Business Briefs: Coding, Payment, & Coverage for Fluorescence Vascular Angiography

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure the accuracy of the information. However, HMP Communications and the authors do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received. The ultimate responsibility for verifying coding, coverage, and payment information accuracy lies with the reader.   While attending the exhibits at the 2013 Symposium on Advanced Wound Care/Wound Healing Society Spring conference, I learned about a fascinating new technology — fluorescence vascular angiography. Currently, numerous approaches are used to determine vascular flow, including the ankle-brachial index test, Doppler measurement, duplex ultrasound scanning, arteriogram, toe systolic pressure index, transcutaneous oxygen measurement, and other more invasive procedures such as computed tomography fluoroscopy. While similar to these procedures, fluorescence vascular angiography provides qualified healthcare professionals (QHPs) with real-time arterial blood flow to an ulcer, capillary perfusion within the tissue in question, and venous outflow (including potential congestion as well as the most current degree of necrosis). This technology allows wound care QHPs to assess macrovascular blood flow and microvascular perfusion in extremities. It is ideal for assessment of both arterial and venous issues, selection for hyperbaric oxygen therapy, interventional surgery, limb salvage, and serial assessment of wound healing and wound care effectiveness. (For more information on this subject, see “Product Spotlight” on page 22.)   It’s probably no surprise that I had many reimbursement questions regarding fluorescence vascular angiography. The manufacturer was kind enough to answer all of my questions. This article shares these reimbursement questions and answers.   Q: Hospital-based outpatient wound care departments (HOPDs) will want to know if a code exists for the use of fluorescence vascular angiography in their site of service. Have the Centers for Medicare & Medicaid Services (CMS) established a Healthcare Common Procedure Coding System code for the procedure?   A: Yes, in April 2012 CMS established the temporary pass-through code:     C9733 Non-ophthalmic fluorescent vascular angiography.   Q: Has C9733 been assigned to an ambulatory payment classification (APC) group?   A: Yes, C9733 has been assigned to APC group 0397 since April 2012. Therefore, C9733 is separately billable when used in HOPDs. CMS did assign the Q2-status indicator: no separate payment is provided when billed with procedures that are assigned a T-Status indicator, eg, surgical debridement (11042-11047), application of skin substitutes (15271-15278), removal of devitalized tissue (97597-97598), negative pressure wound therapy (97605-97606), and negative pressure, not durable medical equipment (G0456-G0457). Some common wound care services/procedures that do not have a T-status indicator are: application of rigid leg cast (29445), application of paste boot (29580), application of multilayer compression (29581-29584), office/outpatient visits (99201-99204, 99211-99214), and hyperbaric oxygen (C1300). See Table 1 for the 2013 APC payment rates.   Q: Some wound care physicians may wish to use this technology in an ambulatory surgery center (ASC). Is this procedure separately payable in ASCs?   A: CMS assigned the N1-status indicator to C9733 when performed in an ASC. That status indicator tells wound care QHPs that C9733 is considered a packaged service/item that does not have separate payment when used in the ASC.   Q: What Current Procedural Terminology (CPT®) code should QHPs use when they perform this procedure?   A: Like other new medical services, no Level I CPT code currently exists that specifically describes the non-ophthalmic fluorescence vascular angiography. Until such time that a specific CPT code is established, CPT coding conventions require that these procedures be reported using an “unlisted procedure” CPT code. Whenever reporting a service using an unlisted CPT code, it is strongly recommended that the freeform field of the CMS 1500 claim form (Field 19, “reserved for local use,” which is 61 characters in length) be used to present a crosswalk to another procedure believed to be fairly equivalent and/or comparison to a CPT code for which there is an existing valuation. For example: XXX99 (unlisted code) comparable to XXXXX, payment of $XXX.XX expected.   QHPs should consider the following four CPT coding options for fluorescence vascular angiography:     OPTION 1:     37799 Unlisted procedure vascular surgery     The possible crosswalk is:     75710 Angiography, extremity, unilateral, radiological supervision and interpretation, and 15860 Intravenous injection of agent (eg, fluorescein) to test vascular flow in flap or graft.     In this case, the crosswalk in Field 19 of the CMS 1500 claim form might be: 37999 comparable to 75710 and 15860, payment of $XXX.XX expected.     OPTION 2:     76499 Unlisted diagnostic radiographic procedure     The possible crosswalk is:     75710 Angiography, extremity, unilateral, radiological supervision and interpretation, and 15860 Intravenous injection of agent (eg, fluorescein) to test vascular flow in flap or graft     In this case, the crosswalk in Field 19 of the CMS 1500 claim form might be: 76499 comparable to 75710 and 15860, payment of $XXX.XX expected.     OPTION 3:     17999 Unlisted procedure, skin, mucous membrane, subcutaneous tissue.     OPTION 4:     28899 Unlisted foot or toe procedure.   Q: Does Medicare typically cover fluorescence vascular angiography for patients living with chronic wounds, and do any local coverage determinations exist pertaining to this procedure?   A: In the absence of a local or national coverage determination, the local Medicare Administrative Contractor (MAC) will determine whether coverage is available for fluorescence vascular angiography on a case-by-case basis. CMS requires all MACs to manually review all claims submitted with unlisted procedure codes. Therefore, it is recommended that prior to any claim submission that QHPs directly contact their MAC to establish definitive coding direction and intended payment amounts for fluorescence vascular angiography procedures. Failure to do so may result in unnecessary claim rejection and denials. This will require that QHPs write to their respective MAC and express their coding and relative value unit recommendations. Direct physician interaction with MACs is critical to proactively ensure they fully understand the fluorescence vascular angiography procedure.   Q: Do private payers cover fluorescence vascular angiography for patients living with chronic wounds?   A: Private payer coverage depends on the patient’s insurance plan. Before using fluorescence vascular angiography for a particular patient, the QHP should verify the patient’s insurance benefits and obtain written prior authorization, when required. QHPs should keep in mind that prior authorization is never a guarantee of payment. To prior-authorize fluorescence vascular angiography before the procedure is rendered, the following information should be provided to the payer’s prior-authorization department:     • Beneficiary name     • Beneficiary address     • Beneficiary ID number     • Date of birth     • ICD-9-CM diagnosis code     • CPT procedure code     • Requesting physician     • Requesting physician address     • Insurer tax identification or provider name     • Facility name     • Facility address     • Date of service   Q: What type of documentation is typically required to prove medical necessity for fluorescence vascular angiography?   A: All payers will require supporting clinical documentation, which should include:     • Detailed patient history with description of patient’s current status, including diagnosis, complaints, and level of impairment. Describe functional impairments, and how the patient’s condition has impacted his/her activities of daily life.     • Previous treatment efforts – note procedures, medications, and/or therapies attempted; include outcome of each treatment.     • The medical necessity and rationale for fluorescence vascular angiography, eg, specifics substantiating why this procedure is an appropriate option at this point in the patient’s care, therapeutic goals and anticipated outcomes, and risk to patient if procedure is not performed.     • Description of the procedure.     • Clinical benefits of the procedure, eg, how fluorescence vascular angiography will impact physician management of the patient, anticipated improvement in outcomes, etc.     • FDA clearance letter for the procedure.     • Operative report (if the QHP performed one).     • Clinical references supporting the appropriateness and efficacy of the procedure.   See Table 2 for items to consider documenting as part of medical necessity.   Q: Has Medicare specified diagnosis codes that it deems prove medical necessity?   A: No, Medicare has not provided any diagnosis code guidelines.   Q: Are there any National Correct Coding Initiative (NCCI) edits pertaining to C9733?   A: As of June 2013, there are no NCCI edits pertaining to C9733. However, remember that the Q2 APC-status indicator prevents payment of C9733 when procedures assigned T-status indicators are performed.   Q: I understand that plastic and reconstructive surgeons also use this technology in the operating room (OR). Is there an ICD-9-CM procedure code for the work performed in the OR?   A: Yes, in 2007 CMS established ICD-9-CM code:     17.71 Non-coronary intra-operative fluorescence vascular angiography. Kathleen D. Schaum is president and founder of Kathleen D. Schaum & Associates Inc., Lake Worth, FL. She may be reached for questions and consultation by calling 561-964-2470 or emailing kathleendschaum@bellsouth.net.