study.

As noted in the Radiology Business Management Association Bulletin, September 1993:

Diagnostic procedures that are specified with contrast are assigned higher professional relative values than those that are specified without contrast (e.g., MRI, CT). These differences in the professional relative values reflect differences in the amount of professional work performed by the radiologist. The higher relative values assigned to the procedures with contrast were intended to cover the extra effort and time taken by the radiologist to administer the contrast materials and interpret the enhanced images. The injection should not be billed separately for CT, MRI, IVP or nuclear medicine studies, since the value of the work is already built into the RVUs for radiology.