Category: Article

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The topic of scout endoscopies is one that comes up often for coders in all different specialties because surgeons often perform these procedures during non-endoscopic procedures in the chest, abdomen, and pelvis to help them visualize the organs/structures they are working on or ensure successful completion of their procedure. Distinguishing a diagnostic endoscopy from a scout endoscopy can be difficult at first, but fortunately, we have some guidelines that can help us.

In the NCCI Policy Manual which is published each year by the Centers for Medicare & Medicaid Services (CMS) a “scout endoscopy” is defined a couple of different ways. The first definition we see for a “scout endoscopy” is a type of endoscopy that may be performed before a non-endoscopic surgery:

A “scout” endoscopy to assess anatomic landmarks or assess extent of disease preceding another surgical procedure at the same patient encounter is not separately reportable. – NCCI Policy Manual, Chapter 6, section C.6

An electromyogram (or EMG) is a test commonly performed by neurologists to test the health and electrical response of the muscles. During an EMG, small needle electrodes are passed through the skin and into the muscles being tested to measure the electrical activity of the muscles as patients are asked to contract and relax the muscle being tested. The physician uses special equipment to listen to and/or visualize the muscle activity. The goal of the EMG is to confirm if muscle activity is normal or if there are abnormalities which indicate a disease/disorder of the muscles. An EMG test can be useful in diagnosing disorders of the muscles or nerves that provide electrical signals to those muscles including conditions such as carpel tunnel syndrome, multiple sclerosis (MS), and muscular dystrophy.

An EMG is most commonly performed on muscles in the arms and legs (also known as the “limb muscles”), but may be performed on muscles of the head, neck, and trunk as well. Our article today will focus on how to code EMGs of the limb muscles since these procedures are so commonly performed. If you do have questions about coding EMGs of the head/neck/trunk muscles, head over to our “contact” page on our website to ask your question there or comment on this article, and I will be happy to assist with those additional questions.

The first thing to know about EMG testing of the limbs is that it may be performed by itself or in conjunction with another test known as a nerve conduction study (NCS) during the same encounter. Nerve conduction studies measure the speed at which nerves relay signals to the muscles they innervate (or communicate with). There are different codes for EMGs of the arms/legs when performed with an NCS when compared to EMGs performed by themselves without an NCS. We will look at our code options in detail in just a moment.

The next thing to know about EMGs of the limbs is that they may be either limited or complete.

• A limited EMG of the limb involves testing 4 or fewer muscles in a single limb.

• A complete EMG of the limb involves testing 5 or more muscles in a single limb.

One common mistake I see coders make when counting muscles to determine if the EMG is limited or complete is counting all muscles tested in multiple limbs together and then concluding the EMG is complete. So to clarify this concept of limited vs. complete, you need to determine how many muscles are tested in a “single limb” and decide if the EMG in that one limb is limited or complete. While more than one limb is often tested in a single encounter, you will count “one” for each named muscle tested in each limb to get your total muscle count for that limb — the muscles tested in each limb are counted separately “by limb” and not calculated all together for purposes of EMG coding. Example: If a physician performs an EMG on the right arm and right leg that is “two limbs” for purposes of EMG coding. You will need to determine if the EMG in the right arm is limited or complete and then decide separately if the EMG in the right leg is limited or complete. Using this example of an EMG on the right arm and right leg, if the right deltoid, right biceps brachii, right triceps brachii, and right abductor pollicis longus were tested (all of which are right arm muscles which gives us four muscles in total for the right arm) and then the right vastus lateralis, right biceps femoris, right tibialis anterior, right peroneus brevis, and right extensor digitorum longus muscles were tested (all of which are right leg muscles which gives us five muscles in total for the right leg), the right arm EMG would be limited (four or fewer muscles in that limb) while the right leg EMG would be complete (five or more muscles tested in that limb). As you can see, not all limbs have to undergo the same level of testing (some may be limited while others are complete). Whether a limited or complete EMG is performed in each limb depends on the patient’s symptoms and the condition the physician is trying to rule out or confirm.

Now that we have some ground rules laid out, let’s look at the codes for EMGs. We will first look at the codes for EMGs performed alone without a nerve conduction study during the same case/encounter:

• CPT 95870: Needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles other than thoracic paraspinal, cranial-nerve innervated muscles, or sphincters

• CPT 95860: Needle electromyography; 1 extremity with or without related paraspinal areas

• CPT 95861: Needle electromyography; 2 extremities with or without related paraspinal areas

• CPT 95863: Needle electromyography; 3 extremities with or without related paraspinal areas

• CPT 95864: Needle electromyography; 4 extremities with or without related paraspinal areas

Much of the confusion regarding how to code EMGs starts with the wording of these particular CPT codes. As you can see, CPT 95870 may be used for a “limited electromyography (EMG) in 1 extremity” (so we at least see the words limited and extremity in this code description); however, CPT 95870 also may be used for a variety of other purposes (e.g., to report EMG testing of non-limb muscles other than the exclusions such as sphincter muscles listed in the CPT code description). The number of different reasons that one might report CPT 95870 often confuses coders and makes the “limited EMG 1 extremity” portion of the code description easy to overlook. Neveretheless, if your physician performs a limited EMG of a limb(s) and does not perform a nerve conduction study during that same encounter, CPT 95870 is your code. You will report one unit of 95870 for each limited EMG performed in a different extremity. Example: If a physician tests the right arm and left arm during an EMG with testing of the bilateral deltoid, bilateral biceps brachii, bilateral triceps brachii, and bilateral adductor pollicis longus muscles, you have four muscles tested in each limb which is two limited EMGs. You would code 95870 x1 for the right arm and then 95870.59 (or XS for separate site if the patient has Medicare) x1 for the left arm. Note: Payer guidelines may vary on whether they want you to code 95870 x2 on one line of code or 95870 x1 and 95870.59 x1 (or XS) on two lines of code. In my experience, reporting on separate lines of code is generally more accepted by payers, but be sure to check your payer guidelines to ensure appropriate coding.

CPT codes 95860-95864 are worded in a more straightforward manner than CPT 95870 (in that the descriptions contain the word electromyography which again means EMG and tells us how many extremities should be tested to report the code). However, nowhere in these code descriptions do we see the word “complete” which we discussed earlier. We have to go to the CPT guidelines which appear in the paragraphs leading up to these codes in the CPT manual to get our instructions about these codes being restricted to reporting complete EMGs only and about what is considered a limited and what is considered a complete EMG to even begin choosing between these codes. Here are the CPT guidelines that support what I shared earlier about how a limited and complete EMG are defined: “Use 95870 or 95885 when four or fewer muscles are tested in an extremity. Use 95860-95864 or 95886 when five or more muscles are tested in an extremity.” Therefore, even though the code descriptions of CPT 95860-95864 themselves don’t mention the word “complete,” because the CPT guidelines restrict the use of these codes to complete EMGs where five or more muscles are tested in an extremity, you may only report 95860-95864 if you are reporting complete EMGs in the number of extremities listed in the code description.

Another interesting part of the CPT code description for 95860-95864 is the phrase “with or without related paraspinal areas.” The paraspinal muscles run alongside the spine. Related paraspinal muscles refers to those paraspinal muscles that line the part of the spine with nerves that are branching off of the spinal cord and innervating the limb muscles being tested during the EMG (e.g., cervical paraspinal muscles would be included in EMG testing of the arm(s) as the “related paraspinal muscles” while lumbar paraspinal muscles would be included in EMG testing of the leg(s) as the “related paraspinal muscles”). The AMA has stated in CPT Assist December 2010 that the paraspinal muscles in these related paraspinal areas cannot be tested independently without testing the corresponding limb muscles which is why the testing of these muscles is included in codes 95860-95864 and not separately reported. The AMA also states in this same article that you may count the paraspinal muscles as one of your five muscles needed to code a complete EMG in the limb being tested.

Now that we have looked at the codes for the stand-alone EMG codes, let’s take a look at the codes for EMGs performed with nerve conduction studies during the same case/encounter:

• CPT 95885: Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure)
• CPT 95886: Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete (List separately in addition to code for primary procedure)

These codes are more optimally worded. As you can see, CPT 95885 is reported for a limited EMG during a nerve conduction study while CPT 95886 is reported for a complete EMG during a nerve conduction study. These codes also include the phrase “each extremity” confirming that one unit of the code should be reported for each limb in which a limited or complete EMG is performed. Example: If the bilateral legs are tested with EMG during a nerve conduction test with testing of the vastus lateralis, biceps femoris, and tibialis anterior muscles on both legs, this case would be coded as CPT 95885 x2 for the two limited EMGs during a nerve conduction test since three muscles are tested in each leg (which is two limbs in total). As with codes 95870 and 95860-95864, it’s possible for one limb to be tested and support a complete EMG while the other limb is tested and only supports a limited EMG. It’s important to assign the code that most accurately reflects the level of testing “per limb.” Finally, we see the phrase “list separately in addition to code for primary procedure” which means these codes 95885-95886 are “add on codes” in CPT. They may only be reported when a nerve conduction study (CPT 95907-95913) has been reported. If a nerve conduction study was not performed, do not report these codes (instead go back to codes 95870 or 95860-95864 to report your EMG test).

I hope this information helps you the next time you code an EMG case. If you have specific questions about challenging EMG scenarios, feel free to drop us an email using the contact form on our website.

Adjacent tissue transfer involves rearranging/transferring local areas of the skin along with the underlying subcutaneous tissues to repair a defect. The “defect” repaired may be a traumatic wound/injury or may be a defect left after excision of a lesion/mass. Some examples of adjacent tissue transfer include the following techniques:

• W-plasty: An adjacent tissue transfer technique where additional incisions in the shape of the letter W are made along the edges of the wound to reduce tension on the edges of the wound and create some laxity in the tissue that allows the wound edges to come together to repair the wound.
• Z-plasty: An adjacent tissue transfer technique where additional incisions are made on either side of a wound creating a shape that resembles the letter Z. These additional incisions create flaps of tissue that are then sutured together to repair the wound.

If you are having trouble picturing what a W-plasty or Z-plasty looks like, check out this link with a great picture of each technique (I’m a visual learner so, for me, pictures are worth a thousand words): W and Z plasty

• V-Y plasty: An adjacent tissue transfer technique where incisions are made in a shape resembling the letter V to create a flap that is then advanced (moved from one position to another) to repair a defect. The final repair which includes a straight line of sutures to repair the area where the flap came from and two additional lines of sutures to sew in the advancement flap in the defect looks like the letter Y which is where this technique “V-Y plasty” gets its name. Again if you are more of a visual learner, here’s a picture showing the “V” portion of the technique in designing the flap and the “Y” portion of the technique in advancing and suturing the flap into place over the defect: V-Y Plasty .
• Rotation flap: An adjacent tissue transfer technique where additional incisions are made to create a flap next to a defect that is then “rotated” over the defect to repair it. Here is a visual for this technique: Rotation Flap
• Random Island Flap: An adjacent tissue transfer technique that involves creation of a flap where the skin is divided all the way around the flap (the incisions completely surround the flap much like water completely surrounds an island which is where this technique gets its name). This island flap receives its blood supply from random non-dominant blood vessels in the subdermal plexus which is where the term “random” island flap comes in. The flap receives blood flow from the donor site where the flap is created and is then moved over or under other tissues to reach the defect needing repair.
• Advancement Flaps: An adjacent tissue transfer technique where incisions are made to create a flap that slides or “advances” forward from its normal location into a defect for repair. Here is a visual for this type of flap: Advancement Flap

There are some other less common techniques that might also fit the definition of adjacent tissue transfer like S-plasty, H-plasty, etc.. As a general rule, though, any technique that involves creating additional incisions to create flaps of tissue that include skin and/or subcutaneous tissues that are then advanced, rotated, or relocated in some manner to repair a defect could meet the definition of adjacent tissue transfer.

Now that we have discussed some common adjacent tissue transfer techniques, let’s take a look at the codes themselves. The first thing we will notice is that there are adjacent tissue transfer codes for specific anatomic sites as long as area requiring the adjacent tissue transfer is not larger than 30 sq cm.

Trunk:

For adjacent tissue transfer of the trunk (e.g., back, chest, abdomen), when the area repaired by adjacent tissue transfer is 30 square centimeters or less, assign one of the following codes:

• CPT 14000: Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less
• CPT 14001: Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm

Scalp/Arms/Legs:

For adjacent tissue transfer of the scalp, arms, and/or legs when the area repaired by adjacent tissue transfer is 30 square centimeters or less, assign one of the following codes:

• CPT 14020: Adjacent tissue transfer or rearrangement, scalp, arms, and/or legs; defect 10 sq cm or less
• CPT 14021: Adjacent tissue transfer or rearrangement, scalp, arms, and/or legs; defect 10.1 sq cm to 30.0 sq cm

Forehead/Cheeks/Chin/Mouth/Neck/Axillae/Genitalia/Hands/Feet

For adjacent tissue transfer of the forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet when the area repaired by adjacent tissue transfer is 30 square centimeters or less, assign one of the following codes:

• CPT 14040: Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hand and/or feet; defect 10 sq cm or less
• CPT 14041: Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hand and/or feet; defect 10.1 sq cm to 30.0 sq cm

Eyelids/Nose/Ears/Lips

For adjacent tissue transfer of the eyelids, nose, ears and/or lips, when the area repaired by adjacent tissue transfer is 30 square centimeters or less, assign one of the following codes:

• CPT 14060: Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less
• CPT 14061: Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 sq cm to 30.0 sq cm

Once the defect being repaired with adjacent tissue transfer reaches an area of 30.1 sq cm or larger, instead of reporting the codes we have discussed above that are specific for different anatomic sites, we have special codes that are reported for “any area” larger than 30 sq cm.

Any Anatomic Area (Defect larger than 30 sq cm):

When adjacent tissue transfer is performed for a single defect at any anatomic site and the defect is larger than 30 sq cm, report CPT 14301 for the first 60 sq cm and 1 unit of CPT 14302 for each additional 30 sq cm or part thereof.

• CPT 14301: Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60 sq cm
• CPT 14302: Adjacent tissue transfer or rearrangement, any area; each additional 30 sq cm, or part thereof

The CPT guidelines have some very specific rules regarding coding adjacent tissue transfer that it is important to understand to ensure proper use of these codes.

Rule #1: If the edges of a wound are “undermined” (lifted up and mobilized) without creating any additional incisions, this is not an adjacent tissue transfer. CPT states that for undermining alone, you should code a complex repair code (CPT codes 13100-13160).

Rule #2: If a traumatic wound is in a shape that “incidentally” results in one of the techniques we just discussed for adjacent tissue transfer (e.g, a W-plasty), this is also not an adjacent tissue transfer. To code adjacent tissue transfer, the surgeon must make incisions and intentionally create the shapes/flaps that meet the definition of adjacent tissue transfer.

Rule #3: Because adjacent tissue transfer can be reported for repair of a defect following excision of a lesion, the excision of a lesion at the same anatomic site as an adjacent tissue transfer is not separately coded. Do not report codes 11400-11446 or 11600-11646 for excision of benign or malignant skin lesions at the site of adjacent tissue transfer.

Rule #4: Adjacent tissue transfer is coded based on the total square centimeters of area repaired with adjacent tissue transfer techniques. When coding adjacent tissue transfer, the term “defect” refers to the primary defect (the area needing repair in the first place) and the secondary defect (any defect created by the effort of designing and mobilizing a flap) together. Add together the total square centimeters of the primary and secondary defect areas to get your total area for repair. Coding tip: Sometimes a surgeon will give you the total area in terms of square centimeters but other times you have to calculate that yourself. If the surgeon provides measurements of the length and width of a wound in centimeters, multiply those measurements together to get your total square centimeters. For example, if a surgeon stated that a traumatic laceration on the arm was 8 cm x 2 cm, and that wound was repaired with a W-plasty, I would multiply 8 x2 to arrive at 16 square centimeters of area for my adjacent tissue transfer code.

Rule #5: If two non-contiguous areas (two areas that are not touching and have distinct margins) are repaired with adjacent tissue transfer and those anatomic areas happen to fall under the same range of CPT codes for a defect that is 30 sq cm or smaller, report separate adjacent tissue transfer codes for each area. For example, if the surgeon performs a rotational flap for an area that is 7 x2 cm on the neck and then an advancement flap for an area that is 3 x4 cm on the foot, you would code 14041 x1 for the adjacent tissue transfer of 14 sq cm on the neck and then 14041 x1 again for the adjacent tissue transfer of 12 sq cm on the foot. On the second line of code with CPT 14041, you would report either modifier 51 or modifier 59 (depending on payer guidelines). 

Let’s put this all together with a couple of chart examples. 

Example #1: A 55-yr-old patient presents with a traumatic laceration that is 8 x3 cm on the right forearm. After sterile prep and drape, W-plasty relaxing incisions were made along the length of the wound. The edges of the wound then came together nicely allowing us to complete our adjacent tissue transfer over the entire wound surface area. The patient tolerated the procedure well and will be seen in our office in a week for a standard wound check.

Answer Example #1: The bolded portions of the note above are keys to our code selection. We see the wound dimensions are “8 x 3 cm.” We also see the location on the “right forearm.” Next we see the technique used of a “W-plasty” with additional incisions created all along the wound edge to create some laxity in the tissues. Finally, we see that the wound edges comes together and that this adjacent tissue transfer technique of a W-plasty was performed “over the entire wound surface area.”  Since the entire wound surface area was repaired with adjacent tissue transfer, we will multiply the length (8 cm) by the width (3 cm) to calculate the total square centimeters of the wound which is 24 sq cm. Since the wound is on the forearm, our code will be CPT 14021.

Example #2: A 66-yr-old patient presents with a very extensive area of melanoma on the back. After sterile prep and drape, the large area of melanoma measuring 10 cm on the lower back was excised down through the subcutaneous fat. Generous wide margins were obtained from the superior, inferior, and lateral margins to ensure complete removal of disease. This left a very extensive defect measuring 20 cm x 5 cm. Next, back cuts were made all along the wound edges, raising rotational flaps that were brought into the defect and sutured to achieve repair. Drains were inserted in the upper portion of the prior defect in the area of deepest dissection. Patient will present to the office in 5 days for a drain removal, wound check, and to discuss final pathology results.

Answer Example #2: Once again, the bolded portions of the note are keys to our code selection. In this case, rather than starting with an open traumatic wound, the surgeon is “excising” melanoma and then repairing a defect created by that excision. As previously discussed, the excision of a malignant skin lesion at the site of adjacent tissue transfer is bundled to the adjacent tissue transfer and should not be reported with a separate code. Here, because the melanoma is excised and then rotational flaps are used for repair in the defect left by the removal of the melanoma, we will not code any additional CPT code for excision of the melanoma.

From there, “back cuts” are made “all along the wound edge.” Back cuts are additional incisions made starting at the wound edge and working outward into the surrounding tissue. These incisions are often used to create flaps along the wound edge that can be brought together for repair. Therefore, the term “back cuts” might be a key word that confirms an adjacent tissue transfer since the required “additional incisions” needed to mobilize adjacent tissue for repair are met by stating that “back cuts” were made. From there, we see the surgeon designing “rotational flaps” that are then “rotated into the defect” and sutured to repair the area. This is an adjacent tissue transfer per CPT guidelines.

While multiple rotational flaps are created, the flaps are all repairing one contiguous large defect of 20 cm x 5 cm left behind after this excision of the melanoma. Since one contiguous defect is repaired, we will code this entire area as “one” for purposes of adjacent tissue transfer. First, we will calculate the total area of repair which is 20 cm x 5 cm or 100 sq cm in total. Since the total area is greater than 30 sq cm, we cannot use codes 14000/14001 even though the adjacent tissue repair is on the back which is part of the trunk. Instead, we need to go to codes 14301/14302 for “any anatomic area” with an adjacent tissue transfer greater than 30 sq cm. We will code CPT 14301 x1 for the first 60 sq cm of repair and then CPT 14302 x2 for the remaining 40 sq cm of repair. Notice, we have 2 units of CPT 14302 since this code is reported for each additional 30 sq cm “or part thereof.” So the first unit of 14302 is coded for an additional 30 sq cm which takes us to 90 sq cm in total when combined with 14301 which captured the first 60 sq cm of repair. We then have 10 sq cm leftover so the second unit of 14302 is for “part of 30 sq cm” (10 sq cm to be exact) which gives us our total repair area of 100 sq cm.

In vascular surgery, the question of how to code an abdominal aortogram is the topic of many emails I have received over my career and a question I see posted on forums online pretty regularly. So I wanted to dedicate today’s article to answering the question of whether to code CPT 75630 or 75625 when coding a report describing an abdominal aortogram. Distinguishing these codes becomes particularly challenging when imaging of some or all of the arteries of the legs (a lower extremity angiogram) is performed in conjunction with the aortogram. Before we dive into some guidelines and examples, here are a few terms you need to be familiar with to help you understand reports for this procedure:

• Aorta: The aorta is largest artery in the body. This artery extends from the heart to the iliac arteries in the pelvis. The aorta is divided into four segments in anatomy. I have explained the definition and location of all four segments below, but today, we will be focused on the abdominal aorta.
• Abdominal aorta: The segment of the aorta which begins at the level of the diaphragm (the muscle that separates your chest cavity from your abdomen) and continues to what is known as the aortic bifurcation where the abdominal aorta branches into the right and left common iliac arteries which supply blood flow to your legs. This is the segment of the aorta we will be discussing today.
• Descending thoracic aorta: The segment of the aorta which begins at the lower end of the aortic arch (explained below) and proceeds down to the level of the diaphragm.
• Aortic arch: The segment of the aorta which is located between the ascending aorta and the descending thoracic aorta and is the portion of the aorta where the “head vessels” (the subclavian, the carotid, and the brachiocephalic trunk arteries which supply blood flow to the head, neck, and arms) branch off.
• Ascending Aorta: The segment of the aorta that begins at the upper end of the aortic arch and continues through the aortic root and down to the aortic valve.  The aortic root is where the coronary arteries which supply blood flow to your heart connect to the aorta.  The aorta ends at this point (the heart is located on the other side of the aortic valve).
• Aortogram: A set of images obtained in one segment of the aorta after introducing dye into the aorta through a catheter. An aortogram is sometimes referred to as aortography. These two terms mean the same thing.
• Arteriogram: A more general term used to refer a set of images obtained in any artery in the body after introducing dye into that artery through a catheter. When the term “arteriogram” is used to refer to dye introduced into the aorta, arteriorgram is a synonym for aortogram and would mean the same thing in a report.
• Angiogram: An even broader term than arteriogram, an angiogram refers to a set of images obtained in any blood vessel in the body (artery or vein) after introducing dye into that blood vessel through a catheter. When the term “angiogram” is used to refer to dye introduced into the aorta, it is a synonym for aortogram and would mean the same thing in a report.
• Abdominal aortogram: A set of images of most or all of the abdominal aorta specifically taken after introducing dye into that part of the aorta through a catheter.
• Renal Artery Orifices: The place where the renal arteries connect to the abdominal aorta.
• Aortic Bifurcation: The place where the abdominal aorta ends and branches off into the right and left common iliac arteries.
• Infrarenal Aorta: Term used to describe the portion of the abdominal aorta below the renal artery orifices and above the aortic bifurcation.
• Distal Abdominal Aorta: Term generally used to describe the last few centimeters of the abdominal aorta right above the aortic bifurcation.
• Iliofemoral: A term used to refer to the iliac arteries and femoral arteries together. The iliac arteries are located just below the aortic bifurcation and help to supply blood flow to the legs and the pelvis while the femoral arteries are major arteries in the thigh that help supply blood flow to the legs.
• Lower Extremity Angiogram: A term used to refer to an angiogram obtained of the arteries of the legs. Lower extremity angiograms can be either unilateral (images of the arteries of one leg only) or bilateral (images of the arteries of both legs).
• Serialography: A technique that involves taking multiple images during an angiogram rather than a single image.

Now that we have some of the key terms outlined, let’s look at the description of the two codes we are discussing today:

• CPT 75625: Aortography, abdominal, by serialography, including radiological supervision and interpretation
• CPT 75630: Aortography, abdominal plus bilateral iliofemoral lower extremity, by serialography, including radiological supervision and interpretation

As you can see, CPT 75625 states “aortography abdominal” (referring to an aortogram of the abdominal segment of the aorta) by serialography. So CPT 75625 reports multiple pictures of the abdominal aorta by itself. This code can also be paired with codes for lower extremity arteriograms which we will see in a moment. CPT 75630 is for aortography again in the abdominal segment of the aorta, but it also includes imaging of the iliofemoral arteries bilaterally (both the left and the right sides are imaged).

Where much of the confusion comes in with these two codes lies in whether to code 75625 with a lower extremity arteriogram for imaging of the arteries of the legs (75710 or 75716) or whether to code 75630 alone. There are two keys to look for when trying to decipher these two codes:

1. How much of the arteries of the legs were imaged? To determine this, focus on the physician’s interpretation of the images. Is he/she talking only about findings in the upper legs (e.g., do they see the iliac arteries and femoral arteries alone), or are they talking about findings of arteries all the way down the legs (e.g., can you see findings of the below the knee popliteal and the tibial/peroneal arteries which lie in the calf)?
2. Where is the catheter at the time dye is introduced, and does that catheter “move” after obtaining the images of the abdominal aorta and before obtaining images of the arteries of the legs? With CPT 75630, the catheter is usually placed in one position towards the top of the abdominal aorta near the renal arteries, dye is introduced once from this one catheter position, and multiple images of the abdominal aorta, iliac, and femoral arteries are obtained. When coding CPT 75625 alone, the catheter is again placed near the top of the abdominal aorta near the renal arteries, dye is introduced from this one catheter position, and multiple images of the abdominal aorta alone are taken. From there the physician may move the catheter down to just above the aortic bifurcation or into the arteries of one or both legs and introduce more dye and then take more images/pictures of the arteries of the legs from this new catheter position(s). It is this movement of the catheter and introduction of more dye from that second catheter position followed by additional imaging that allows us to code 75625 and code 75710 or 75716 together, which tells the payer that the aortogram and the lower extremity artery angiograms were separate studies.

There are a couple of additional tips we need to keep in mind when coding for aortograms:

1. CPT codes from the radiology section of the manual like CPT 75625 and 75630 include “radiology supervision and interpretation.” That means that it is not enough for the physician to just tell us where the catheter is located and the fact that he is introducing dye and taking images/pictures (the supervision part). He also has to tell us what he sees on those images/pictures (the interpretation part) to be able to give credit for these CPT codes.
2. Per the CPT guidelines, all codes that have the language “radiology supervision and interpretation” in their CPT code description require images to be stored in the patient’s medical record. This means that if the physician introduces dye to visualize the arteries but doesn’t take any images that are stored (e.g., in a system like PACS), you cannot bill one of these codes with the term “radiology supervision and interpretation” in its CPT code description. During aortograms, physicians/hospitals do typically store their images (it would be very rare that they do not store images), but if you work for a coding/billing company where you are coding for clients and cannot see the images on file in the patient’s chart (e.g., you are coding from an electronic medical record and the images are stored in a separate PACS system that you cannot access), it is important to talk to your clients directly or to your management team internally and ensure they understand this rule and have confirmed that the clients are permanently storing all of their images before you proceed with coding and billing.
3. When you code an aortogram (either CPT 75625 or 75630), you are indicating that the physician is imaging most or all of the abdominal aorta (based on the definition of an aortogram). If the physician were to image just the last few centimeters of the abdominal aorta (the distal aorta only), he/she would not be meeting the definition of an aortogram. Incidental imaging of just those last few centimeters of the abdominal aorta wouldn’t be billed separately as an aortogram because the physician is not imaging enough of the aorta to confirm or rule out presence of disease in the abdominal aorta. Incidental imaging of those last few centimeters of the aorta just above the aortic bifurcation would be considered part of the lower extremity angiogram and not reported with an aortogram code.
4. These codes we are discussing today are for the radiology supervision and interpretation only (obtaining and interpreting the images). They do not include the placement of catheter(s) into the arteries or ultrasound guidance to gain access into the arteries. These procedures are reported with their own CPT codes. We are focusing today on the radiology codes for aortograms, but you can check your CPT manual for guidelines regarding coding your catheter placements and ultrasound guidance separately or head over to our “contact” portion of the Coding Mastery page and reach out if you have questions regarding coding this part of the procedure.

Okay let’s put this in context with a couple of examples and see if we can determine whether 75630 or 75625 is appropriate:

Example #1: The right femoral artery was accessed using Seldinger technique. A 6 French sheath was then inserted and advanced to the proximal abdominal aorta where contrast was introduced. An aortogram was obtained. The catheter was then withdrawn to the distal aorta where additional contrast was introduced. We then obtained images in a step-wise fashion in the bilateral lower extremities. Findings of angiographic imaging are noted below:

Aorta: The abdominal aorta is patent without significant plaque/lesions. The renal artery orifices are patent without significant stenosis.

Right Lower Extremity: The right common iliac artery has minimal plaque that is non-obstructing. The arteries are patent down through the right superficial femoral artery, but in the region of the above the knee popliteal artery, there is a high-grade stenosis (~70%). This artery reconstitutes below the knee. The tibio-peroneal trunk, anterior tibial, and posterior tibial arteries are patent, but the peroneal artery has stenosis on the order of 90%.

Left Lower Extremity: The left common iliac artery is severely stenotic with a near total occlusion just above the origin of the external iliac artery. The remaining arteries including the external iliac, femorals, popliteal, and tibial/peroneal arteries are patent with minimal plaque but no obstructing lesions.

The patient will be referred to vascular surgery to discuss revascularization options based on the left iliac, right SFA, and right peroneal findings.

Answer Coding Example #1: The bolded portions of the note are keys to selecting our CPT code. We first see the physician entering the femoral artery through Seldinger technique (which is a percutaneous approach). He then threads the catheter up into the “proximal” abdominal aorta (so he is up at the top of the abdominal aorta with his catheter). He then tells us that he obtains an aortogram (so the aortogram was obtained with the catheter in the upper part of the abdominal aorta). He then moves the catheter down to just above the aortic bifurcation and introduces more dye where he obtains the lower extremity angiograms. From there, we need to make sure we have an interpretation of findings in both the aorta and the lower extremity arteries. When we go to the findings, we first see findings of the aorta. The aorta is patent (or wide open/normal) and the renal artery orifices are patent as well without any stenosis. These findings confirm that the physician is seeing most of the abdominal aorta (all the way from where the renal arteries connect to the aorta down to the aortic bifurcation) so he has met the definition of an aortogram. When then see findings of the arteries in both of the legs all the way down the legs. The physician is talking about the iliac, femoral, popliteal, tibial, and peroneal arteries (these arteries extend from around the hip area all the way down to the ankle). With these findings from the imaging and confirmation of the fact that the physician first obtained an aortogram from one catheter position up at the top of the aorta and then the lower extremity angiograms of both legs from a second catheter position just above the aortic bifurcation after moving the catheter, we can code CPT codes 75625 and 75716.

Example #2: The left femoral artery was accessed using Seldinger technique. A 6 French sheath was then inserted and advanced to the proximal abdominal aorta where contrast was introduced. An aortogram with iliofemoral runoff was obtained. Findings of angiographic imaging are noted below:

Aorta: The abdominal aorta is patent from the renal arteries to the aortic bifurcation.

Right Lower Extremity: The right common iliac artery has minimal plaque that is non-obstructing. The external iliac, common and superficial femoral, and above the knee popliteal are patent throughout their course.

Left Lower Extremity: The left common iliac artery is patent, but the external iliac artery has a stenosis on the order of 60%. This reconstitutes at the level of the common femoral artery which along with the superficial femoral and above the knee popliteal arteries is patent.

We will discuss the possibility of angioplasty/stenting of the left external iliac artery.

Answer Example #2: We again see the physician entering the femoral artery through Seldinger technique (percutaneous access). He then threads a catheter up into the proximal aorta much like we saw in example #1. He then introduces dye into the aorta and takes images of the abdominal aorta, and “bilateral iliofemoral runoffs” (or images of the iliofemoral arteries on both sides as the dye travels downstream from the aorta and into these arteries). We see no documentation of catheter movement between obtaining images of the aorta and images of the bilateral iliofemoral arteries.

We then need to look at our findings to see what images were obtained and confirm that we have an interpretation of those images. We first see the findings of the aorta. Again the physician has confirmed that the aorta is patent from the renal arteries to the aortic bifurcation, confirming that he is seeing most of the abdominal aorta on these images. He then comments on the bilateral iliac arteries, femoral arteries, and even makes mention of the above the knee popliteal. All of these arteries are patent/normal except for the left external iliac artery where we see a 60% stenosis. Since the physician obtains images of most of the abdominal aorta and the bilateral iliofemoral arteries together from “one catheter position,” this documentation supports CPT 75630. As one final coding tip, the physician may see and comment on arteries below the femoral arteries in a procedure coded with CPT 75630 (as he did in this case where he’s commenting on the above the knee popliteal arteries). This confuses many coders because CPT 75630 states “bilateral iliofemoral arteries” only so often when coders see other arteries mentioned they are tempted to steer away from code 75630. However, if the physician is obtaining the combined abdominal aortic images plus the bilateral lower extremity artery images from a single catheter position, your code is still CPT 75630 even if the physician comments on some additional arteries other than the iliac and femoral arteries that he can see while obtaining his images of the aorta and bilateral iliofemoral arteries.

In our last article, we discussed the differences between a partial mastectomy and excision of a breast mass and what documentation you would need to code each scenario. If you haven’t checked out that article, you can do so here:
http://codingmastery.com/2019/05/04/distinguishing-lumpectomies-and-excision-of-breast-mass/ . 

Today, we are going to continue on the topic of surgeries of the breast with a discussion about image-guided percutaneous breast biopsies. The codes to report this procedure changed back in 2014, and coders often still have some questions about how to appropriately code this procedure as technology advances and physicians in different facilities perform part but not all of the work described by these codes.

Before we take a look at the codes, there are a few terms that you need to know to understand the code descriptions and guidelines for reporting this service:

• Percutaneous means to puncture through the skin.
• Stereotactic guidance in the context of these codes involves the use of low-dose mammogram images (aka x-rays of the breast) to locate a lesion for biopsy.
• Ultrasound guidance involves the use of ultrasound images to locate a lesion for biopsy
• MR guidance involves the use of magnetic resonance imaging (MRI imaging) to locate a lesion for biopsy.
• Tomosynthesis is an imaging technique that uses low-dose x-rays (i.e., mammogram images) along with computer reconstruction to create 3D images of the breast.
• A localization device is a device such as a clip or pellet that helps to identify an abnormality in the breast that is small and cannot be felt during an exam. These devices are used to help physicians locate these abnormalities for biopsy, removal, or future exams.
• Calcifications are calcium deposits in the breast that are visible on mammogram images. These calcium deposits may further be described as macrocalcifications (larger deposits of calcium) or microcalcifications (very tiny deposits of calcium).
• A mass or lesion is a generic term meaning an  abnormal accumulation of tissue. We will use the term “lesion” to refer to all different abnormalities that may be found in the breast tissue for the remainder of this article, but definitions of specific types of abnormalities are provided here so you understand the difference in these terms when you see them in physician reports.

Now that we have our terminology down, let’s take a look at the CPT codes available for percutaneous biopsies of the breast:

• CPT 19081: Biopsy, breast, with placement of breast localization device(s) (e.g., clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including stereotactic guidance.
• +CPT 19082: each additional lesion, including stereotactic guidance (list separately in addition to code for primary procedure).
• CPT 19083: Biopsy, breast, with placement of breast localization device(s) (e.g., clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including ultrasound guidance.
• +CPT 19084: each additional lesion, including ultrasound guidance (list separately in addition to code for primary procedure).
• CPT 19085: Biopsy, breast, with placement of breast localization device(s) (e.g., clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including magnetic resonance guidance.
• +CPT 19086: each additional lesion, including magnetic resonance guidance (list separately in addition to code for primary procedure).

As you can see, for each of the different types of imaging guidance that may be used during a percutaneous breast biopsy, we have one “parent code” to report the first lesion biopsied using that type of imaging guidance and then an add on code that is reported for each additional lesion biopsied using that same type of imaging guidance.

It’s also important to note that the physician “may” insert a localization device or “may” image the specimen that was removed to ensure the area of concern is included in the tissue removed. When these additional procedures are performed during the same encounter as the biopsy they are included in CPT codes 19081-19086 and should not be reported with separate CPT codes. These additional procedures though are not “required” to report these CPT codes. Anytime we see that a part of the code description is followed by the phrase “when performed” it is an optional service that may be performed but is not required in order to report the CPT code. The portions of the procedure description that must be performed to code CPT codes 19081-19086 is a percutaneous breast biopsy performed using the imaging guidance described by the code (e.g., stereotactic guidance).

Another important rule to know about these codes is how to report multiple biopsies during the same encounter. If more than one biopsy is performed using the same imaging guidance technique, you will report the parent code for the first lesion biopsied followed by the add on code for each additional lesion biopsied. This rule applies even if the two biopsies are in different breasts (i.e., a bilateral procedure with one procedure performed on the right breast and the other on the left). However, if multiple biopsies are performed during the same encounter and different image guidance techniques are used for each biopsy, you will report the parent code for each of the imaging techniques. For example, if a stereotactic-guided biopsy is performed on a lesion on the left breast and an ultrasound-guided biopsy on a lesion on the right breast, we would report CPT 19081 for the initial stereotactic biopsy on the left and CPT 19083 for the initial ultrasound guided biopsy on the right. Again it is the two different image guidance techniques that change how the case is coded.

Physicians have also started using tomosynthesis for guidance during percutaneous breast biopsies in recent years. Unfortunately, we do not have a code for performing a percutaneous breast biopsy using tomosynthesis. Some coders are inclined to report CPT codes 19081/19082 for a tomosynthesis-guided breast biopsy because this technique in part involves taking low dose x-rays (aka mammogram images). However, the remainder of the technique which involves using computer reconstruction with these mammogram images to create 3D images of the breast is not accurately described by these codes. The AMA has recommended reporting an unlisted code (CPT 19499) when tomosynthesis is the only image guidance technique used during the breast biopsy.

The CPT guidelines regarding image storage requirements were revised in 2019 to clarify that CPT codes in the surgery section of the CPT manual that include both the definitive procedure (e.g., biopsy) and image guidance or radiology supervision and interpretation (S&I) also require permanent storage of images from that imaging guidance or radiology S&I just as a radiology code for imaging guidance or radiology S&I alone would require permanent storage of images. The physician is not obligated to state in his/her report for the procedure that images were permanently stored, but this revision to the guidelines highlights the importance of having a conversation with your physicians or your coding management team to ensure that images are being permanently stored before reporting a code that requires this image storage.

As we have already discussed, CPT codes 19081-19086 all require the use of the imaging guidance listed in the code description to perform the biopsy. If a percutaneous needle biopsy of the breast is performed without the use of imaging guidance, report CPT 19100.

Finally, physicians will sometimes use image guidance to place a localization device without performing any biopsy of the breast during the same encounter. When the physician places a localization device alone without a percutaneous breast biopsy, report an appropriate code(s) from CPT range 19281-19288. We will not discuss these codes in detail in this article, but you can see a complete description in your CPT manual.

Let’s put this all together with a couple of examples to illustrate how to use these codes appropriately.

Example #1: The patient was brought back to the mammography suite and positioned appropriately on the stereotactic imaging table. Using stereotactic guidance the area of microcalcifications in the upper outer quadrant of the left breast was localized and a needle inserted into the area of concern. Three passes of the needle were performed to ensure an adequate specimen. After completion of the biopsy, the tissue removed was imaged and found to contain multiple clusters of microcalcifications confirming a successful biopsy. This concluded our procedure. Patient was instructed to call our office for a follow appointment in 7-10 days for results.

Coding for Example #1: The areas bolded in the note above are keys to our CPT coding. We first see that the physician is using “stereotactic guidance.” We then see that a single lesion (an area of microcalcifications in the upper outer quadrant of the left breast) was targeted for biopsy. We then see the physician passing a needle multiple times to get enough tissue while still using that stereotactic guidance. Note that even though “multiple passes” of the needle are made, the physician is still performing a biopsy of just one lesion/area of concern so this is still only counted as “one biopsy.” Finally, we see that the physician imaged the specimen removed to make sure it contained the microcalcifications. While this part of his procedure is not required per CPT guidelines, it is included when performed so we will not report any additional CPT code such as 76098 for this work. The CPT code supported for this procedure is CPT 19081.

Example #2: The patient was brought back to the interventional radiology suite. After sterile prep and drape, the area of calcifications in the right lower quadrant was imaged using MRI. The needle was then inserted using the MRI to guide the trajectory. Adequate tissue was obtained and a clip was inserted at the site of biopsy. Attention was then turned to a mass in the left inner upper quadrant. We brought in the ultrasound probe and localized the mass with a needle under ultrasound guidance. We obtained adequate tissue and concluded our procedure. Patient will follow up in 7-10 days for pathology results.

Coding for Example #2: The portions of the note above that are bolded are keys to our CPT coding. We see that the patient has an abnormality in the right lower quadrant. This initial lesion is approached with MRI guidance. We see the physician “inserting a needle using the MRI to guide the trajectory” (which confirms that the MRI is being used as guidance to get the needle to the right location). The physician then inserts a clip (a type of localization device) at the site of this biopsy. While inserting a localization device is not required to use this code, it is included when performed so we won’t report any additional code from range 19281-19288 for this work. We then see a second area of abnormality in the left inner upper quadrant. The physician switches from MRI guidance to ultrasound guidance during this second biopsy. We again see the ultrasound being used to “localize” (aka to locate) the mass and guide the needle into the mass. In this case, we will report CPT 19085 for the MRI guided biopsy on the right and CPT 19083 for the ultrasound guided biopsy on the left. Following our CPT guidelines, we will report the “parent code” for each lesion biopsied with a different type of imaging guidance.