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1 2/29/161 Interventional Radiology, Cardiology and Endovascular CPT CodingUpdates for 2016 Presented by:David Zielske, MDCIRCC, CCVTC, COC, CCC, CCS, RCC2 Overview 2016 Interventional Radiology Updates Urinary I nterv ention, Biliary I nterv ention, F luid Collection Sclerosis, Soft Tissue Markers, Thoracic Parasympathetic Block, Neuro- Intervention (embolysis, v a sospa sm), I V US , Guideline changes ov er 2015 and regulatory updates 2016 Cardiology Updates New codes: TPV I (M elody v alv e), Cardiac Contractili ty Modulation System Guideline changes ov er 2015 and regulatory updates3 There are 12 new codes for 2016 (in red) 50392, 50393, 50394, 50398, 74475, & 74480 deleted. All new urinary codes bundle S&I s All codes include any and all imaging guidance (CT, MR, US, and fluoro)utilized throughout the procedure All new codes are billed once per side, unless two procedures done in a duplicated collecting system GU Interventions: 20164 New codes for: Nephrostogramvia new or existing access PCN placement and PCN exchange Initial placement of a nephroureteralcatheter Conversion of a PCN to a nephroureteralcatheter Placement of a ureteral stent via an existing access Placement of a ureteral stent via a new access Placement of a ureteral stent via a new access with additional placement of a new PCNGU Interventions: 20162/29/1625 New add- on codes for.

2 Percutaneous ureteroplasty(includes UPJ) ureteral embolization ureteral and/or calycealbiopsy all add- ons may be via any approach (nephrostomy, ilealconduit, urethra, cystostomy, ureterostomy) Nephrostogram/ureterogramis bundled with catheter placements, replacements, conversions and removalsGU Interventions: 20166 Needle Placement into Renal Pelvis with Contrast Injection for AntegradePyelographyObstructed Renal Collecting System7 Percutaneous AntegradePyelogramor UreterogramviaNew Access 50430 (via newaccess) The study can be performed with a needle or a catheter (that is remov ed a t the end of the session) Bundled ifdone at time of a newpercutaneous nephrostomy, nephroureteralor ureteral catheter placement, ev en if dia g nostic Use 50430with add- on codes 50606, 50705and 50706 Use 50431if nephrostogramis performed v ia an existingaccess8 50431 (via existingaccess) Nephrostogrammust be diagnostic in nature.

3 50431is only billable with add- on codes 50606, 50705, 50706, 50387 and 50389 (necessity must be well documented) Do not use50430and 50431at the same session forthe same si de. Do not use 50431when a nephrostomy, nephrouret eralor ureteral catheter is replaced, converted or removed. Percutaneous AntegradePyelogramor Ureterogramvia Existing Access2/29/1639 Nephrostomy Tube Placement in Renal PelvisObstructed Renal Collecting System10 Percutaneous Nephrostomy (PCN) 50432(bundles 50430) Placementof tube in renal collecting system via the flank that only drains externally Code per collecting system that a PCN is placed. There are two collecting systems on one side when a duplicated ureter is present. Dilation of the tract from skinto kidney is a normal component of a PCN placement.

4 Do not use Nephrostomy (PCN) 50432 PCN placement bundles all imaging guidance(CT, MR, US, and fluoro) and diagnostic nephrostogram PCN is bundled with ureteral stent placement code 50693(via existing access) & 50695(via new access) Parentheticals state to not report 50430- 50435with 50693- 50695 for the same collecting system/ureter12 NephrostomyTube Procedures50432: nephrostomytube placement via new access50434:conversion of nephrostomyto nephroureteralstent50435: nephrostomy tube change (The above codes include diagnostic nephrostogram)50389: nephrostomy tube removal (requires fluoroscopy), 2/29/164 CPT code 50435describes change of a nephrostomy tube. Thi s i ncl udes i magi ng gui dance and di agnosti c nephrostogram If the patient has new symptoms related to the tube, the diagnostic imaging is sti l l bundl ed with a tube change.

5 Nephrostomy tube change is bundled with codes for ureteral stent pl acements (50693- 50695)13 Nephrostomy TubeChange14 Placement of NephroureteralStentObstructed Renal Collection System15 NephroureteralStentProcedures50433: placement of a nephroureteralstent via a new access50434:conversion of nephrostomyto nephroureteralstent50435: remove nephroureteralstent & place nephrostomy50387: nephroureteralstent change 50389: nephroureteralstent removal, (requires fluoro)2/29/16517 Ureteral Stent Placement 50693: ureteral stent v ia existing nephrostomy access (appears PCN remov a l (50389) or repla cement (50435), nephroureteralstent remov a l (50389),and nephroureteralstent removaland repla cement with a PCN (50435)at the same sessionis bundled at the same session as the ureteral stent parentheticals).

6 50694ureteral stent v ia newaccess withoutplacement of PCN 50695ureteral stent v ia new access withplacement of new PCN 50382: non- accessableureteral stent exchange (PCN placement (50432) or exchange (50435) is coded in addition to 50382 or 50384 50384:non- accessableureteral stent remov al18 Ureteral Stricture near Uretero- Pelvic Junction with ObstructionPercutaneous Ureteroplastywith BalloonResolution of Stricture and Obstruction19 +50606- Biopsy of the Ureter or Renal Pelvis +50705- Ureteral Occlusion or Embolization +50706- Balloon Dilation of the Ureter These add- on codes can be reported when performed via nephrostomy, ureterostomy, urethra, and ilealconduit approaches Add- on Percutaneous Urinary Procedures20 Procedures Through an IlealConduit 50684, 74425 Injection (no change in 2016) 50688, 75984 External l y accessi bl e ureteral stent change via ilealconduit (usually a PNU via the ilealconduit).)

7 (No change in 2016) For combined flank and ilealconduit approaches to exc hange a c at het er, c ode t he approac h t hrough whi c h t he new catheter is i nserted. Biopsy, ureteroplastyand ureteral embolization can be performed via this access2/29/16621 Urological Catheter Removal Codes(not externally accessible via percutaneous approach) 50382 Removal and replacementof ureteral stent; this is used when the patient has a pre- exis tin g u reteral s ten t th at is n o t extern allyacces s ible. Th is can b e via a n ewly p laced s h eath in th e b ack o r via apre- exis tin g PCN e s ten t is th en s n ared an d pu lled o u t thro u gh thesheath,a wire placed into the bladder and a new double pigtail s tent or PNUstentis placed. Th e sheath is then removed 50384 Removalonlyof ureteral stent is the same procedure as above, but a new ureteral stent is not placed Guidance, imaging, tract dilation, and sheath placement are included.

8 These are unilateral codes. May use - 50 modifier. Add code 50432if PCN is left in place when via new access or 50435if via a prior access the PCN or NPU is replaced with a new PCN at the end of the case)22 50387 Removalof old nephroureteralstent and replacement with a newnephroureteralstent 50389 Removal only of a nephrostomy (or nep h ro uret eralstent) requiring fluoros copy (may be necessarywh en a d o u b le p igtailureteral stent and a nephrostomy are in place, and the nephrostomy is to be removed without entangling the ureteralstent in the string of the nephrostomy) Use an E&M code for removals not requiring fluoroscopy. Guidance, imaging, tract dilation, and sheath placement are included. These are unilateral codes . M ay us e - 50 Removal Codes(externally accessible)23 Nephrostomy Case 1 guided needle placement int o right k rastinjection reveals high grade obstruction dueto a stone in the distal separate accessa sheath is placed along with buddy wire.

9 A 26cm 8FR double pigtail ureteral stent is placed. A separate 8FR nephrostomytube is placed over the buddy wire. guided needle placement into dilated renal pelvis in patient with non- funct i oni ngureteral stent. Contrast injection shows dilated sy stemwithfr a ct ur ed ureteralstent(fr om attempted cy st oscopi cremoval). Sheath isplaced, tract dilated, brok en stent remov ed by snare technique andreplacement of a new stent, leaving a separate external nephrostomy to drain due to patient as (B) required balloon dilation of the mid ureter for a stricture prior to ureteral stent patient as (B) returned for PCN removal w/ patient as (B) returned for ureteral stent removal. The PCN is removed over a wire, the ureteral stent is snared and removed and a new PCN is Case 1 Codes.

10 C50706D50389E50384504352/29/16725 Biliary Interventions 2016 There are 14 new bundled percutaneous biliary codes for 2016 Codes 47500, 47505, 47510, 47511, 47525, 47530, 47630, 74305, 74320, 74327, 75980, and 75982 are deleted in 201626 Percutaneous TranshepaticCholangiogramShowing Distal Common Bile Duct Obstruction, With Dilated Ducts and Distended Gallbladder27 PTC - Percutaneous TranshepaticCholangiogram 47532 Initialdiagnostic studyperformed to ev aluate biliaryductal sy stem Performedvia a new access by injecting contrast through a percutaneous needle placed in a bile duct or through a catheter if the catheter is placed and remov ed at endof session These codes should not be used when contrast is injected tolocalize a duct for puncture (no code submitted for guidance ) or when injection isinto a pre- existing biliary drainage catheter for evaluation of the bile ducts.