2022 Removal Intracardiac Vegetation Coding Knowledge Continued

As discussed last month, new category III codes that could impact your interventional radiology coding services are now effective as of January 1, 2022. With these codes now active, interventional radiology providers and stakeholders should be aware of the scope of changes in place for the new year. New code 0644T mentioned in last month’s insight, has a significant amount of detail for correct coding and comprehension. By knowing the rationale, staff and coders can prepare for a successful year while safeguarding compliance.

Diving into 0644T Coding

As a reminder from last month’s insight, Category III code 0644T is reported for the suction of intracardiac thrombus or vegetations (endocarditis). While this may be performed more often in a cardiology lab, many interventional radiology physicians are also performing this procedure. Code 0644T represents a comprehensive code that includes access, sheath, and device introduction, manipulation and positioning of wires and catheters, dilation, embolic protection, and closure. This code also includes the following components:

• the work of percutaneous access
• all associated sheath device introduction
• manipulation and positioning of guidewires and selective and non-selective catheterizations (e.g., 36140, 36200, 36215, 36216, 36217, 36218, 36245, 36246, 36247, 36248)
• blood vessel dilation
• embolic protection if used
• percutaneous venous thrombectomy (e.g., 37187, 37188)
• and closure of the blood vessel by pressure or application of an access vessel arterial closure device.

Understand that if an axillary, femoral, or iliac conduit is required to facilitate access of the catheter, 34714, 34716, or 34833 may be reported in addition to 0644T. Extensive repair or replacement of a blood vessel (e.g., 35206, 35226, 35231, 35236, 35256, 35266, 35286, 35302, 35371) may be reported separately. When it comes to fluoroscopic and ultrasound guidance used in conjunction with percutaneous intracardiac mass removal is not separately reported. However, transesophageal echocardiography guidance may be reported separately, when provided by a separate provider.

Reporting with Other Services Continued

The insertion and removal of arterial and/or venous cannula(e) (e.g., 33951, 33952, 33953, 33954, 33955, 33956, 33965, 33966, 33969, 33984, 33985, 33986) and initiation (e.g., 33946, 33947) of the extracorporeal circuit (veno-arterial or veno-venous) for intraoperative reinfusion of aspirated blood is included in the procedure. If prolonged extracorporeal membrane oxygenation (ECMO) or extracorporeal life support (ECLS) is required at the conclusion of the procedure, then the appropriate ECMO cannula(e) insertion code (e.g., 33951, 33952, 33953, 33954, 33955, 33956), removal code (33965, 33966, 33969, 33984, 33985, 33986), and initiation code (e.g., 33946, 33947) may be reported in addition to 0644T.

Note that other interventional procedures performed at the time of percutaneous intracardiac mass removal may be reported separately (e.g., removal of infected pacemaker leads, removal of tunneled catheters, placement of dialysis catheters, valve repair, or replacement).

Understand that when transcatheter ventricular support is required in conjunction with percutaneous intracardiac mass removal, 0644T may be reported with the appropriate ventricular assist device (VAD) procedure code (33975, 33976, 33990, 33991, 33992, 33993, 33995, 33997, 33999) or balloon pump insertion code (33967, 33970, 33973). When cardiopulmonary bypass is performed in conjunction with percutaneous intracardiac mass removal, 0644T may be reported with the appropriate add-on code for percutaneous peripheral bypass (33367), open peripheral bypass (33368), or central bypass (33369).

0644T Clinical Example:

CLINICAL HISTORY: Tricuspid endocarditis with persistent fevers despite medical management.

SIDE/SITE: Imaging guidance was utilized to select the precise skin entry point just prior to the procedure.

ANESTHESIA: GETA. A transesophageal echocardiography probe was placed and operated by anesthesiologist. An arterial line was inserted into the radial artery.

A small skin incision was made in the right neck. The right internal jugular vein was accessed with a micropuncture needle under direct ultrasound guidance. The system was upsized with placement of a 0.035″ Amplatz wire advanced into the IVC. Two Perclose devices were advanced and used to preclose the vein at 10 o’clock and 2 o’clock. The sutures were clamped to the side. Over the wire, sequential dilatation of the tract was performed with eventual placement of a 26-French Dry Seal sheath positioned in the IVC. The Angiovac circuit was primed and the Angiovac cannula was inserted through the 26-French sheath. On pump, the cannula was used to engage the tricuspid vegetation under fluoroscopic and transesophageal
echocardiographic guidance.

All of the mobile vegetation was removed. There remains thickening of the anterior leaflet of the tricuspid valve which could relate to adherent vegetation. Specimens were sent to surgical pathology and for culture. After completion, blood was returned to the patient and the circuit removed. The right common femoral 17-French cannula was removed, and hemostasis achieved with the two perclose sutures. The 26-French right internal jugular vein sheath was removed, and hemostasis achieved with the two perclose sutures.

IMPRESSION:
Successful Angiovac removal of vegetation on the septal leaflet of the tricuspid valve.

These are not all the coding updates impacting interventional radiology. Explore more coding knowledge and additional pressing topics to master compliance and coding with our 2022 Radiology Coding Update on-demand webcast.