StreamlineMD Documentation, Coding & Billing Updates for Radiology & Interventional Specialists

Below are updates for Radiology and Interventional specialists regarding documentation and coding for:

• IVUS
• JZ/JW Modifiers
• Cardiac Velocity Flow Mapping
• PET coding for Posluma

Aetna eviCore Peripheral Vascular Interventional Radiology IVUS Policy Update 

This updated policy, effective 9/1/23, contains detailed information on coverage for lower extremity revascularization: CPTs 37220-37235, 37236-37238, 37246-37247, 37252-37253 & 0238T.

The updated Aetna eviCore policy excerpted below addresses IVUS and the % of stenosis supporting medical necessity for angioplasty and atherectomy for arterial LE revascularization.

“Intravascular Ultrasound (IVUS) for the treatment of lower extremity arterial occlusive disease is considered not medically necessary as there is insufficient evidence to support its routine use for this type of treatment.”

“Atherectomy can be approved as an adjunct to angioplasty prior to stenting in lesions that are ≥70% stenosis caused by a highly calcified eccentric plaque; AND able to pass a wire fully across the lesion into the true lumen; AND all of the following:

• Treatment of target lesion will establish inline flow to the foot, with at least 1 runoff vessel.
• Lesion is 20 cm or less in length.
• Rutherford chronic ischemia classification 2 or higher, documented in clinical notes.
• Debulking to <30% diameter stenosis is attainable.”

Now, more than ever, it is extremely important for concise statements to support medical necessity when using IVUS, most notably, the % of stenosis, which also supports medical necessity for the Atherectomy & PTA portion of this policy as well.

See previous Aetna/eviCore IVUS blog here.

JZ/JW Modifiers Reporting Waste/No Waste Single Dose Packaged Drugs

• JZ/JW CMS Modifiers for drug waste/no waste reporting became a requirement 7/1/23. If your practice bills for drugs, it is imperative to report waste/no waste for single dose packages. Beginning 10/1/23 if not reported, CMS will deny the claim which may also trigger a CMS audit.
• Be sure to document as appropriate for accurate billing & reimbursement.
• See previous JZ/JW blog here.

Hospital-Based Radiology Practice Updates

Cardiac Velocity Flow Mapping

+75565 may now be billed more than once per date of service (DOS), effective 10/1/23. This change will be most noticeable for evaluating congenital cardiac patients. Due to the complexity of the disease and surgical planning, multiple measurements are required for this patient population.

• Code/bill CPT +75566 when performed with CPTs 75557, 75559, 75561 and 75563.
• Clearly document the number values for valves, vessels, shunts, baffles, and flows to decrease denial risks.

PET Hospital Pass Through Code for Posluma

CMS has granted transitional pass-through payment status for a key PET imaging agent:

• Bracco company, Blue Earth Diagnostics’, Posluma, is a prostate-specific membrane antigen-targeted radiopharmaceutical.
• Beginning 10/1/23, CMS will provide separate reimbursement for C9156, the diagnostic radiopharmaceutical, and will reimburse the PET/CT scan itself when used in hospital outpatient settings.
• Posluma is indicated for imaging of PSMA-positive lesions in men with prostate cancer suspected to have metastasized.

StreamlineMD provides Revenue Cycle Solutions to Radiology & Interventional Specialists. Our Mission is to Improve Healthcare for All Americans.  Our Core Values that guide us on our mission are Service Quality, Teamwork, Accountability, Efficiency, Adaptability, Communication, and Integrity. Learn more about us at streamlineMD.com.