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OUTPATIENT HOSPITAL USE OF MODIFIERS

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  • We have seen a proliferation of procedures utilizing percutaneous methods and catheters. Stents, endothrombectomy, nephrostograms, liver procedures, etc.
  • The SIR will frequently seek guidance from CMS, but CMS has never said that SIR is the official source of IR guidelines.
  • Show the photos, books, explain Medlearn has the procedure plus the codes needed, both surgical and S&I
  • Always verify vendor information with official guidance. Surgical APCS do have the APC.
  • Many errors in matching revenue codes to CPT codes. IR and radiology revenue codes in the 400’s Ingenix has software also.
  • C1725 Cath, translumin non-laser C1874 Stent, coated/cov w/del sys C1876 Stent, non-coa/non-cov w/del C1885 Cath, translumin angio laser C2625 Stent, non-cor, tem w/del sy Stent or cath
  • Need both Surgical and S&I on the claim.
  • Can visualize a tree with trunk and branches, or driving on streets.
  • You can have more than one 36218 in a case vascular family. Show diagram
  • Show in photo.
  • Cath must be placed in the renal arteries with contrast injected to code 36245 and 75722. This is usually for a documented problem. If only a drive by, this is coded to G0275.
  • Do not bill S&I for the post angiography.
  • Do not bill S&I for the post angiography.
  • 75625 for aortogram does not have selective in the code. 75662 or external carotid bilateral does require the cath in vessel.
  • Documentation is important here to distinguish which side of graft is being PTA’d.
  • Dr Z has 3 zones
  • Loose interpretation based on SIR guidance and DR Z. Right now I sent a letter to CC for HCPCS to see if 35476 should be used or G0393 for each zone. There is currently some confusion on if the subclavian and superior vena cava are really the graft or not.
  • Missed opportunity if two lesions, SFA and popliteal Transluminal balloon angioplasty; femoral-popliteal, two lesions CPT Assistant, August 2006 Page: 10 Category: Coding Communication Surgery: Cardiovascular System Question: When both the femoral and popliteal arteries are treated with transluminal balloon angioplasty from a percutaneous approach, is CPT code 35474, Transluminal balloon angioplasty, percutaneous; femoral-popliteal, reported twice? AMA Comment: Since the inception of component coding for interventional radiology procedures, the femoral and popliteal arteries have been considered two distinct vessels. If there are distinct lesions found in both the femoral and popliteal arteries and each lesion is treated separately with Transluminal balloon angioplasty, CPT code 35474 would be reported twice. CPT Assistant © Copyright 1990–2006 American Medical Association. All Rights Reserved
  • No edits given on both so watch it. CMS in their provider policy manual indicates that when angioplasty and atherectomy are performed at the same site, the higher level intervention, the atherectomy, is all that should be billed. Prior to this coming out I would have coded for both because this is a good example of where both are indicated, one failed and was documented as a failure and the other was necessary (although it also failed). The SIR has said all along to bill for both in these circumstances, and still supports coding of both the atherectomy and the angioplasty. So there is the rub, CMS saying one thing and the society saying something else. I happen to fully agree with SIR because the pricing scheme for these procedures and the discounting by CMS was accounted for when the codes and rules were created. Unfortunately what I think is less important than what you think. Do you use CMS guidance or do you use SIR guidance (which is also supported by the AMA). Your choice. Hopefully soon, the two groups can come to an agreement as to what is correct, and hopefully it will be what we have done for the 11 years prior to the provider policy manual statements to the contrary. When this is resolved I will immediately let you know, but until then I am going along with CMS, hoping for them to change. Dr.z 10-25-06 Coding Rules applicable for dates:
  • You will see “pre dilated” the lesion was dilated and stent deployed.”
  • Varies with DRG 621, 622, 623
  • Explain how hard it is to get pressures outside of the aortic valve.
  • Crosses the Mitral Valve as it opens Blood flows into the Left Ventricle The Mitral Valve closes and Aortic Valve opens Blood flows into the Aorta Blood flows to the entire body, crosses capillaries into veins where it is carried through the Vena Cava back to the Right Atrium The cycle repeats again
  • The Medlearn book is very helpful for coding cardiac caths.

Transcript

  • 1. Interventional Radiology Coding...What You Need To Know April, 27 2007 Pat Maccariella-Hafey, RHIA, CCS, CCS-P Director of Education Health Information Associates [email_address] 843-602-6181
  • 2. Objectives
    • Discuss resources
    • Review common problem issues in IR coding including documentation
    • Explain basic conventions/rules used in interventional radiology surgical codes
    • Discuss importance of supervision and interpretation codes.
    • Discuss action plans to rectify coding and charging issues
  • 3. Interventional Radiology
    • What is it?
    • Interventional radiology is the non-surgical treatment of a growing number of diseases using radiologic imaging to guide catheters (hollow, flexible tubes), balloons, filters, and other tiny instruments through the body's blood vessels and other organs.
  • 4. Official Guidance Issues
    • Check all Program Memorandums at http://cms.hhs.gov/Transmittals/2007Trans/list.asp
    • Although CMS does not get specific, industry standard is that SIR conventions be used to assign codes.
    • www.sirweb.org The Society of Interventional Radiology
      • Coding section
  • 5. Official Guidance Issues
    • http://www.zhealthpublishing.com/ David Zielske, MD. Website Q&A, books, seminars. Many complicated cases.
    • www.medlearn.com Books, seminars
    • www.AHIMA.org Communities of Practice, Radiology Coding and Compliance
    • http://www.medicalassetmanagement.com/
    • Color illustrations, seminars, books
  • 6. Official Guidance Issues
    • CPT Assistant may have old information. Coding Clinic for HCPCS is now the official source for HOPPS coding guidance
    • Relevant Coding Clinic for HCPCS Issues:
      • 3 rd Quarter 2005 page 10
      • 4 th Quarter 2004 pages 4-5
      • 3 rd Quarter 2004 page 16
      • 3 rd Quarter 2002 pages 8-9
  • 7. Official Guidance Issues
    • Beware of the “pink sheets” or vendor info. These have been found to contain erroneous info.
    • For hospital billing, angiography APCs are driven by the S&I codes, (7XXXX) and the surgical codes (3XXXX) are packaged. (APC 19900)
    • Beware of Category III codes in the back and also any HCPCS level II codes or G codes.
    • See Appendix L for ordered vessels.
  • 8. IR and Billing Issues
    • Revenue Codes are used in hospitals, 0001-0999
    • They act as “buckets” or cost centers for third party payers to allow tracking of services provided.
    • There must be agreement between the revenue codes and CPT codes, or the line rejects. Most rejections initially are due to wrong revenue codes, not CPT codes.
    • Revenue codes differ by state. Ingenix has a book UB92/04 Editor with all revenue codes for each state.
  • 9. IR and Billing Issues
    • Not matching CPT codes with correct device codes “C Codes”
    • http:// www.cms.hhs.gov/HospitalOutpatientPPS/01_overview.asp#TopOfPage
    • i.e. 35473-LT for PTA of left iliac can match with C1725, C1874, C1876, C1885 or C2625.
    • Chargemaster driven
    • Audit recommended
  • 10. IR Modifier Usage
    • FOR PHYSICIAN BILLING ONLY:
    • CMS may no longer support use of bilateral modifier "-50" or "-RT"/"-LT" when reporting multiple selective catheterization services
      • For Carriers (Physician billing) only
    • FACILITY modifiers, refer to state MAC (FI/Carrier). Always verify with payor.
    • Use of modifier -50 rare among MACs. See Transmittal 442 (PM A-00-73)
  • 11. IR Modifier Usage
    • Modifiers typically used by the hospital for radiology:
    • -RT and -LT
    • -25 ( on ER cases or clinic cases)
    • -50 bilateral (if surgical in nature and MAC likes it)
    • -52 reduced services
    • -58 staged procedure (biliary mostly)
    • -59 distinct procedure
    • -76 repeat procedure same MD
    • -77 repeat procedure different MD
    • -78 Return to OR, related procedure (tunneled caths)
    • -79 Unrelated procedure by MD same day
  • 12. IR Modifier Usage
    • When using modifier –59 with another modifier i.e.;
      • 36216 RT
      • 36215-59-LT
    • Be sure that the –59 is on the lower ordered vessel and that –59 is before any other modifiers. The modifier that most affects payment should be listed first b
    • Many FI s still only look at the first modifier. Check with “MAC” to be sure.
  • 13. IR Review of Coding Rules
    • Surgical codes (3XXXX) deal with actual procedural work (such as needle positioning, catheter placement or manipulation, angioplasty or stent deployment). HOW YOU DID IT.
    • Supervision and Interpretation (Imaging) (S&I) codes (7XXXX) describe the imaging guidance and image interpretation portions. (Studying the vessels)
    • Some S&I codes are specifically paired with a surgical code 35473 and 75962
    • There are also S&I codes for image interpretation, without a similar one-to-one matched relationship. WHAT YOU DID
  • 14. IR Review of Coding Rules
    • A vascular FAMILY is a group of vessels which is fed by a primary branch off the aorta, vena cava, OR the vessel punctured.
    • Smaller vessels need microcatheters.
    • Cath to the aorta follows natural flow. No work to get there so this is non-selective.
    • Other vessels off aorta or
    • vessel punctured are selected.
  • 15. IR Review of Coding Rules
    • Non selective cath insertion is when it is placed directly into an artery or vein with no further advancement of the catheter past the punctured vessel OR the catheter is placed into any portion of the aorta or superior/ inferior vena cava from any approach (TLA, femoral, axillary, brachial)
  • 16. IR Review of Coding Rules
    • Selective catheter is guided, negotiated or advanced into any arterial or venous vessel other than the aorta or vena cavae, or the original vessel punctured.
      • (The intent of reimbursement differences is that it takes more skill to negotiate other than the main large vessels. Each time a bifurcation is passed, the difficulty increases. Used for MD billing RBRVS)
  • 17. Pigtail Catheter
  • 18. IR Review of Coding Rules
    • Always code the highest ordered vessel first, and then any additional second or third order vessels in the same family to 36218. (head/neck)
      • Contrast injections on the way up are included in the highest ordered vessel code.
    • For example, if cath placed in right subclavian (36216-RT), and then placed in right internal carotid (36217-RT) code 36217-RT and 36218-RT (for the right subclavian which is an additional second or third order but lower than 36217.) This assures the appropriate depiction of the case.
  • 19. IR Review of Coding Rules
    • Each entry into a vascular family is coded separately; i.e., catheter to right common carotid then to left common carotid, code both of these 36215-59-LT, 36216-RT. The 59 will be appended on the lower numbered vessel.
    • Add on code 36218 for head and neck and 36248 for abdomen down are when you are in same vascular family.
  • 20. IR Review of Coding Rules
    • Catheters inserted “at origin of” “at origins” for “road-mapping” “flush aortogram” “close to” “drive by” do NOT constitute a selective catheter of the structure. MD has to state that he negotiated the catheter into the vessels.
    • Prevalent in renal angiograms.
    • Transmittal AB-03-119 8/8/03
  • 21. IR Review of Coding Rules
    • 36245-LT Renal angiogram (Cath in renal)
    • APC 19900 packaged $0
    • 75722-LT Selective renal angiography
    • S&I unilateral
    • APC 280 $1,211.03
    • -------------------------------------------
    • G0275 Renal Angiogram Flush (cath aorta)
    • APC 19900 packaged $0
    • Also code cardiac cath codes
  • 22. IR Review of Coding Rules
    • Selective codes take precedence over
    • non-selective codes, if done from the same
    • puncture site. Only code the selective.
    • Guide wires are inserted as far as they
    • can get it to anchor. Do not confuse catheter
    • placement with guidewire placement.
    • Post-angiography S&I or road-mapping
    • S&I, “quick injections” are not coded/
    • charged. These are part of the procedure.
  • 23. IR Review of Coding Rules
    • 37205 Stent in common iliac
      • APC 081 $2,497.15
    • 36245-LT Catheter in common iliac
      • APC 19900 Packaged $0
    • 75962 S&I PTA peripheral artery unilateral
      • APC 668 $363.29
    • ----------------------------------------
    • If trying to bill follow up angiography
    • 75710-59 Angiography unilateral lower extremity S&I
      • APC 280 $1,211.03
      • THIS IS INCORRECT!
  • 24. IR Review of Coding Rules
    • Again, S&I codes describe the imaging. If
    • “ selective” is not in the imaging code
    • description, the cath does not need to be in the
    • vessel imaged to use the S&I code. If “selective”
    • is in the description, then yes the cath has to be
    • in that vessel. See 75625 and 75662 for example.
    • Code 75774 is used to report additional
    • selective or supra-selective exams performed in
    • the same area as the base exam. It has to be a
    • SELECTIVE cath (cath in vessel interpreted)
  • 25. Example 1
    • “ Abdominal aortogram and bilateral lower extremity arteriograms and run off via high and low catheter placement and injections from a single, left groin stick.” (very common)
  • 26. Example 1 Answer
    • What you did:
    • 75625 Abdominal Aortogram
    • APC 280 $1,211.03
    • 75716 Bilateral Lower Extremity Arteriogram
    • APC 280 $1,211.03
    • (Full lower ext exam does not need to go all the way to the toes)
    • How you did it:
    • 36200 Catheter placed high and low in
    • aorta (it does not matter that two injections were
    • done in the aorta, only code it once)
    • APC 19900 packaged
  • 27. Example 1 Answer
    • 75630, Abdominal aortogram with
    • bilateral iliofemoral angiogram is only
    • used when the abdominal aorta and
    • lower extremities are studied with a
    • single catheter position and as a single
    • exam. 75630 can also be used when the
    • catheter is repositioned and only the
    • pelvis is imaged.
    • APC 280 $1,211.03
  • 28. Example 2
    • Bilateral renal angiogram, selective, additional selective study of accessory left renal arteries with 3 entrances
      • 75724 S&I APC 280 $1,211.03
      • 75774 x 2 S&I for additional views
        • APC 279 $552.87 Often missed
        • APC 279 $552.87 Often missed
      • 36245 -RT right side APC 19900 packaged $0
      • 36245-59-LT left side (or 36245-50 plus)
      • 36245-59-LT first accessory left
      • 36245-59-LT second accessory left
  • 29. AV Fistula/Graft APC 88
    • Creation of AV fistula by other than direct AV anastomosis, autogenous graft (CPT code 36825) describes a procedure in which a donor's vein is used to connect an artery and vein.
    • Creation of AV fistula by other than direct AV anastomosis, non-autogenous graft (e.g., biological collagen, thermoplastic graft, Gortex) (CPT code 36830) is used to report placement of a synthetic subcutaneous tube graft with one end anastomosed to the brachial artery and the other to a large vein.
      • This method is the most commonly performed hemodialysis access procedure performed today (50,000/yr).
    • 36818 and 36819 are arm vein transpositions
  • 30. AV Fistula/Graft
    • Be sure to code the catheterization of the limbs in addition to therapeutic procedures. If both the arterial and venous sides are both punctured, 36145 would be reported twice. You may need modifier –59 with this. It is also called “fistulogram.”
    • Report S&I code 75790 for imaging
      • APC 279 $552.97
    • Code S&I 75790 includes imaging of outflow to the level of the right atrium. Do not report the vena cavagram S&I with this. It is included. Additional 75790-59 APC 279 $552.97 is incorrect
  • 31. AV Fistula/Graft
    • Thrombus is not the same as stenosis.
    • Thrombus is a clot within the blood vessel, blocking blood flow. It is the final result of blood coagulation thru aggregate of platelets. Thrombectomy is the choice to alleviate thrombus.
    • Stenosis is plaque (arteriosclerosis) or hyperplasia of the intimal layer of the arterial wall, causing narrowing of the vessel, also blocking blood flow.
    • PTA is the choice to alleviate stenosis.
  • 32. AV Fistula/Graft
    • Declotting (most thrombus occurs on venous side)
      • 36870 describes percutaneous removal of clot from an AV fistula/graft by any method.
      • There is no S&I code for this procedure.
      • 36145 is used for puncture, code twice if both artery and venous limbs punctured
      • 75790 is used for fistulogram and only reported once despite 2 punctures.
        • APC 279 $ 552.87
  • 33. AV Fistula/Graft
    • Q: If our radiologist performs thrombolytic infusion on a dialysis graft for more than one hour (i.e. 4 hours) should we assign 37201 and 75896 instead of 36870?
    • A: Duration does not affect coding. If thrombolysis is done within a graft, it is considered part of the procedure and reported with 36870. If the infusion is done outside the graft, (with the outflow veins or distal artery) 37201 and 75896 would be used.
  • 34. AV Fistula/Graft
    • 36870 AV thrombectomy APC 653 $1,883.31
    • 36145 x 2 (APC 19900 packaged)
    • 75790 S&I for fistulogram APC 279 $552.87
    • Do not report the below if thrombolysis in graft
    • 37201-59 Infusion APC 676 $60.29 at 50%
    • 75898 S&I for infusion APC 263 $98.62
    • If documented as outside graft this is coded see CPT Assistant May 2001 page 3-4. Normally a vessel is selected and cath advanced to outflow thrombus.
  • 35. AV Fistula/Graft
    • Angioplasty of AV fistula use 35476 + 75978 or G0393 + 75978 for Venous PTA of AV graft Medicare or G0392 + 75962 for Arterial only PTA for of AV graft Medicare
      • Venous Includes treatment of one or more stenoses at the arterial anastomosis, within the graft, at the venous anastomosis, or in the outflow vessels to the level of the axillary vein.
      • ****if arterial and venous PTA done, only code the venous side. Code arterial PTA if ONLY that is done. The graft vessel that is PTA’d is considered a vein.
      • Code 36870 for thrombectomy if this is also performed.
      • Code puncture 36145 (x2 if done) and 75790.
  • 36. AV Fistula/Graft Example
    • Two catheters are used to puncture the arterial and venous limbs of the AV fistula. Fistulogram and vena cavagram are performed, revealing strictures at both the arterial and venous anastomosis. PTA done of artery and venous limbs. Medicare.
  • 37. AV Fistula/Graft Example
    • G0393 AV venous PTA APC 081 $2,491.15
      • 35476 Non-Medicare same APC
    • 75978, S&I PTA APC 668 $363.29
    • 36870 Thrombectomy APC 653 $941.66
    • 36145 X 2, for both limbs APC 19900 packaged
    • 75790 for fistulogram APC 279 $552.87
    • Do not code G0392, 75962 for arterial side of graft APC 81 $1,248.57 at 50%
    • APC 668 $363.29
  • 38. Zones for AV Graft/Upper
    • Upper Extremity
    • Zone 1 : Arterial anastomosis, intra-graft, venous anastomosis and outflow veins to axillary vein
    • Zone 2 : Subclavian and brachiocephalic veins (central extremity veins)
    • Zone 3 : Superior Vena Cava
    • Only one venoplasty per zone
    • can be reported in this
    • Interpretation.
  • 39. Zones for Lower Extremity
    • Lower Extremity
    • Zone 1 : Arterial anastomosis, intra-graft to venous anastomosis (common femoral vein)
    • Zone 2 : External iliac and common iliac veins (central extremity veins)
    • Zone 3 : Inferior Vena Cava
    • Only one venoplasty per zone can be reported
  • 40. PTA Non AV Graft
    • PTA surgical codes are 35470-35476
    • Code one PTA for each VESSEL treated
      • PTA of three lesions in the SFA = one PTA, 35474, 75962
      • PTA of one lesion in the SFA and two in the iliac = two PTA’s 35474 + 35473, 75962, 75964
    • Code any catheter placements (i.e., 36245, 36246, etc)
    • Per CPT Asst Aug 2006 page 10 the SFA and popliteal are 2 separate vessels so both can be coded.
  • 41. PTA Non AV Graft
    • If PTA and atherectomy of same vessel, code only atherectomy of that vessel, CMS policy
    • If PTA and atherectomy both done at separate vessels, report both codes (35470-35476, 35490-35495) Check with MAC as some only allow 1.
    • Code the S&I codes (75962-75968, 75978, 75992-75996)
    • Code diagnostic angiogram S&I if performed (75710, etc)
    • Do not code the “completion” or follow up angiogram which is done to check after the procedure is done. Do not report a surgical or S&I code for this at all.
  • 42. Transcatheter Stent
    • Transcatheter placement of intravascular stent is coded to 37205-37206 (75960 each stent)
    • Assign one code for each vessel stented
      • If multiple stents in same vessel, only one stent placement code is assigned
      • Multiple vessels stented = 37205 for the first vessel and 37206 for each additional
      • Be careful, this is different than ICD-9-CM procedure coding.
    • Code diagnostic angiogram if performed (75710)
    • Code any catheter placements (36245, 36246, etc.
  • 43. Angioplasty with Stent
    • Angioplasty performed as the means of stent deployment to expand the stent) is NOT separately coded. For example, with 30% lesion, they pre-dilate and then insert stent. (or balloon mounted)
    • Therapeutic angioplasty performed before or after the stent placement should be separately coded.
      • Failed angioplasty
      • Angioplasty of a separate lesion
      • Another example is a lesion of 70%, treated with PTA, which still shows 30% lesion so stent is now inserted. Code both in this situation.
  • 44. VAD and Line Placements
    • See 36555 thru 36597
    • Codes grouped by
      • Central, Non –tunneled
        • Insert/Repair/Replace
      • Central Tunneled
        • W/O Sub Q port or pump/With Sub Q port/With Sub Q Pump
        • All above, insert, Repair, Replace, Remove
      • Peripherally inserted/PICC
        • W/O Sub Q port or Pump/With Sub Q port
        • Insert/Repair/Replace/Remove (sub Q port)
  • 45. Central Tunneled
    • Central = Cath or device tip must terminate in the subclavian, brachio cephalic (innominate) or iliac veins, the superior OR inferior vena cava or the right atrium
      • 36556 APC 621 $510.91 77001 packaged
    • Central = jugular, subclavian, femoral vein or inferior vena cava catheter entry site)
    • Tunneled means that a portion of the cath is tunneled underneath the skin and then the end comes out of vessel/skin and is exposed to outside (W/O port or pump)
      • 36558 APC 623 $1,318.27 77001 packaged
  • 46. Peripherally Inserted (PICC)
    • Peripherally inserted includes cath entry site from basilic (inner side of forearm to elbow) or cephalic veins (upper arm).
    • W/O Sub Q port or pump
      • Insert, < 5 yrs 36568; >5 yrs, 36569
      • APC 621 $510.91
      • Repair, 36575; Replace, 36584; remove, E/M
    • With Sub Q Port
      • Insert, ,5 yrs 36570; >5 yrs, 36571
      • APC 622 $1,218.27
      • Repair 36576; Replace cath only, 36578; complete replace, 36585,
      • Remove, 36590
  • 47. Cardiac Caths
    • Cardiac catheterization is the insertion and passage of small plastic tubes (catheters) into arteries and veins up to the heart to obtain x-ray pictures of coronary arteries and cardiac chambers as well a to measure pressures in the heart (intracardiac hemodynamics). Diagnostic angiography is also performed to obtain images and determine the function of the cardiovascular system for diseases of the aorta, pulmonary and peripheral vessels.
  • 48. Cardiac Caths
    • Check to see if a true left heart cath is being done.
    • If you look at the pressures or pressure result (mmhg), and see “LV”, then you know that the physician did a left heart catheterization. He has to cross the aortic valve to get these pressures.
    • 93510 for left heart cath, 93508 if only coronary artery angiogram and no left heart cath. Same APC.
    • If you see “RV” pressure measurements, then you know that the physician did a right heart catheterization. To do a right cath, the entrance way is through the vena cava. Usually there is a venous puncture to thread the catheter
  • 49.  
  • 50.  
  • 51. Cardiac Caths
    • Two other codes, 93561 and 93562 cannot be assigned for cardiac outputs during cardiac cath as NCCI edit 20 is elicited.
    • Define arterial and venous bypass injections individually.
    • For right and left heart catheterizations, the patients usually have a diagnosis of COPD, CHF, Valve stenosis. In some cases they complete RT cath because the left coronary artery does not come off in the normal fashion and is closer to the right. They need to do a right heart cath in order assess the pulmonary artery which is in between.
  • 52. Cardiac Caths
    • An IVUS (intravascular ultrasound) is an ultrasound catheter, which they are using more and more. It saves the patient from being exposed to more dye.
      • 92978 IVUS APC 670 $1,877.71
    •  
    • If the iliacs are injected to see if the closure device (angio seal or plugs) can be inserted, it is not coded separately.
    • AngioSeal, Perclose, etc used to close access assigned G0269 packaged APC 19900
  • 53. IR G Codes
    • See PM A-02-129
    • G0275 Renal artery angiography with Cardiac Cath (non selective, drive by only)
    • G0278 Iliac artery angiography with Cardiac Cath (non selective, drive by only)
    • Both include cath insertion, dye, S&I. APC 19900 Packaged
    • Effective January 1, 2003 for hospitals
    • If diagnostic selective, use 3634X and S&I
  • 54.  
  • 55.
    • Thank You!