The use of endovascular aneurysm repair (EVAR) to treat ruptured abdominal aortic aneurysms has increased over the past decade. Abdominal aortic aneurysm (AAA) is condition that describes a bulging, weak spot in the abdominal aorta. Rupture of the bulge is a life-threatening event. EVAR is an advanced, preferred technique for the treatment of abdominal aortic aneurysm (AAA). EVAR is a minimally-invasive procedure to place the stent and graft to support the aneurysm and does not involve a large incision as required for open repair. In 2018, there are new and revised CPT codes as well as new guidelines for reporting Endovascular Repair (EVR). Medical coding outsourcing to an experienced service provider is a practical option for vascular surgeons to ensure accurate reporting of services using the new EVR code set.

  • New CPT Codes to Capture Work Involved in Performing EVAR

    The changes in the EVR code set were prompted by Relative Value Scale Update Committee (RUC) screening which identified simultaneous reporting of several endovascular aortic repair codes as potentially misvalued. It was found that the previous codes did not distinguish between ruptured and elective aneurysm repair, and did not recognize the unique challenges and benefits of percutaneous arterial access. According to a paper published in the Journal of Vascular Surgery in February 2018, the code revisions to update current endovascular practices, introduce new codes to reflect technological advances and allow bundling of codes that could be reported together, was accomplished by a multi specialty effort.
    The new EVR codes are structured based on the vascular anatomy involved (i.e., infrarenal aorta and/or iliac arteries) and the type of endograft used. They distinguish between endovascular repair “with rupture” and for “other than rupture.” The CPT code changes for endovascular repair of abdominal aorta and/or iliac arteries include:

    • Addition of 16 new codes (34701–34716)
    • Revision of four related codes (34812, 34820, 34833, and 34834)
    • Deletion of codes 34800–34806, 34825, 34826, and 34900
    • New guidelines for endovascular repair of abdominal aorta and/or iliac arteries and addition, revision and deletion of parenthetical notes to support correct reporting of the services.
  • Endovascular Repair CPT Codes 2018
    • EVR Base Line Codes

      The new EVR CPT codes sets, which include rupture codes, extend the anatomic pathology treated via endovascular methods and acknowledge the higher level of clinical intensity involved.

      34701 Endovascular repair of infrarenal aorta by deployment of an aorto-aortic tube endograft including pre-procedure sizing and device selection, all non selective catheterization(s), all associated radiological supervision and interpretation, all endograft extension(s) placed in the aorta from the level of the renal arteries to the aortic bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the aortic bifurcation; for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer)

      34702 for rupture including temporary aortic and/or iliac balloon occlusion, when performed (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer, traumatic disruption)

      34703 Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-uni-iliac endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft extension(s) placed in the aorta from the level of the renal arteries to the iliac bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the iliac bifurcation; for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer)

      34704 for rupture including temporary aortic and/or iliac balloon occlusion, when performed (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer, traumatic disruption)

      34705 Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-bi-iliac endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft extension(s) placed in the aorta from the level of the renal arteries to the iliac bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the iliac bifurcation; for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer)

      34706 for rupture including temporary aortic and/or iliac balloon occlusion, when performed (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer, traumatic disruption)

      34707 Endovascular repair of iliac artery by deployment of an ilio-iliac tube endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and all endograft extension(s) proximally to the aortic bifurcation and distally to the iliac bifurcation, and treatment zone angioplasty/stenting, when performed, unilateral; for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation)

      34708 for rupture including temporary aortic and/or iliac balloon occlusion, when performed (eg, for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation, traumatic disruption)

    • New and Revised Codes for Ancillary Procedures

      In 2018, there are new and revised codes to report additional EVAR-related work separately. Procedures performed outside of the treatment zone in the external or internal iliac artery, such as angioplasty or embolization, may be reported separately. On the other hand, if an endograft terminates in the common iliac artery, any additional treatment performed in that artery is not reported separately.

      +34709 Placement of extension prosthesis(es) distal to the common iliac artery(ies) or proximal to the renal artery(ies) for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, penetrating ulcer, including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and treatment zone angioplasty/stenting, when performed, per vessel treated

      34710 Delayed placement of distal or proximal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, endoleak, or endograft migration, including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and treatment zone angioplasty/stenting, when performed; initial vessel treated

      +34711 each additional vessel treated (List separately in addition to code for primary procedure).
      Proximal fixation devices such as anchors or screws can now be reported either at the time of EVR therapy or at a later date.

      +34712 Transcatheter delivery of enhanced fixation device(s) to the endograft (eg, anchor, screw, tack) and all associated radiological supervision and interpretation

    • New Options for Reporting Arterial Exposure, Repair, and Conduit

      The new EVR codes include a comprehensive set of arterial exposure, repair, and conduit reporting options. Open arterial exposure is performed during endovascular repair of abdominal aorta and/or iliac artery procedures when a vessel is too small in diameter to accommodate passage of the endograft. All of the exposure codes are now add-on codes. Placement of a prosthetic conduit in the femoral artery can now also be reported.

      +34713 Percutaneous access and closure of femoral artery for delivery of endograft through a large sheath (12 French or larger), including ultrasound guidance, when performed, unilateral (List separately in addition to code for primary procedure)

      +34714 Open femoral artery exposure with creation of conduit for delivery of endovascular prosthesis or for establishment of cardiopulmonary bypass, by groin incision, unilateral

      +34715 Open axillary/subclavian artery exposure for delivery of endovascular prosthesis by infraclavicular or supraclavicular incision, unilateral (List separately in addition to code for primary procedure)

      +34716 Open axillary/subclavian artery exposure with creation of conduit for delivery of endovascular prosthesis or for establishment of cardiopulmonary bypass, by infraclavicular or supraclavicular incision, unilateral (List separately in addition to code for primary procedure)

      Before 2018, the open arterial exposure codes were standalone codes with a global period. In 2018, the arterial exposure codes (34812, 34820, 34833, 34834) have been revised to be add-on codes since they will never be performed as standalone procedures.

      +34812 (revised) Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral (List separately in addition to code for primary procedure)

      +34820 (revised) Open iliac artery exposure for delivery of endovascular prosthesis or iliac occlusion during endovascular therapy, by abdominal or retroperitoneal incision, unilateral (List separately in addition to code for primary procedure)

      +34833 (revised) Open iliac artery exposure with creation of conduit for delivery of endovascular prosthesis or for establishment of cardiopulmonary bypass, by abdominal or retroperitoneal incision, unilateral (List separately in addition to code for primary procedure)

      +34834 (revised) Open brachial artery exposure for delivery of endovascular prosthesis, unilateral (List separately in addition to code for primary procedure)

    • Adjunctive Therapy and Open Salvage Procedures — No Changes

      Adjunctive therapy in the setting of endovascular exclusion of the aorta and or iliac segments includes the use of occlusion devices and femoral-femoral bypass. There are no changes to the codes for these additional procedures as well as for open salvage procedures in the setting of failed endovascular aortoiliac repair:

      +34808 Endovascular placement of iliac artery occlusion device (List separately in addition to code for primary procedure)

      +34813 Placement of femoral-femoral prosthetic graft during endovascular aortic aneurysm repair (List separately in addition to code for primary procedure)

      34830 Open repair of infrarenal aortic aneurysm or dissection, plus repair of associated arterial trauma, following unsuccessful endovascular repair; tube prosthesis

      34831 aorto-bi-iliac prosthesis

      34832 aorto-bifemoral prosthesis

  • Example of New EVAR CPT Code Use

    In an MDedge Vascular Specialist report, an expert points out that the new EVAR CPT codes reflect a shift from being device-based and attempt to “capture the work involved in performing the procedures based upon the anatomy of the aneurysm and the treated vessels”. He explains that the impact of the new EVR codes will depend upon the surgeon’s practice pattern and illustrates how use of the new CPT codes will lead to a more accurate description of work done and higher revenue.

    Suppose a patient undergoes elective EVAR of the aorta and both iliac arteries with percutaneous access and placement of a bifurcated device with one docking limb.

    In 2017, this surgical strategy may have been reported using CPT codes 34802, 36200-50, and 75952-26, with a total of 31.05 Relative Value Units (RVUs) of work. In 2018, this technique would be reported as: 34705 (elective endovascular repair of infrarenal aorta and/or iliac artery or arteries) plus 34713 x 2 (percutaneous access and closure) with a total of 34.58 RVUs. The additional 3.53 RVUs in 2018 would translate to an extra $126.30.

  • New 2018 EVR CPT Codes – Points to Note

    The highlights of the new EVR CPT codes, according to the American College of Surgeons,are:

    • Services bundled into 34701–34708 include time-intensive preoperative work of sizing the aneurysm and selecting the appropriate type of endograft to be deployed.
    • Radiological supervision and interpretation for endovascular repair of abdominal aorta and/or iliac arteries represented by deleted codes 75952–75954 have been bundled into 34701–34708.
    • Add-on code 34709 may be reported in conjunction with codes 34701–34708. However, endograft extension(s) that terminate(s) within the common iliac arteries are included in codes 34703–34708 and are not reported separately.
    • Code 34712 is reported once per operative session, regardless of the number of fixation devices deployed, and includes radiological supervision and interpretation.
    • Add-on code 34713 may be reported with endovascular repair of the descending thoracic aorta codes 33880–33886, endovascular repair of abdominal aorta and/or iliac arteries codes 34701–34708, or endovascular fenestrated repair of the visceral aorta/infrarenal abdominal aorta codes 34841–34848, as appropriate.
    • Unilateral procedures are reported using add-on codes 34812, 34820, 34833, 34834, 34714, 34715, and 34716.
    • Prior to 2018, bilateral arterial exposure was reported by appending modifier 50 to the appropriate code. For 2018, medical coding service providers have to report the open exposure add-on code with two units when performed bilaterally.
    • Regardless of the number of anchors or screws, code 34712 may only be reported once. Code 34712 may be reported with both the abdominal and thoracic aortic endovascular repair codes or separately.

To report the appropriate CPT codes for services performed, providers need to carefully review the new code descriptors, guidelines, and parenthetical notes. A practical option would be to take advantage of the vascular medical coding services offered by experienced outsourcing companies. Expert coders can ensure accurate claim submission with existing, new, and revised vascular surgery codes, preventing denials and promoting optimal reimbursement.