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Home > Medical Professionals > Health Policy and Government Relations > New 2005 Vascular CPT Codes and Medicare Payments

New 2005 Vascular CPT Codes and Medicare Payments December 2004

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In 2005, we will see a host of new Category I and Category III CPT* vascular codes ranging from standard open surgery to high-tech intervention. These codes and their associated RVUs represent the work product of a large number of vascular surgeons, but Tony Sidawy, our CPT Advisor, and Gary Seabrook, the SVS RUC Advisor, deserve special credit.

CPT codes and national total RVUs are provided in this article. Your actual RVUs will reflect adjustments in physician work, practice expense, and malpractice RVUs based on the regional Geographic Practice Cost Indices (GPCIs). For example, the actual practice expense payment equals the national PE RVUs multiplied by your regional PE GPCI. The analogous adjustment is made for physician work and malpractice RVUs using regional work and malpractice GPCIs, and the total Medicare payment is the sum of adjusted RVUs multiplied by the Conversion Factor. For 2005, the Medicare Conversion factor will be $37.90 per RVU.

Endovascular Aneurysm Repair

A new addition to the endovascular infrarenal aortic aneurysm repair family will occur next year with CPT 34803, Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using modular bifurcated prosthesis (two docking limbs). This code will be used to report the Cook-Zenith aortic stent-graft, which was approved by FDA in 2003. The long interval between FDA approval and creation of a Category I CPT code reflects the protracted process of code creation and valuation. The total RVUs for 34803 will be 36.20, a value slightly greater than the other aortic endografts, reflecting the incremental work of deploying an additional iliac docking limb. The Category III CPT code (0001T) used previously to report this procedure will be retired. The standard endovascular AAA repair component coding rules will apply to new code 34803.

Hemodialysis Access

CMS has chosen to spotlight hemodialysis access with their “Fistula First” program, and 2005 will see a new hemodialysis fistula code and a new vascular lab vein mapping code. SVS requested a CPT code for upper arm cephalic vein transposition. This new code, CPT 36818, will be used to report a procedure requiring two incisions and creation of a tunnel to allow mobilization of the cephalic vein to the medial aspect of the arm for anastomosis with the brachial artery. This access operation is typically required when there is no adequate antecubital branch vein for a direct fistula. Total RVUs for 36818 will be 19.43, which is more than the value for a forearm synthetic graft placement, but slightly less than the basilic vein transposition. 

CMS took the initiative to create a pre-fistula vessel mapping code. Since this code did not pass through the CPT process it has a “G” (for Government) designation and will be reported as G0365. The code will be used to report mapping superficial veins as well as evaluating the arterial inflow and venous outflow of the target extremity. The RVUs were obtained by crosswalk from CPT 93990 (evaluation of an established hemodialysis access). Office-based global RVUs are 4.49, reflecting 4.13 practice RVUs and 0.36 professional RVUs. Hospital-based labs will use APC 0267 to report the technical component for outpatient studies, and the professional interpretation in that setting will be reported as G0365-26. G0365 can only be reported in patients who have had no previous hemodialysis access, and the study can only be reported twice per year. SVS applauds CMS’ effort in recognizing the need for pre-access vein mapping, but we see the frequency and no prior access restrictions as potential problems. We plan to request refinements from CMS for next year.

Carotid Stent

A multispecialty coalition worked to develop a carotid stent deployment code for 2005. SVS blocked carotid stent CPT coding efforts in prior years for lack of sufficient safety and efficacy data, but with SAPPHIRE, ARCHER, and CREST lead-in data available, the Society decided it was time to take leadership role in the effort to move forward. The new carotid stent CPT codes break from the traditional interventional component coding in that a single code will be used to report virtually all the work involved in the complete episode of care. CPT 37215 - Transcatheter placement of intravascular stent(s), cervical carotid artery, percutaneous; with distal embolic protection – will include all required catheterization, embolic protection device deployment and retrieval, stent deployment, all pre- and post-stent balloon angioplasty, and all radiological supervision and interpretation. In short, the easiest way to understand how to code the typical carotid stent is to think “one code” and ignore the established conventions of component coding.

A second new code, 37216, has been created for carotid stent deployment when performed without distal embolic protection. As with 37215, 37216 will be used to report all the associated catheterization and imaging work. The only situation wherein additional codes are reportable will occur when diagnostic catheterization is performed on the opposite carotid artery and/or the vertebrals. When these other vessels are studied during a carotid stent procedure, the standard component coding rules for catheterization and unilateral supervision and interpretation codes will apply – for those other vessels. The new carotid stent codes, 37215 and 37216 should not be used to report intrathoracic common carotid artery or vertebral artery stenting. These procedures will be reported with a new Category III code, 0075T.

It should be noted that creation of these new CPT codes for carotid stenting is not equivalent to a coverage decision by CMS or any other payors. At the time of this writing, CMS has extended a positive coverage decision only to participants in post FDA-approval trials. The Agency is actively considering coverage for high-risk patients outside of the trials, but no decision has been made. We anticipate a decision regarding  Medicare coverage for carotid stent patients outside the auspices of a trial in early 2005.

Endovenous Vein Ablation

The American Academy of Dermatology and the Society of Interventional Radiology took the lead in requesting this new family of CPT codes to report minimally invasive superficial vein ablation. One set of two new codes (CPT 36475 and 36476) was created to report radiofrequency ablation (e.g. VNUS), and a second set (CPT 36478 and 36479) will be used to report vein ablation using laser energy. CPT 36475 (radiofrequency ablation) and 36478 (laser ablation) will be used to report the first vein treated. These are both 0-day global codes, meaning that any office follow-up visits will be separately reportable. The second code in each pair (36476 and 36479) are add-on codes, which will be used to report second and subsequent veins treated in a single extremity through separate access sites during the same episode of care. All four of these codes include all imaging guidance and monitoring. No other catheterization, embolization, radiological supervision & interpretation, or vascular laboratory codes are simultaneously reportable with these procedures.

These new endovenous codes are unusual for vascular surgery in that they have been valued in the office setting as well as the hospital. For instance, CPT 36475 –radiofrequency ablation, 1st vein, has been assigned 9.62 RVUs when performed in the hospital but 58.48 RVUs when performed in the office setting. The large difference, almost 50 RVUs, reflects the fact that the office payment includes coverage for the cost of clinical labor, equipment and supplies. Vascular surgeons will need to undertake an individualized analysis to determine the safety and cost-effectiveness of performing these procedures in-office. An additional note of caution, the “office” payment is not the same as a surgicenter payment. Medicare has a separate fee schedule for surgicenters. The office-based RVUs noted here truly apply only when the procedure is performed in the physician’s office.

Transcranial Doppler

Rounding out the new 2005 CPT code schedule are three new codes to report special transcranial Doppler services. CPT 93980 is a TCD vasoreactivity study. CPT 93892 is TCD for emboli detection without microbubble injection, and CPT 93893 will be used to report TCD emboli detection with microbubble injection. These three new codes cannot be co-reported with the limited TCD study 93888, but they can be co-reported if performed simultaneously with a complete bilateral TCD study, CPT 93886.

2005 Medicare Payments

As noted above, Medicare payment for any particular procedure is calculated as the sum of work, practice expense, and malpractice RVUs after each of the national values has been adjusted for geographic practice costs.  The total RVUs are multiplied by the conversion factor, the amount in dollars paid for each RVU, $37.90 in 2005. The RVUs for most open vascular surgery cases will remain essentially constant in 2005, with trivial changes in practice expense and professional liability relative values. For instance, the total national relative value for carotid endarterectomy (CPT 35301) will fall 0.08 RVUs from 29.86 to 29.78. This will be counterbalanced by the 1.5% increase in conversion factor, making the national payment for carotid endarterectomy $1,129 in 2005 compared to $1,115 this year. RVUs for most other major vascular surgery procedures remain stable or increase slightly. For instance, CPT 34803 – endovascular AAA repair using a two-piece modular bifurcated device – increases by 0.21 RVUs in 2005, and in combination with the conversion factor update, total payment for this service will increase by approximately $28.  There are changes in some of the geographic practice cost indices that will affect individual providers to a more substantial degree.

The one significant bright spot on the Medicare horizon in 2005 will be the technical payments for office-based vascular lab studies. CMS incorporated realistic direct cost inputs for vascular lab equipment, and that change will be reflected by substantial upgrades in technical component practice expense RVUs.

The SVS Practice Council and Government Relations Committee are already at work on CPT and Medicare issues for 2006 and 2007, including more new CPT codes and CMS’ third “five-year review” of physician work RVUs. We need continued member cooperation in terms of completion of the RUC physician work surveys for these efforts, and we thank everyone in advance for their efforts.

*CPT codes and their Descriptors are property of the American Medical Association.