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If you have been coding vascular surgery or interventional radiology over the past few years, you have likely encountered procedures to insert an iliac branched endograft (IBE) a number of times.

Before we review the codes for an IBE and some of the key guidelines for coding these services, let’s talk more about what an iliac branched endograft is and how to recognize it in an operative report. An iliac branched endograft is a graft inserted into the iliac artery through a catheter where the graft is placed at the iliac bifurcation (the point at which the common iliac artery splits to form the external and internal iliac arteries). This type of graft extends into all three iliac arteries on the same side (i.e., a graft that extends into the right common, right internal, and right external arteries). Think of this point where the graft is placed as an intersection between the three arteries: if you head north, you are on common iliac lane; if you head east in the right leg or west in the left leg, you are on internal iliac avenue; and if you head south you are on external iliac drive. If you are a visual learner and need to see this “intersection” for yourself, check out this link which shows the common, external, and internal iliac arteries and the point where they all come together: https://i.ytimg.com/vi/wdsXmpZIgnM/hqdefault.jpg.

An IBE is placed to treat an aneurysm, a rupture of the artery, or other disease/trauma such as a dissection. An IBE is placed when the goal is to maintain/preserve blood flow into the external and internal iliac arteries despite the presence of an aneurysm or other disease in the artery at a point that would normally compromise blood flow to those arteries.

Coding Tip: Remember, an IBE is a graft that extends into all three iliac arteries – the common, the internal, and the external iliac arteries. If an iliac endograft is placed in the iliac arteries but only extends into one or two of these iliac arteries (e.g., an endograft which extends across the iliac bifurcation into the left common and left external iliac artery without extension into the left internal iliac artery), it is not an IBE. This type of endograft should not be coded with a CPT code for an iliac branched endograft.

Now that we have a good definition of what an iliac branched endograft is, let’s look at how to code the procedure for inserting this type of graft. You will have two different code options:

• + CPT 34717: Endovascular repair of iliac artery at the time of aorto-iliac artery endograft placement by deployment of an iliac branched endograft including pre-procedure sizing and device selection, all ipsilateral selective iliac artery catheterization(s), all associated radiological supervision and interpretation, and all endograft extension(s) proximally to the aortic bifurcation and distally in the internal iliac, external iliac, and common femoral artery(ies), and treatment zone angioplasty/stenting, when performed, for rupture or other than rupture (e.g. for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation, penetrating ulcer, traumatic disruption), unilateral (list separately in addition to code for primary procedure)
• CPT 34718: Endovascular repair of iliac artery not associated with placement of an aorto-iliac artery endograft at the same session by deployment of an iliac branched endograft including pre-procedure sizing and device selection, all ipsilateral selective iliac artery catheterization(s), all associated radiological supervision and interpretation, and all endograft extension(s) proximally to the aortic bifurcation and distally in the internal iliac, external iliac, and common femoral artery(ies), and treatment zone angioplasty/stenting, when performed, for other than rupture (e.g. for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation, penetrating ulcer, traumatic disruption), unilateral

There is a lot of important terminology in the code descriptions above so let’s break this down a bit at a time.

Timing of the Procedure: The first thing to notice is that the timing of the procedure determines the code selected for the IBE:

1) If the IBE is inserted at the same time (i.e., during the same surgery) as another aorto-iliac endograft, assign CPT code 34717 for your IBE procedure. Notice the plus sign in front of 34717 – this means that the CPT code is an add on code. To report CPT 34717, you must first code one of the following CPT codes for the other aorto-iliac endograft inserted during the same surgery: 34703, 34704, 34705, or 34706,

2) If the IBE is not inserted during the same surgery as another aorto-iliac endograft (e.g., the patient had an aorto-iliac endograft previously and is now having an IBE placed at a later time), you should assign CPT 34718 instead.

Indications: Notice that CPT 34717 is reported for any IBE procedure performed in conjunction with another aorto-iliac endograft procedure, whether the IBE is placed for rupture or for some condition other than rupture (e.g., aneurysm). When it comes to CPT 34718, though, for the stand-alone/isolated IBE procedure, this code is restricted to conditions “other than rupture” per its CPT code description. This is not an oversight in CPT. We have a CPT instructional note under CPT 34718 that states “for placement of an isolated iliac branched endograft for rupture, use 37799.” So for an IBE placed without another aorto-iliac endograft placement during the same surgery, if the indication is rupture, code unlisted CPT 37799 rather than CPT 34718. For a stand-alone/isolated IBE procedure for all other indications other than rupture, CPT 34718 is your code.

What is Included: Whether the IBE is placed at the time of another aorto-iliac endograft placement or separately from that placement, several procedures/services that may be performed during the IBE placement are included:

• Pre-Procedure Sizing and Device Selection: Any angiograms or other imaging to visualize the anatomy of the iliac arteries and determine the diameter of the graft to insert are included in this procedure.
• Ipsilateral Selective Iliac Artery Catheter Placement(s): The term ipsilateral means “same side.” So placing one or more catheters into any of the iliac arteries on the same side where the IBE is placed is included in the procedure. Do not code CPT codes 36140 or 36245-36248 separately with these codes for those ipsilateral catheter placements.
• Radiological Supervision & Interpretation: Any imaging needed to guide the procedure and confirm successful deployment of the IBE (e.g., angiograms) is included in the procedure.
• Extension Grafts from the Aortic Bifurcation through the Internal/External Iliac Arteries and the Common Femoral Artery: Sometimes it is necessary to add another piece of graft called an extension graft above the IBE or below it to seal the graft and prevent continued blood flow into the area of the artery being repaired by the endograft. When these extension grafts are placed anywhere between the aortic bifurcation (the point at which the abdominal aorta splits to form the right and left common iliac arteries) and the common femoral artery (a major artery of the thigh just below the iliac arteries anatomically), including extension grafts in the internal/external iliac arteries which lie between these two points anatomically, the extension grafts cannot be coded separately.
• Treatment Zone Angioplasty/Stenting: The treatment zone in any endograft procedure is defined as all of the vessels into which the graft passes. So in the context of an IBE, the treatment zone would include the common, internal, and external iliac arteries into which the endograft passes. Any angioplasty (enlarging the diameter of the arteries with a balloon or other similar technique) or stenting (placing additional metal or drug-eluting stents in the arteries to keep the arteries open) within the treatment zone for the IBE are not separately billable.

What is not included: Like other aorto-iliac endograft procedures for repair of the abdominal aorta and/or iliac arteries, the following services can be billed in addition to CPT 34718 for a stand-alone/isolated IBE procedure.

• Large Sheath: If a 12 French or larger sheath is used during percutaneous access to deploy an IBE, CPT 34713 can be coded in addition to CPT 34718.
• Open Femoral Artery Exposure: If a cutdown incision is made over the femoral artery to deliver the IBE, CPT 34812 can be coded in addition to CPT 34718.  Alternatively, if a cutdown incision is made over the femoral artery followed by creation of a conduit (attaching a piece of graft to the artery to allow delivery of the IBE or to place the patient onto cardiopulmonary bypass), CPT 34714 can be coded in addition to CPT 34718.
• Open Iliac Artery Exposure: If a cutdown incision is made over the iliac artery to deliver the IBE, CPT 34820 can be coded in addition to CPT 34718.  Alternatively, if a cutdown incision is made over the iliac artery followed by creation of a conduit, CPT 34833 can be coded in addition to CPT 34718.
• Open Brachial Artery Exposure: If a cutdown incision is made over the brachial artery to deliver the IBE, CPT 34834 can be coded in addition to CPT 34718. 
• Open Axillary/Subclavian Artery Exposure: If a cutdown incision is made over the axillary or subclavian artery to deliver the IBE, CPT 34715 can be coded in addition to CPT 34718.  Alternatively, if a cutdown incision is made over the axillary or subclavian artery followed by creation of a conduit, CPT 34716 can be coded in addition to CPT 34718.

Final Coding Tip: Note that the CPT guidelines only address these additional services being billed with CPT 34718 not CPT 34717. While this may feel contradictory at first, it is important to remember that CPT 34717 is an add-on code. That means that CPT 34717 would always be billed with another primary CPT for an aorto-iliac endograft (e.g., 34703, 34704, etc.). Because the CPT guidelines already specify that all of these additional services may be billed with the CPT codes for the primary procedure codes that CPT 34717 would be billed with, it is not necessary for the parenthetical guidelines to be updated to list all of these same services as being billable with the add on code 34717. The intent here is not to say that what is included and what is separately billable in CPT code 34718 is different from what is included and what is separately billable in CPT 34717.

I hope that the guidelines and explanations above help you code IBE procedures with confidence. If you have additional questions about how to code these procedures, feel free to drop your questions in the comments, so we can all learn from each other.