StreamlineMD’s January 2024 blog discussed the top five denials for Interventional Radiology. One of those topics was diagnostic angiography during therapeutic treatment, which continues to be a hot topic. And now the OIG is adding Lower Extremity Revascularization procedures to its 2025 work plan.
Increased OIG Scrutiny
- The lower extremity revascularization procedures, CPTs 37220-37235 and 0234T-0238T, have been assigned to the OIG work plan for 2025.
- In CY 2022 and 2023, Medicare paid approximately $1.16 billion for these procedures performed in the office setting.
- CMS and whistleblower fraud reporting have identified these procedures as vulnerable to improper payments.
- The OIG will analyze these specific procedures for program integrity, waste, fraud, and abuse. No other details regarding the work plan’s focus have been provided.
More Insurance Denials
- Commercial Insurance carriers have recently begun to deny these claims and recoup prior payments going back to 2022.
- The coding guidelines for these procedures are according to authoritative entities in order of pertinence and should be taken under advisement.
- Insurance carriers regularly deny unilateral and bilateral extremity angiography codes when billed with lower extremity revascularization procedures, especially when documentation does not meet medical necessity.
| CPT | Description | wRVU | OBL MC Average Allowable |
| 75710 | Angio Extremity Unilateral | 1.75 | $149.79 |
| 75716 | Angio Extremity Bilateral | 1.97 | $162.44 |
| +76937 | US Guidance Vascular Access | 0.3 | $38.28 |
- Insurance carriers often scrutinize vascular US guidance code 76937, which has 0.3 wRVU and four coding elements:
- Evaluation of potential sites
- Vessel patency
- Visualization of needle entry
- Permanent saved image) elements
- These elements are not a CPT or CMS documentation requirement but are often denied by carriers when absent from the report.
- Insurance carriers used algorithms before implementing AI to search requested records for documentation deficiencies and quickly deny the claim. This delays reimbursement and the amount of work needed to secure provider payment.
Not Worth the Risk
- When comparing larger wRVUs for the lower extremity arteriograms in comparison to vascular US guidance, the target and risk are larger and higher.
- Failing a CMS audit can result in fines up to three times the total damages and extrapolated up to 10 years.
Understanding the Difference Between Roadmapping versus Diagnostic Angiography
Diagnostic angiography:
- Means the disease is being diagnosed.
- If the patient has known PAD, describing the degree of disease in each vessel while determining the area(s) to treat is not considered a diagnostic angiography and not a billable service.
Roadmapping:
- Typically performed before any vascular therapy to determine where to treat which is often mistaken for diagnostic angiography.
- Documenting the imaging findings does not equate to a billable service unless one of the criteria is met and clearly documented in the report.
CMS Guidance
- CMS added language in 2023 regarding diagnostic angiography at the same time as a therapeutic treatment:
- NCCI Manual Ch 5 D13, effective 1/1/2023: “Open and percutaneous interventional vascular procedures include operative angiograms and/or venograms which shall not be separately reported as diagnostic angiograms/venograms. The “CPT Manual” describes the circumstances under which a provider/supplier may separately report a diagnostic angiogram/venogram at the time of an interventional vascular procedure. A diagnostic angiogram/venogram may be separately reportable with modifiers 59 or XU. The provider/supplier shall not separately report a diagnostic angiography code. If a diagnostic angiogram (fluoroscopic or computed tomographic) was performed before the date of the open or percutaneous intravascular interventional procedure, a second diagnostic angiogram cannot be reported on the date of the open or percutaneous intravascular interventional procedure unless it is medically reasonable and necessary to repeat the study to further define the anatomy and pathology.”
AMA/CPT Rules
- The AMA/CPT and CMS have clear instructions on the documentation requirements to bill for diagnostic angiography during therapeutic treatment.
- The four criteria to meet medical necessity along with a statement of treatment decision was based upon the angiographic findings.
- No prior study available
- Change in patient’s condition since prior study
- Inadequate visualization of anatomy
- A clinical change in the patient during the procedure
- Insurance companies are enforcing this by denying angiography services when documentation requirements are not met.
SIR Coding Guidelines for Lower Extremity Revascularization CPT Codes
- “These codes take into account the fact that multiple techniques may be needed to open areas of disease in some vessels and that these interventions may take place in different vascular territories. In general, the codes for interventions progress up a hierarchy of intensity with the work of the less-intense intervention included in the higher-intensity code. For example, angioplasty before a stent placement would be a progression up this hierarchy and only the stent code would be reported. Each of these codes includes the work of accessing the artery, selecting the vessel, crossing the lesion, interpreting the images, performing therapeutic intervention(s) in the entire vessel segment,using any embolic protection device, performing final image interpretation, and closing the arteriotomy by any method.”
What Does This Mean for Providers?
- Diagnostic angiography should not be routinely billed with every lower extremity revascularization procedure or any other therapeutic service unless meeting one of the four criteria and clearly documenting such in the report.
- Do not confuse roadmapping for diagnostic angiography.
- The inclusion of these procedures into the OIG work plan signals a need for heightened attention to compliance and accurate billing practices.
- Following CMS coding and billing guidelines is considered industry best practice.
- Review existing templates and update them as appropriate.
- Aligning with CPT descriptions helps eliminate confusion for coders, billers, and insurance companies.
- Patients are increasingly accessing their medical records and closely reviewing their bills. This heightened awareness emphasizes the importance of clear and accurate documentation to ensure transparency and trust in our healthcare services.
References: AMA/CPT, SIR, CMS, and OIG
