0
1
InterventionalInterventional
RadiologyRadiology
Coding...What YouCoding...What You
Need To KnowNeed To Know
April, 27 20...
2
ObjectivesObjectives
 Discuss resourcesDiscuss resources
 Review common problem issues in IRReview common problem issu...
3
InterventionalInterventional
RadiologyRadiology
What is it?What is it?
Interventional radiology is the non-Interventiona...
4
Official GuidanceOfficial Guidance
IssuesIssues
 Check all Program Memorandums atCheck all Program Memorandums at
http:...
5
Official GuidanceOfficial Guidance
IssuesIssues
 http://www.zhealthpublishing.com/http://www.zhealthpublishing.com/ Dav...
6
Official GuidanceOfficial Guidance
IssuesIssues
 CPT Assistant may have old information.CPT Assistant may have old info...
7
Official GuidanceOfficial Guidance
IssuesIssues
 Beware of the “pink sheets” or vendor info.Beware of the “pink sheets”...
8
IR and Billing IssuesIR and Billing Issues
 Revenue Codes are used in hospitals, 0001-0999Revenue Codes are used in hos...
9
IR and Billing IssuesIR and Billing Issues
♦ Not matching CPT codes withNot matching CPT codes with
correct device codes...
10
IR Modifier UsageIR Modifier Usage
 FOR PHYSICIAN BILLING ONLY:FOR PHYSICIAN BILLING ONLY:
CMS may no longer support u...
11
IR Modifier UsageIR Modifier Usage
 Modifiers typically used by the hospital forModifiers typically used by the hospit...
12
IR Modifier UsageIR Modifier Usage
 When using modifier –59 with anotherWhen using modifier –59 with another
modifier ...
13
IR Review of CodingIR Review of Coding
RulesRules
Surgical codes (3XXXX) deal with actualSurgical codes (3XXXX) deal wi...
14
IR Review of CodingIR Review of Coding
RulesRules
♦ A vascularA vascular FAMILYFAMILY is a group ofis a group of
vessel...
15
IR Review of CodingIR Review of Coding
RulesRules
Non selectiveNon selective cath insertion is when it iscath insertion...
16
IR Review of CodingIR Review of Coding
RulesRules
♦ SelectiveSelective catheter is guided,catheter is guided,
negotiate...
17
Pigtail Catheter
18
IR Review of CodingIR Review of Coding
RulesRules♦ Always code the highest ordered vessel first,Always code the highest...
19
IR Review of CodingIR Review of Coding
RulesRules
♦Each entry into aEach entry into a vascular familyvascular family is...
20
IR Review of CodingIR Review of Coding
RulesRules
♦ Catheters inserted “at origin of” “atCatheters inserted “at origin ...
21
IR Review of CodingIR Review of Coding
RulesRules
36245-LT Renal angiogram (Cath in renal)36245-LT Renal angiogram (Cat...
22
IR Review of CodingIR Review of Coding
RulesRules♦ Selective codes take precedence overSelective codes take precedence ...
23
IR Review of CodingIR Review of Coding
RulesRules37205 Stent in common iliac37205 Stent in common iliac
♦ APC 081 $2,49...
24
IR Review of CodingIR Review of Coding
RulesRules
♦ Again, S&I codes describe the imaging. IfAgain, S&I codes describe ...
25
Example 1Example 1
““Abdominal aortogram and bilateralAbdominal aortogram and bilateral
lower extremity arteriograms an...
26
Example 1 AnswerExample 1 Answer
What you did:What you did:
75625 Abdominal Aortogram75625 Abdominal Aortogram
 APC 28...
27
Example 1 AnswerExample 1 Answer
75630, Abdominal aortogram with75630, Abdominal aortogram with
bilateral iliofemoral a...
28
Example 2Example 2
 Bilateral renal angiogram, selective, additionalBilateral renal angiogram, selective, additional
s...
29
AV Fistula/Graft APCAV Fistula/Graft APC
8888 Creation of AV fistula by other than direct AVCreation of AV fistula by ...
30
AV Fistula/GraftAV Fistula/Graft
 Be sure to code the catheterization of theBe sure to code the catheterization of the...
31
AV Fistula/GraftAV Fistula/Graft
Thrombus is not the same as stenosis.Thrombus is not the same as stenosis.
 ThrombusT...
32
AV Fistula/GraftAV Fistula/Graft
 Declotting (most thrombus occurs onDeclotting (most thrombus occurs on
venous side)v...
33
AV Fistula/GraftAV Fistula/Graft
 Q: If our radiologist performs thrombolyticQ: If our radiologist performs thrombolyt...
34
AV Fistula/GraftAV Fistula/Graft
 36870 AV thrombectomy36870 AV thrombectomy APC 653 $1,883.31APC 653 $1,883.31
 3614...
35
AV Fistula/GraftAV Fistula/Graft
 Angioplasty of AV fistula use 35476 + 75978Angioplasty of AV fistula use 35476 + 759...
36
AV Fistula/GraftAV Fistula/Graft
ExampleExample
 Two catheters are used to punctureTwo catheters are used to puncture
...
37
AV Fistula/GraftAV Fistula/Graft
ExampleExample G0393 AV venous PTAG0393 AV venous PTA APC 081 $2,491.15APC 081 $2,491...
38
Zones for AVZones for AV
Graft/UpperGraft/Upper
Upper ExtremityUpper Extremity
 Zone 1Zone 1: Arterial anastomosis, in...
39
Zones for LowerZones for Lower
ExtremityExtremity
Lower ExtremityLower Extremity
 Zone 1Zone 1: Arterial anastomosis, ...
40
PTA Non AV GraftPTA Non AV Graft
 PTA surgical codes are 35470-35476PTA surgical codes are 35470-35476
 Code one PTA ...
41
PTA Non AV GraftPTA Non AV Graft
 If PTA and atherectomy of same vessel, codeIf PTA and atherectomy of same vessel, co...
42
Transcatheter StentTranscatheter Stent
 Transcatheter placement of intravascular stentTranscatheter placement of intra...
43
Angioplasty with StentAngioplasty with Stent
 Angioplasty performed as the means of stentAngioplasty performed as the ...
44
VAD and LineVAD and Line
PlacementsPlacements
 See 36555 thru 36597See 36555 thru 36597
 Codes grouped byCodes groupe...
45
Central TunneledCentral Tunneled
 CentralCentral = Cath or device tip must terminate in= Cath or device tip must termi...
46
Peripherally InsertedPeripherally Inserted
(PICC)(PICC)
 PeripherallyPeripherally inserted includes cath entry siteins...
47
Cardiac CathsCardiac Caths
 Cardiac catheterization is the insertionCardiac catheterization is the insertion
and passa...
48
Cardiac CathsCardiac Caths
Check to see if a true left heart cath is being done.Check to see if a true left heart cath ...
49
50
51
Cardiac CathsCardiac Caths
• Two other codes, 93561 and 93562 cannot beTwo other codes, 93561 and 93562 cannot be
assig...
52
Cardiac CathsCardiac Caths
• An IVUS (intravascular ultrasound) is anAn IVUS (intravascular ultrasound) is an
ultrasoun...
53
IR G CodesIR G Codes
 See PM A-02-129See PM A-02-129
 G0275 Renal artery angiography withG0275 Renal artery angiograp...
54
55
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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.
  • C1725Cath, translumin non-laser
    C1874Stent, coated/cov w/del sys
    C1876Stent, non-coa/non-cov w/del
    C1885Cath, translumin angio laser
    C2625Stent, 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 10-25-06Coding 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 of "OUTPATIENT HOSPITAL USE OF MODIFIERS"

    1. 1. 1 InterventionalInterventional RadiologyRadiology Coding...What YouCoding...What You Need To KnowNeed To Know April, 27 2007 Pat Maccariella-Hafey, RHIA, CCS, CCS-P Director of Education Health Information Associates PMaccariella-Hafey@hiacode.com 843-602-6181
    2. 2. 2 ObjectivesObjectives  Discuss resourcesDiscuss resources  Review common problem issues in IRReview common problem issues in IR coding including documentationcoding including documentation  Explain basic conventions/rules used inExplain basic conventions/rules used in interventional radiology surgical codesinterventional radiology surgical codes  Discuss importance of supervision andDiscuss importance of supervision and interpretation codes.interpretation codes.  Discuss action plans to rectify codingDiscuss action plans to rectify coding and charging issuesand charging issues
    3. 3. 3 InterventionalInterventional RadiologyRadiology What is it?What is it? Interventional radiology is the non-Interventional radiology is the non- surgical treatment of a growingsurgical treatment of a growing number of diseases using radiologicnumber of diseases using radiologic imaging to guideimaging to guide catheterscatheters (hollow,(hollow, flexible tubes), balloons, filters, andflexible tubes), balloons, filters, and other tiny instruments through theother tiny instruments through the body's blood vessels and otherbody's blood vessels and other organs.organs.
    4. 4. 4 Official GuidanceOfficial Guidance IssuesIssues  Check all Program Memorandums atCheck all Program Memorandums at http://cms.hhs.gov/Transmittals/2007Trahttp://cms.hhs.gov/Transmittals/2007Tra  Although CMS does not get specific,Although CMS does not get specific, industry standard is that SIRindustry standard is that SIR conventions be used to assign codes.conventions be used to assign codes.  www.sirweb.orgwww.sirweb.org The Society ofThe Society of Interventional RadiologyInterventional Radiology  Coding sectionCoding section
    5. 5. 5 Official GuidanceOfficial Guidance IssuesIssues  http://www.zhealthpublishing.com/http://www.zhealthpublishing.com/ DavidDavid Zielske, MD. Website Q&A, books,Zielske, MD. Website Q&A, books, seminars. Many complicated cases.seminars. Many complicated cases.  www.medlearn.comwww.medlearn.com Books, seminarsBooks, seminars  www.AHIMA.orgwww.AHIMA.org Communities of Practice,Communities of Practice, Radiology Coding and ComplianceRadiology Coding and Compliance  http://www.medicalassetmanagement.com/http://www.medicalassetmanagement.com/ Color illustrations, seminars, booksColor illustrations, seminars, books
    6. 6. 6 Official GuidanceOfficial Guidance IssuesIssues  CPT Assistant may have old information.CPT Assistant may have old information. Coding Clinic for HCPCS is now theCoding Clinic for HCPCS is now the official source for HOPPS codingofficial source for HOPPS coding guidanceguidance  Relevant Coding Clinic for HCPCSRelevant Coding Clinic for HCPCS Issues:Issues:  33rdrd Quarter 2005 page 10Quarter 2005 page 10  44thth Quarter 2004 pages 4-5Quarter 2004 pages 4-5  33rdrd Quarter 2004 page 16Quarter 2004 page 16  33rdrd Quarter 2002 pages 8-9Quarter 2002 pages 8-9
    7. 7. 7 Official GuidanceOfficial Guidance IssuesIssues  Beware of the “pink sheets” or vendor info.Beware of the “pink sheets” or vendor info. These have been found to contain erroneousThese have been found to contain erroneous info.info.  For hospital billing,For hospital billing, angiographyangiography APCs areAPCs are driven by the S&I codes, (7XXXX) and thedriven by the S&I codes, (7XXXX) and the surgical codes (3XXXX) are packaged. (APCsurgical codes (3XXXX) are packaged. (APC 19900)19900)  Beware of Category III codes in the back andBeware of Category III codes in the back and also any HCPCS level II codes or G codes.also any HCPCS level II codes or G codes.  See Appendix L for ordered vessels.See Appendix L for ordered vessels.
    8. 8. 8 IR and Billing IssuesIR and Billing Issues  Revenue Codes are used in hospitals, 0001-0999Revenue Codes are used in hospitals, 0001-0999  They act as “buckets” or cost centers for thirdThey act as “buckets” or cost centers for third party payers to allow tracking of servicesparty payers to allow tracking of services provided.provided.  There must be agreement between the revenueThere must be agreement between the revenue codes and CPT codes, or the line rejects. Mostcodes and CPT codes, or the line rejects. Most rejections initially are due to wrong revenuerejections initially are due to wrong revenue codes, not CPT codes.codes, not CPT codes.  Revenue codes differ by state. Ingenix has aRevenue codes differ by state. Ingenix has a book UB92/04 Editor with all revenue codes forbook UB92/04 Editor with all revenue codes for each state.each state.
    9. 9. 9 IR and Billing IssuesIR and Billing Issues ♦ Not matching CPT codes withNot matching CPT codes with correct device codes “C Codes”correct device codes “C Codes” http://http:// www.cms.hhs.gov/HospitalOutpatientPPSwww.cms.hhs.gov/HospitalOutpatientPPS ♦ i.e. 35473-LT for PTA of left iliaci.e. 35473-LT for PTA of left iliac can match with C1725, C1874,can match with C1725, C1874, C1876, C1885 or C2625.C1876, C1885 or C2625. ♦ Chargemaster drivenChargemaster driven ♦ Audit recommendedAudit recommended
    10. 10. 10 IR Modifier UsageIR Modifier Usage  FOR PHYSICIAN BILLING ONLY:FOR PHYSICIAN BILLING ONLY: CMS may no longer support use ofCMS may no longer support use of bilateral modifier "-50" or "-RT"/"-LT"bilateral modifier "-50" or "-RT"/"-LT" when reporting multiple selectivewhen reporting multiple selective catheterization servicescatheterization services  For Carriers (Physician billing) onlyFor Carriers (Physician billing) only  FACILITY modifiers, refer to state MACFACILITY modifiers, refer to state MAC (FI/Carrier). Always verify with payor.(FI/Carrier). Always verify with payor.  Use of modifier -50 rare among MACs.Use of modifier -50 rare among MACs. See Transmittal 442 (PM A-00-73)See Transmittal 442 (PM A-00-73)
    11. 11. 11 IR Modifier UsageIR Modifier Usage  Modifiers typically used by the hospital forModifiers typically used by the hospital for radiology:radiology:  -RT and -LT-RT and -LT  -25 ( on ER cases or clinic cases)-25 ( on ER cases or clinic cases)  -50 bilateral (if surgical in nature and MAC likes it)-50 bilateral (if surgical in nature and MAC likes it)  -52 reduced services-52 reduced services  -58 staged procedure (biliary mostly)-58 staged procedure (biliary mostly)  -59 distinct procedure-59 distinct procedure  -76 repeat procedure same MD-76 repeat procedure same MD  -77 repeat procedure different MD-77 repeat procedure different MD  -78 Return to OR, related procedure (tunneled-78 Return to OR, related procedure (tunneled caths)caths)  -79 Unrelated procedure by MD same day-79 Unrelated procedure by MD same day
    12. 12. 12 IR Modifier UsageIR Modifier Usage  When using modifier –59 with anotherWhen using modifier –59 with another modifier i.e.;modifier i.e.;  36216 RT36216 RT  36215-59-LT36215-59-LT  Be sure that the –59 is on the lowerBe sure that the –59 is on the lower ordered vessel and that –59 is before anyordered vessel and that –59 is before any other modifiers. The modifier that mostother modifiers. The modifier that most affects payment should be listed first baffects payment should be listed first b  Many FI s still only look at the firstMany FI s still only look at the first modifier. Check with “MAC” to be sure.modifier. Check with “MAC” to be sure.
    13. 13. 13 IR Review of CodingIR Review of Coding RulesRules Surgical codes (3XXXX) deal with actualSurgical codes (3XXXX) deal with actual procedural work (such as needle positioning,procedural work (such as needle positioning, catheter placement or manipulation,catheter placement or manipulation, angioplasty or stent deployment).angioplasty or stent deployment). HOW YOUHOW YOU DID IT.DID IT. Supervision and Interpretation (Imaging) (S&I)Supervision and Interpretation (Imaging) (S&I) codes (7XXXX) describe the imaging guidancecodes (7XXXX) describe the imaging guidance and image interpretation portions. (Studyingand image interpretation portions. (Studying the vessels)the vessels)  Some S&I codes are specifically paired with aSome S&I codes are specifically paired with a surgical code 35473 and 75962surgical code 35473 and 75962  There are also S&I codes for imageThere are also S&I codes for image interpretation, without a similar one-to-oneinterpretation, without a similar one-to-one matched relationship.matched relationship. WHAT YOU DIDWHAT YOU DID
    14. 14. 14 IR Review of CodingIR Review of Coding RulesRules ♦ A vascularA vascular FAMILYFAMILY is a group ofis a group of vessels which is fed by avessels which is fed by a primaryprimary branch off the aorta, vena cava, ORbranch off the aorta, vena cava, OR the vessel punctured.the vessel punctured. ♦ Smaller vessels need microcatheters.Smaller vessels need microcatheters. ♦ Cath to the aorta follows natural flow.Cath to the aorta follows natural flow. No work to get there so this is non-No work to get there so this is non- selective.selective. ♦ Other vessels off aorta orOther vessels off aorta or vessel punctured arevessel punctured are selected.selected.
    15. 15. 15 IR Review of CodingIR Review of Coding RulesRules Non selectiveNon selective cath insertion is when it iscath insertion is when it is placed directly into an artery or veinplaced directly into an artery or vein with no further advancement of thewith no further advancement of the catheter past the punctured vesselcatheter past the punctured vessel OR the catheter is placed into anyOR the catheter is placed into any portion of the aorta or superior/portion of the aorta or superior/ inferior vena cava from any approachinferior vena cava from any approach (TLA, femoral, axillary, brachial)(TLA, femoral, axillary, brachial)
    16. 16. 16 IR Review of CodingIR Review of Coding RulesRules ♦ SelectiveSelective catheter is guided,catheter is guided, negotiated or advanced into anynegotiated or advanced into any arterial or venous vessel other thanarterial or venous vessel other than the aorta or vena cavae, or thethe aorta or vena cavae, or the original vessel punctured.original vessel punctured.  (The intent of reimbursement(The intent of reimbursement differences is that it takes more skill todifferences is that it takes more skill to negotiate other than the main largenegotiate other than the main large vessels. Each time a bifurcation isvessels. Each time a bifurcation is passed, the difficulty increases. Usedpassed, the difficulty increases. Used for MD billing RBRVS)for MD billing RBRVS)
    17. 17. 17 Pigtail Catheter
    18. 18. 18 IR Review of CodingIR Review of Coding RulesRules♦ Always code the highest ordered vessel first,Always code the highest ordered vessel first, and then any additional second or third orderand then any additional second or third order vessels in the same family to 36218. (head/neck)vessels in the same family to 36218. (head/neck) ♦ Contrast injections on the way up are included inContrast injections on the way up are included in the highest ordered vessel code.the highest ordered vessel code. ♦ For example, if cath placed in right subclavianFor example, if cath placed in right subclavian (36216-RT), and then placed in right internal(36216-RT), and then placed in right internal carotid (36217-RT) codecarotid (36217-RT) code 36217-RT and 36218-RT36217-RT and 36218-RT (for the right subclavian which is an additional(for the right subclavian which is an additional second or third order but lower than 36217.)second or third order but lower than 36217.) This assures the appropriate depiction of theThis assures the appropriate depiction of the case.case.
    19. 19. 19 IR Review of CodingIR Review of Coding RulesRules ♦Each entry into aEach entry into a vascular familyvascular family isis coded separately; i.e., catheter to rightcoded separately; i.e., catheter to right common carotid then to left commoncommon carotid then to left common carotid, code both of these 36215-59-LT,carotid, code both of these 36215-59-LT, 36216-RT. The 59 will be appended on36216-RT. The 59 will be appended on the lower numbered vessel.the lower numbered vessel. ♦Add on code 36218 for head and neckAdd on code 36218 for head and neck and 36248 for abdomen down are whenand 36248 for abdomen down are when you are in same vascular family.you are in same vascular family.
    20. 20. 20 IR Review of CodingIR Review of Coding RulesRules ♦ Catheters inserted “at origin of” “atCatheters inserted “at origin of” “at origins” for “road-mapping” “flushorigins” for “road-mapping” “flush aortogram” “close to” “drive by” doaortogram” “close to” “drive by” do NOT constitute a selective catheter ofNOT constitute a selective catheter of the structure. MD has to state that hethe structure. MD has to state that he negotiated the catheter into thenegotiated the catheter into the vessels.vessels. ♦ Prevalent in renal angiograms.Prevalent in renal angiograms. ♦ Transmittal AB-03-119 8/8/03Transmittal AB-03-119 8/8/03
    21. 21. 21 IR Review of CodingIR Review of Coding RulesRules 36245-LT Renal angiogram (Cath in renal)36245-LT Renal angiogram (Cath in renal) ♦ APC 19900 packaged $0APC 19900 packaged $0 75722-LT Selective renal angiography75722-LT Selective renal angiography S&I unilateralS&I unilateral ♦ APC 280 $1,211.03APC 280 $1,211.03 -------------------------------------------------------------------------------------- G0275 Renal Angiogram Flush (cath aorta)G0275 Renal Angiogram Flush (cath aorta) ♦ APC 19900 packaged $0APC 19900 packaged $0 ♦ Also code cardiac cath codesAlso code cardiac cath codes
    22. 22. 22 IR Review of CodingIR Review of Coding RulesRules♦ Selective codes take precedence overSelective codes take precedence over non-selective codes, if done from the samenon-selective codes, if done from the same puncture site. Only code the selective.puncture site. Only code the selective. ♦ Guide wires are inserted as far as theyGuide wires are inserted as far as they can get it to anchor. Do not confuse cathetercan get it to anchor. Do not confuse catheter placement with guidewire placement.placement with guidewire placement. ♦ Post-angiography S&I or road-mappingPost-angiography S&I or road-mapping S&I, “quick injections” are not coded/S&I, “quick injections” are not coded/ charged. These are part of the procedure.charged. These are part of the procedure.
    23. 23. 23 IR Review of CodingIR Review of Coding RulesRules37205 Stent in common iliac37205 Stent in common iliac ♦ APC 081 $2,497.15APC 081 $2,497.15 36245-LT Catheter in common iliac36245-LT Catheter in common iliac ♦ APC 19900 Packaged $0APC 19900 Packaged $0 75962 S&I PTA peripheral artery unilateral75962 S&I PTA peripheral artery unilateral ♦ APC 668 $363.29APC 668 $363.29 -------------------------------------------------------------------------------- If trying to bill follow up angiographyIf trying to bill follow up angiography 75710-59 Angiography unilateral lower75710-59 Angiography unilateral lower extremity S&Iextremity S&I ♦ APC 280 $1,211.03APC 280 $1,211.03 ♦ THIS IS INCORRECT!THIS IS INCORRECT!
    24. 24. 24 IR Review of CodingIR Review of Coding RulesRules ♦ Again, S&I codes describe the imaging. IfAgain, S&I codes describe the imaging. If ““selective” is not in the imaging codeselective” is not in the imaging code description, the cath does not need to be in thedescription, the cath does not need to be in the vessel imaged to use the S&I code. If “selective”vessel imaged to use the S&I code. If “selective” is in the description, then yes the cath has to beis in the description, then yes the cath has to be in that vessel. See 75625 and 75662 for example.in that vessel. See 75625 and 75662 for example. ♦ CodeCode 7577475774 is used to report additionalis used to report additional selective or supra-selective exams performed inselective or supra-selective exams performed in the same area as the base exam. It has to be athe same area as the base exam. It has to be a SELECTIVE cath (cath in vessel interpreted)SELECTIVE cath (cath in vessel interpreted)
    25. 25. 25 Example 1Example 1 ““Abdominal aortogram and bilateralAbdominal aortogram and bilateral lower extremity arteriograms andlower extremity arteriograms and run off via high and low catheterrun off via high and low catheter placement and injections from aplacement and injections from a single, left groin stick.” (verysingle, left groin stick.” (very common)common)
    26. 26. 26 Example 1 AnswerExample 1 Answer What you did:What you did: 75625 Abdominal Aortogram75625 Abdominal Aortogram  APC 280 $1,211.03APC 280 $1,211.03 75716 Bilateral Lower Extremity Arteriogram75716 Bilateral Lower Extremity Arteriogram  APC 280 $1,211.03APC 280 $1,211.03  (Full lower ext exam does not need to go all the way(Full lower ext exam does not need to go all the way to the toes)to the toes) How you did it:How you did it: 36200 Catheter placed high and low in36200 Catheter placed high and low in aorta (it does not matter that two injections wereaorta (it does not matter that two injections were done in the aorta, only code it once)done in the aorta, only code it once) APC 19900 packagedAPC 19900 packaged
    27. 27. 27 Example 1 AnswerExample 1 Answer 75630, Abdominal aortogram with75630, Abdominal aortogram with bilateral iliofemoral angiogram is onlybilateral iliofemoral angiogram is only used when the abdominal aorta andused when the abdominal aorta and lower extremities are studied with alower extremities are studied with a single catheter position and as a singlesingle catheter position and as a single exam. 75630 can also be used when theexam. 75630 can also be used when the catheter is repositioned and only thecatheter is repositioned and only the pelvis is imaged.pelvis is imaged.  APC 280 $1,211.03
    28. 28. 28 Example 2Example 2  Bilateral renal angiogram, selective, additionalBilateral renal angiogram, selective, additional selective study of accessory left renal arteriesselective study of accessory left renal arteries with 3 entranceswith 3 entrances  7572475724 S&IS&I APC 280 $1,211.03APC 280 $1,211.03  75774 x 275774 x 2 S&I for additional viewsS&I for additional views  APC 279 $552.87 Often missedAPC 279 $552.87 Often missed  APC 279 $552.87 Often missedAPC 279 $552.87 Often missed  3624536245 -RT right side-RT right side APC 19900 packaged $0APC 19900 packaged $0  36245-59-LT36245-59-LT left side (or 36245-50 plus)left side (or 36245-50 plus)  36245-59-LT36245-59-LT first accessory leftfirst accessory left  36245-59-LT36245-59-LT second accessory leftsecond accessory left
    29. 29. 29 AV Fistula/Graft APCAV Fistula/Graft APC 8888 Creation of AV fistula by other than direct AVCreation of AV fistula by other than direct AV anastomosis, autogenous graft (CPT codeanastomosis, autogenous graft (CPT code 36825) describes a procedure in which a donor's36825) describes a procedure in which a donor's vein is used to connect an artery and vein.vein is used to connect an artery and vein.  Creation of AV fistula by other than direct AVCreation of AV fistula by other than direct AV anastomosis, non-autogenous graft (e.g.,anastomosis, non-autogenous graft (e.g., biological collagen, thermoplastic graft, Gortex)biological collagen, thermoplastic graft, Gortex) (CPT code 36830) is used to report placement of(CPT code 36830) is used to report placement of a synthetic subcutaneous tube graft with onea synthetic subcutaneous tube graft with one end anastomosed to the brachial artery and theend anastomosed to the brachial artery and the other to a large vein.other to a large vein.  This method is the most commonly performedThis method is the most commonly performed hemodialysis access procedure performedhemodialysis access procedure performed today (50,000/yr).today (50,000/yr).  36818 and 36819 are arm vein transpositions36818 and 36819 are arm vein transpositions
    30. 30. 30 AV Fistula/GraftAV Fistula/Graft  Be sure to code the catheterization of theBe sure to code the catheterization of the limbs in addition to therapeutic procedures.limbs in addition to therapeutic procedures. If both the arterial and venous sides areIf both the arterial and venous sides are both punctured, 36145 would be reportedboth punctured, 36145 would be reported twice. You may need modifier –59 with this.twice. You may need modifier –59 with this. It is also called “fistulogram.”It is also called “fistulogram.”  Report S&I code 75790 for imagingReport S&I code 75790 for imaging  APC 279 $552.97APC 279 $552.97  Code S&I 75790 includes imaging of outflowCode S&I 75790 includes imaging of outflow to the level of the right atrium. Do not reportto the level of the right atrium. Do not report the vena cavagram S&I with this. It isthe vena cavagram S&I with this. It is included.included. Additional 75790-59 APC 279Additional 75790-59 APC 279 $552.97 is incorrect$552.97 is incorrect
    31. 31. 31 AV Fistula/GraftAV Fistula/Graft Thrombus is not the same as stenosis.Thrombus is not the same as stenosis.  ThrombusThrombus is a clot within the blood vessel,is a clot within the blood vessel, blocking blood flow. It is the final result ofblocking blood flow. It is the final result of blood coagulation thru aggregate of platelets.blood coagulation thru aggregate of platelets. Thrombectomy is the choice to alleviateThrombectomy is the choice to alleviate thrombus.thrombus.  StenosisStenosis is plaque (arteriosclerosis) oris plaque (arteriosclerosis) or hyperplasia of the intimal layer of the arterialhyperplasia of the intimal layer of the arterial wall, causing narrowing of the vessel, alsowall, causing narrowing of the vessel, also blocking blood flow.blocking blood flow.  PTA is the choice to alleviate stenosis.PTA is the choice to alleviate stenosis.
    32. 32. 32 AV Fistula/GraftAV Fistula/Graft  Declotting (most thrombus occurs onDeclotting (most thrombus occurs on venous side)venous side)  36870 describes percutaneous removal of36870 describes percutaneous removal of clot from an AV fistula/graft by anyclot from an AV fistula/graft by any method.method.  There is no S&I code for this procedure.There is no S&I code for this procedure.  36145 is used for puncture, code twice if36145 is used for puncture, code twice if both artery and venous limbs puncturedboth artery and venous limbs punctured  75790 is used for fistulogram and only75790 is used for fistulogram and only reported once despite 2 punctures.reported once despite 2 punctures.  APC 279 $ 552.87APC 279 $ 552.87
    33. 33. 33 AV Fistula/GraftAV Fistula/Graft  Q: If our radiologist performs thrombolyticQ: If our radiologist performs thrombolytic infusion on a dialysis graft for more thaninfusion on a dialysis graft for more than one hour (i.e. 4 hours) should we assignone hour (i.e. 4 hours) should we assign 37201 and 75896 instead of 36870?37201 and 75896 instead of 36870?  A: Duration does not affect coding. IfA: Duration does not affect coding. If thrombolysis is donethrombolysis is done withinwithin a graft, it isa graft, it is considered part of the procedure andconsidered part of the procedure and reported with 36870. If the infusion is donereported with 36870. If the infusion is done outsideoutside the graft, (with the outflow veins orthe graft, (with the outflow veins or distal artery) 37201 and 75896 would bedistal artery) 37201 and 75896 would be used.used.
    34. 34. 34 AV Fistula/GraftAV Fistula/Graft  36870 AV thrombectomy36870 AV thrombectomy APC 653 $1,883.31APC 653 $1,883.31  36145 x 236145 x 2 (APC 19900 packaged)(APC 19900 packaged)  75790 S&I for fistulogram75790 S&I for fistulogram APC 279 $552.87APC 279 $552.87 Do not report the below if thrombolysis in graftDo not report the below if thrombolysis in graft  37201-59 Infusion37201-59 Infusion APC 676 $60.29 at 50%APC 676 $60.29 at 50%  75898 S&I for infusion75898 S&I for infusion APC 263 $98.62APC 263 $98.62 If documented as outside graft this is codedIf documented as outside graft this is coded see CPT Assistant May 2001 page 3-4.see CPT Assistant May 2001 page 3-4. Normally a vessel is selected and cathNormally a vessel is selected and cath advanced to outflow thrombus.advanced to outflow thrombus.
    35. 35. 35 AV Fistula/GraftAV Fistula/Graft  Angioplasty of AV fistula use 35476 + 75978Angioplasty of AV fistula use 35476 + 75978 or G0393 + 75978 for Venous PTA of AV graftor G0393 + 75978 for Venous PTA of AV graft Medicare or G0392 + 75962 for Arterial onlyMedicare or G0392 + 75962 for Arterial only PTA for of AV graft MedicarePTA for of AV graft Medicare  Venous Includes treatment of one or moreVenous Includes treatment of one or more stenoses at the arterial anastomosis, within thestenoses at the arterial anastomosis, within the graft, at the venous anastomosis, or in the outflowgraft, at the venous anastomosis, or in the outflow vessels to the level of the axillary vein.vessels to the level of the axillary vein.  ****if arterial and venous PTA done, only code the****if arterial and venous PTA done, only code the venous side. Code arterial PTA if ONLY that isvenous side. Code arterial PTA if ONLY that is done. The graft vessel that is PTA’d is considereddone. The graft vessel that is PTA’d is considered a vein.a vein.  Code 36870 for thrombectomy if this is alsoCode 36870 for thrombectomy if this is also performed.performed.  Code puncture 36145 (x2 if done) and 75790.Code puncture 36145 (x2 if done) and 75790.
    36. 36. 36 AV Fistula/GraftAV Fistula/Graft ExampleExample  Two catheters are used to punctureTwo catheters are used to puncture the arterial and venous limbs of thethe arterial and venous limbs of the AV fistula. Fistulogram and venaAV fistula. Fistulogram and vena cavagram are performed, revealingcavagram are performed, revealing strictures at both the arterial andstrictures at both the arterial and venous anastomosis. PTA done ofvenous anastomosis. PTA done of artery and venous limbs. Medicare.artery and venous limbs. Medicare.
    37. 37. 37 AV Fistula/GraftAV Fistula/Graft ExampleExample G0393 AV venous PTAG0393 AV venous PTA APC 081 $2,491.15APC 081 $2,491.15  35476 Non-Medicare same APC35476 Non-Medicare same APC  75978, S&I PTA75978, S&I PTA APC 668 $363.29APC 668 $363.29  36870 Thrombectomy36870 Thrombectomy APC 653 $941.66APC 653 $941.66  36145 X 2, for both limbs36145 X 2, for both limbs APC 19900APC 19900 packagedpackaged  75790 for fistulogram75790 for fistulogram APC 279 $552.87APC 279 $552.87 Do not code G0392, 75962 for arterial side ofDo not code G0392, 75962 for arterial side of graftgraft APC 81 $1,248.57 at 50%APC 81 $1,248.57 at 50% APC 668 $363.29APC 668 $363.29
    38. 38. 38 Zones for AVZones for AV Graft/UpperGraft/Upper Upper ExtremityUpper Extremity  Zone 1Zone 1: Arterial anastomosis, intra-graft,: Arterial anastomosis, intra-graft, venous anastomosis and outflow veins tovenous anastomosis and outflow veins to axillary veinaxillary vein  Zone 2Zone 2: Subclavian and brachiocephalic: Subclavian and brachiocephalic veins (central extremity veins)veins (central extremity veins)  Zone 3Zone 3: Superior Vena Cava: Superior Vena Cava Only one venoplasty per zoneOnly one venoplasty per zone can be reported in thiscan be reported in this Interpretation.Interpretation.
    39. 39. 39 Zones for LowerZones for Lower ExtremityExtremity Lower ExtremityLower Extremity  Zone 1Zone 1: Arterial anastomosis, intra-graft: Arterial anastomosis, intra-graft to venous anastomosis (common femoralto venous anastomosis (common femoral vein)vein)  Zone 2Zone 2: External iliac and common iliac: External iliac and common iliac veins (central extremity veins)veins (central extremity veins)  Zone 3Zone 3: Inferior Vena Cava: Inferior Vena Cava Only one venoplasty per zone can beOnly one venoplasty per zone can be reportedreported
    40. 40. 40 PTA Non AV GraftPTA Non AV Graft  PTA surgical codes are 35470-35476PTA surgical codes are 35470-35476  Code one PTA for each VESSEL treatedCode one PTA for each VESSEL treated  PTA of three lesions in the SFA = onePTA of three lesions in the SFA = one PTA, 35474, 75962PTA, 35474, 75962  PTA of one lesion in the SFA and two inPTA of one lesion in the SFA and two in the iliac = two PTA’s 35474 + 35473,the iliac = two PTA’s 35474 + 35473, 75962, 7596475962, 75964  Code any catheter placements (i.e., 36245,Code any catheter placements (i.e., 36245, 36246, etc)36246, etc)  Per CPT Asst Aug 2006 page 10 the SFAPer CPT Asst Aug 2006 page 10 the SFA and popliteal are 2 separate vessels so bothand popliteal are 2 separate vessels so both can be coded.can be coded.
    41. 41. 41 PTA Non AV GraftPTA Non AV Graft  If PTA and atherectomy of same vessel, codeIf PTA and atherectomy of same vessel, code only atherectomy of that vessel, CMS policyonly atherectomy of that vessel, CMS policy  If PTA and atherectomy both done at separateIf PTA and atherectomy both done at separate vessels, report both codes (35470-35476, 35490-vessels, report both codes (35470-35476, 35490- 35495) Check with MAC as some only allow 1.35495) Check with MAC as some only allow 1.  Code the S&I codes (75962-75968, 75978, 75992-Code the S&I codes (75962-75968, 75978, 75992- 75996)75996)  Code diagnostic angiogram S&I if performedCode diagnostic angiogram S&I if performed (75710, etc)(75710, etc)  Do not code the “completion” or follow upDo not code the “completion” or follow up angiogram which is done to check after theangiogram which is done to check after the procedure is done. Do not report a surgical orprocedure is done. Do not report a surgical or S&I code for this at all.S&I code for this at all.
    42. 42. 42 Transcatheter StentTranscatheter Stent  Transcatheter placement of intravascular stentTranscatheter placement of intravascular stent is coded to 37205-37206 (75960 each stent)is coded to 37205-37206 (75960 each stent)  Assign one code for each vessel stentedAssign one code for each vessel stented  If multiple stents in same vessel, only oneIf multiple stents in same vessel, only one stent placement code is assignedstent placement code is assigned  Multiple vessels stented = 37205 for the firstMultiple vessels stented = 37205 for the first vessel and 37206 for each additionalvessel and 37206 for each additional  Be careful, this is different than ICD-9-CMBe careful, this is different than ICD-9-CM procedure coding.procedure coding.  Code diagnostic angiogram if performed (75710)Code diagnostic angiogram if performed (75710)  Code any catheter placements (36245, 36246,Code any catheter placements (36245, 36246, etc.etc.
    43. 43. 43 Angioplasty with StentAngioplasty with Stent  Angioplasty performed as the means of stentAngioplasty performed as the means of stent deployment to expand the stent) is NOTdeployment to expand the stent) is NOT separately coded. For example, with 30%separately coded. For example, with 30% lesion, they pre-dilate and then insert stent.lesion, they pre-dilate and then insert stent. (or balloon mounted)(or balloon mounted)  TherapeuticTherapeutic angioplasty performed before orangioplasty performed before or after the stent placement should be separatelyafter the stent placement should be separately coded.coded.  Failed angioplastyFailed angioplasty  Angioplasty of a separate lesionAngioplasty of a separate lesion  Another example is a lesion of 70%, treated withAnother example is a lesion of 70%, treated with PTA, which still shows 30% lesion so stent is nowPTA, which still shows 30% lesion so stent is now inserted. Code both in this situation.inserted. Code both in this situation.
    44. 44. 44 VAD and LineVAD and Line PlacementsPlacements  See 36555 thru 36597See 36555 thru 36597  Codes grouped byCodes grouped by  Central, Non –tunneledCentral, Non –tunneled  Insert/Repair/ReplaceInsert/Repair/Replace  Central TunneledCentral Tunneled  W/O Sub Q port or pump/With Sub Q port/WithW/O Sub Q port or pump/With Sub Q port/With Sub Q PumpSub Q Pump  All above, insert, Repair, Replace, RemoveAll above, insert, Repair, Replace, Remove  Peripherally inserted/PICCPeripherally inserted/PICC  W/O Sub Q port or Pump/With Sub Q portW/O Sub Q port or Pump/With Sub Q port  Insert/Repair/Replace/Remove (sub Q port)Insert/Repair/Replace/Remove (sub Q port)
    45. 45. 45 Central TunneledCentral Tunneled  CentralCentral = Cath or device tip must terminate in= Cath or device tip must terminate in the subclavian, brachio cephalic (innominate)the subclavian, brachio cephalic (innominate) or iliac veins, the superior OR inferior venaor iliac veins, the superior OR inferior vena cava or the right atriumcava or the right atrium  3655636556 APC 621 $510.91 77001 packagedAPC 621 $510.91 77001 packaged  CentralCentral = jugular, subclavian, femoral vein or= jugular, subclavian, femoral vein or inferior vena cava catheter entry site)inferior vena cava catheter entry site)  TunneledTunneled means that a portion of the cath ismeans that a portion of the cath is tunneled underneath the skin and then thetunneled underneath the skin and then the end comes out of vessel/skin and is exposedend comes out of vessel/skin and is exposed to outside (W/O port or pump)to outside (W/O port or pump)  3655836558 APC 623 $1,318.27 77001 packagedAPC 623 $1,318.27 77001 packaged
    46. 46. 46 Peripherally InsertedPeripherally Inserted (PICC)(PICC)  PeripherallyPeripherally inserted includes cath entry siteinserted includes cath entry site from basilic (inner side of forearm to elbow)from basilic (inner side of forearm to elbow) or cephalic veins (upper arm).or cephalic veins (upper arm).  W/O Sub Q port or pumpW/O Sub Q port or pump  Insert, < 5 yrs 36568; >5 yrs, 36569Insert, < 5 yrs 36568; >5 yrs, 36569 APC 621 $510.91APC 621 $510.91  Repair, 36575; Replace, 36584; remove, E/MRepair, 36575; Replace, 36584; remove, E/M  With Sub Q PortWith Sub Q Port  Insert, ,5 yrs 36570; >5 yrs, 36571Insert, ,5 yrs 36570; >5 yrs, 36571 APC 622 $1,218.27APC 622 $1,218.27  Repair 36576; Replace cath only, 36578; completeRepair 36576; Replace cath only, 36578; complete replace, 36585,replace, 36585,  Remove, 36590Remove, 36590
    47. 47. 47 Cardiac CathsCardiac Caths  Cardiac catheterization is the insertionCardiac catheterization is the insertion and passage of small plastic tubesand passage of small plastic tubes (catheters) into arteries and veins up to the(catheters) into arteries and veins up to the heart to obtain x-ray pictures of coronaryheart to obtain x-ray pictures of coronary arteries and cardiac chambers as well a toarteries and cardiac chambers as well a to measure pressures in the heart (intracardiacmeasure pressures in the heart (intracardiac hemodynamics). Diagnostic angiography ishemodynamics). Diagnostic angiography is also performed to obtain images andalso performed to obtain images and determine the function of the cardiovasculardetermine the function of the cardiovascular system for diseases of the aorta, pulmonarysystem for diseases of the aorta, pulmonary and peripheral vessels.and peripheral vessels.
    48. 48. 48 Cardiac CathsCardiac Caths Check to see if a true left heart cath is being done.Check to see if a true left heart cath is being done.  If you look at the pressures or pressure resultIf you look at the pressures or pressure result (mmhg), and see “LV”, then you know that the(mmhg), and see “LV”, then you know that the physician did a left heart catheterization. He has tophysician did a left heart catheterization. He has to cross the aortic valve to get these pressures.cross the aortic valve to get these pressures.  93510 for left heart cath, 93508 if only coronary93510 for left heart cath, 93508 if only coronary artery angiogram and no left heart cath. Same APC.artery angiogram and no left heart cath. Same APC.  If you see “RV” pressure measurements, then youIf you see “RV” pressure measurements, then you know that the physician did a right heartknow that the physician did a right heart catheterization. To do a right cath, the entrance waycatheterization. To do a right cath, the entrance way is through the vena cava. Usually there is a venousis through the vena cava. Usually there is a venous puncture to thread the catheterpuncture to thread the catheter
    49. 49. 49
    50. 50. 50
    51. 51. 51 Cardiac CathsCardiac Caths • Two other codes, 93561 and 93562 cannot beTwo other codes, 93561 and 93562 cannot be assigned for cardiac outputs during cardiacassigned for cardiac outputs during cardiac cath as NCCI edit 20 is elicited.cath as NCCI edit 20 is elicited. • Define arterial and venous bypass injectionsDefine arterial and venous bypass injections individually.individually. • For right and left heart catheterizations, theFor right and left heart catheterizations, the patients usually have a diagnosis of COPD,patients usually have a diagnosis of COPD, CHF, Valve stenosis. In some cases theyCHF, Valve stenosis. In some cases they complete RT cath because the left coronarycomplete RT cath because the left coronary artery does not come off in the normalartery does not come off in the normal fashion and is closer to the right. They needfashion and is closer to the right. They need to do a right heart cath in order assess theto do a right heart cath in order assess the pulmonary artery which is in between.pulmonary artery which is in between.
    52. 52. 52 Cardiac CathsCardiac Caths • An IVUS (intravascular ultrasound) is anAn IVUS (intravascular ultrasound) is an ultrasound catheter, which they are usingultrasound catheter, which they are using more and more. It saves the patient from beingmore and more. It saves the patient from being exposed to more dye.exposed to more dye. • 92978 IVUS92978 IVUS APC 670 $1,877.71APC 670 $1,877.71 • If the iliacs are injected to see if the closureIf the iliacs are injected to see if the closure device (angio seal or plugs) can be inserted, itdevice (angio seal or plugs) can be inserted, it is not coded separately.is not coded separately. • AngioSeal, Perclose, etc used to close accessAngioSeal, Perclose, etc used to close access assignedassigned G0269G0269 packaged APC 19900packaged APC 19900
    53. 53. 53 IR G CodesIR G Codes  See PM A-02-129See PM A-02-129  G0275 Renal artery angiography withG0275 Renal artery angiography with Cardiac Cath (non selective, drive by only)Cardiac Cath (non selective, drive by only)  G0278 Iliac artery angiography withG0278 Iliac artery angiography with Cardiac Cath (non selective, drive by only)Cardiac Cath (non selective, drive by only)  Both include cath insertion, dye, S&I. APCBoth include cath insertion, dye, S&I. APC 19900 Packaged19900 Packaged  Effective January 1, 2003 for hospitalsEffective January 1, 2003 for hospitals  If diagnostic selective, use 3634X and S&IIf diagnostic selective, use 3634X and S&I
    54. 54. 54
    55. 55. 55 Thank You!Thank You!
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