Peripheral Embolization Coding & Reimbursement Guide

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PERIPHERAL EMBOLIZATION CODING & REIMBURSEMENT GUIDE 2021

2021 Peripheral Embolization Coding & Reimbursement Guide

2

Overview of Coding and Payment for Use of Embolization Devices in Peripheral Vasculature .......................................... 4

ICD-10-CM Diagnosis Codes ................................................................................................................................................... 6

ICD-10-PCS Procedure Codes ................................................................................................................................................. 8

HCPCS II Device Codes .......................................................................................................................................................... 11

CPT Codes ............................................................................................................................................................................... 12

Physician Coding and Payment .............................................................................................................................................. 15

Hospital Outpatient Coding and Payment ............................................................................................................................ 17

Hospital Inpatient Coding and Payment ............................................................................................................................... 19

ASC Coding and Payment ...................................................................................................................................................... 23

TABLE OF CONTENTS


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Medtronic does not represent or guarantee that this information is complete, accurate, or applicable to any particular

patient or third-party payer. Medtronic disclaims all liability for any consequence resulting from reliance on this

document. The final decision of billing for any service must be made by the health care provider considering the

medical necessity of the service furnished as well as the requirements of third-party payers and any local, state, or

federal laws and regulations that apply. Medtronic is providing this information in an educational capacity with the

understanding that Medtronic is not engaged in rendering accounting, or other professional services.

Health care providers should consult with their own advisors regarding coding, coverage, and payment.

Note: Medtronic does not offer products with approved indications for all procedures listed.

For questions or more information, please contact:

Medtronic Vascular Health Economics, Policy & Payment

(866) 260-3987

[email protected]

www.medtronic.com/cvreimbursement

CPT Copyright 2020 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

mailto:[email protected]

https://www.medtronic.com/us-en/healthcare-professionals/reimbursement/cardiovascular-coding-coverage-resources.html


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Overview of Coding and Payment for Use of Embolization Devices in

Peripheral Vasculature

Embolization devices include coils and plugs. Common applications using embolization devices in peripheral vessels

are shown below. Please note this document provides assistance for FDA approved or cleared indications.

Procedures for peripheral embolization are generally performed in the hospital outpatient setting, although

embolizations performed for ruptured aneurysms and traumatic hemorrhage are usually performed as inpatient.

Note: Embolization of head and neck vessels uses different codes and is outside the scope of this guide.

Type of Embolization Vessel(s) Typically Embolized Embolization of non-target vascular beds (prior to Yttrium-90

radioembolization of liver cancer) • Right gastric artery

• Gastroduodenal artery

Embolization of portal vein to increase the size of the remaining

left lobe of liver (prior to resection of the right lobe of the liver

for liver cancer)

• Portal vein

Embolization for varicocele • Internal testicular (spermatic, gonadal) vein

Embolization for uterine fibroids • Uterine arteries

Embolization for pelvic congestion syndrome (pelvic varices) • Ovarian (gonadal) vein

• Internal iliac (hypogastric) vein

Embolization of AAA endoleak from branch vessels (type 2) • Lumbar artery

• Inferior mesenteric artery

• Internal iliac (hypogastric) artery

• Median (middle) sacral artery

Embolization of AAA endoleak at seal zones (type 1) • Abdominal aorta

• Thoracic aorta

• Common iliac artery

Embolization of collateral vessel(s) in conjunction with

placement of AAA endograft • Internal iliac (hypogastric) artery

Embolization of pulmonary arteriovenous malformation • Segmental pulmonary artery

Embolization of uterine arteriovenous malformation • Uterine arteries

Embolization of renal arteriovenous malformation • Renal artery

Embolization to exclude unruptured peripheral aneurysms from

circulation • Superior mesenteric artery



• Splenic artery

• Renal artery

• Hepatic artery


Continues on next page


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Overview of Coding and Payment for Use of Embolization Devices in Peripheral Vasculature –

continued

Type of Embolization Vessel(s) Typically Embolized Embolization to occlude ruptured peripheral aneurysms with

hemorrhage • Superior mesenteric artery



• Splenic artery

• Renal artery

• Hepatic artery


Embolization to occlude vessels with hemorrhage due to

trauma or vessel injury • Renal artery

• Splenic artery


• Celiac artery

• Internal iliac (hypogastric) artery and its

branches (e.g., superior gluteal artery,

obturator artery, internal pudendal artery)

• Arteries of extremities (e.g., axillary,

brachial, ulnar, radial, femoral, popliteal,

tibial, peroneal arteries)


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ICD-10-CM Diagnosis Codes

ICD-10-CM diagnosis codes are used by both hospitals and physicians to document the indication for the procedure.

The codes below are those commonly associated with peripheral coil and plug embolization procedures.

Diagnosis ICD-10-CM

Code

Code Description

Liver cancer (including for non-

target vessels and

to increase lobe size

prior to radio-

embolization or liver

resection)

C22.0 Liver cell carcinoma (hepatocellular carcinoma) C22.1 Intrahepatic bile duct carcinoma (cholangiocarcinoma) C78.7 Secondary malignant neoplasm of liver and intrahepatic bile duct C7B.02 Secondary carcinoid tumors of liver (metastatic neuroendocrine tumor)

Varicocele I86.1 Scrotal varices Uterine fibroids D25.0 - D25.9 Leiomyoma of uterus Pelvic congestion

syndrome

(pelvic varices)

I86.2 Pelvic varices Note: "Pelvic congestion syndrome" is indexed to code N94.89. However, when the term is

used to refer to pelvic varicose veins, code I86.2 is specific to this condition.

AAA endoleak I97.89 Other postprocedural complications and disorders of the circulatory

system, not elsewhere classified (used for type 2) T82.310A Breakdown (mechanical) of aortic (bifurcation) graft (replacement) (used

for type 1, early or type 1, unspecified)

T82.898A Other specified complication of vascular prosthetic devices, implants

and grafts (used for type 1, late)

Abdominal aortic

aneurysm

(including collateral

vessel(s) in

conjunction with

placement of AAA

endograft)

I71.4 Abdominal aortic aneurysm, without rupture

Arteriovenous

malformation,

pulmonary

Q25.72 Congenital pulmonary arteriovenous malformation

Arteriovenous

malformation,

uterine

Q27.39 Arteriovenous malformation, other site (congenital) I77.0 Arteriovenous fistula, acquired

Arteriovenous

malformation, renal Q27.34 Arteriovenous malformation of renal vessel (congenital)



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ICD-10-CM Diagnosis Codes – continued

Diagnosis ICD-10-CM Code Code Description

Aneurysm, peripheral I72.2 Aneurysm of renal artery

I72.3 Aneurysm of iliac artery

I72.8 Aneurysm of other specified arteries (e.g., SMA, splenic,

celiac, hepatic)

Note: The same diagnosis codes are used regardless of whether the peripheral

aneurysm is ruptured or unruptured.

Traumatic injury to

blood vessel S35.211A-S35.218A Injury of celiac artery S35.221A - S35.228A Injury of superior mesenteric artery S35.231A - S35.238A Injury of inferior mesenteric artery S35.291A - S35.298A Injury of branches of celiac and mesenteric artery (including

gastric, gastroduodenal, hepatic, and splenic arteries) S35.411A - S35.412A Laceration of renal artery S35.491A - S35.492A Other specified injury of renal artery S35.511A - S35.512A Injury of iliac artery S35.531A - S35.532A Injury of uterine artery S35.59XA Injury of other iliac blood vessels

S45.011A - S45.099A Injury of axillary artery S45.111A - S45.199A Injury of brachial artery S55.011A - S55.099A Injury of ulnar artery at forearm level S55.111A - S55.199A Injury of radial artery at forearm level S65.011A - S65.099A Injury of ulnar artery at wrist and hand level S65.111A - S65.199A Injury of radial artery at wrist and hand level S75.011A - S75.099A Injury of femoral artery S85.011A - S85.099A Injury of popliteal artery S85.111A - S85.129A S85.141A - S85.159A S85.171A - S85.189A

Injury of tibial artery (anterior, posterior)

S85.211A - S85.299A Injury of peroneal artery


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ICD-10-PCS Procedure Codes

ICD-10-PCS procedure codes are used by hospitals to report inpatient services.

ICD-10-PCS codes are standardized. The third character in each ICD-10-PCS codes is the “root operation” which

captures the objective of the procedure. Three different root operations can be used for embolization:

• L - Occlusion is used when the objective is to completely close the lumen of the vessel and prevent all blood

flow through it, e.g., for tumors, varicoceles, fibroids, varices, endoleak type 2, collateral vessels with AAA,

AVMs, and traumatic hemorrhage.

• V - Restriction is used when the objective is to partially close the vessel to allow blood flow through the lumen

while excluding blood flow to other areas, e.g., for unruptured aneurysm.

• W - Revision is used when the objective is to correct a previously placed device that is now displaced or

otherwise malfunctioning, e.g., for endoleak type 1.

Fifth character 3-Percutaneous is used for the endovascular approach and sixth character D-Intraluminal device is

used for embolization coils and plugs.

ICD-10-PCS

Code

Code Description

Occlusion Procedures, Peripheral Arteries

02LQ3DZ Occlusion of right pulmonary artery with intraluminal device, percutaneous approach 02LR3DZ Occlusion of left pulmonary artery with intraluminal device, percutaneous approach 04L03DZ Occlusion of abdominal aorta with intraluminal device, percutaneous approach

Note: Per the ICD-10-PCS Body Part Key, the abdominal aorta code is also used for the lumbar artery and the

median (middle) sacral artery, which branch directly from the abdominal aorta.

04L13DZ Occlusion of celiac artery with intraluminal device, percutaneous approach 04L23DZ Occlusion of gastric artery with intraluminal device, percutaneous approach 04L33DZ Occlusion of hepatic artery with intraluminal device, percutaneous approach Note: Per the ICD-10-PCS Body Part Key, the hepatic artery code is also used for the gastroduodenal artery,

which is a branch of the hepatic artery.

04L43DZ Occlusion of splenic artery with intraluminal device, percutaneous approach 04L53DZ Occlusion of superior mesenteric artery with intraluminal device, percutaneous approach 04L93DZ Occlusion of right renal artery with intraluminal device, percutaneous approach 04LA3DZ Occlusion of left renal artery with intraluminal device, percutaneous approach 04LB3DZ Occlusion of inferior mesenteric artery with intraluminal device, percutaneous approach

04LE3DZ Occlusion of right internal iliac artery with intraluminal device, percutaneous approach 04LF3DZ Occlusion of left internal iliac artery with intraluminal device, percutaneous approach Note: Per the ICD-10-PCS Body Part Key, the internal iliac artery codes are also used for the obturator artery,

superior gluteal artery, and internal pudendal artery, which are branches of the internal iliac artery.

04LE3DT Occlusion of right uterine artery with intraluminal device, percutaneous approach 04LF3DU Occlusion of left uterine artery with intraluminal device, percutaneous approach



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ICD-10-PCS Procedure Codes – continued

ICD-10-PCS

Code

Code Description

03L53DZ Occlusion of right axillary artery with intraluminal device, percutaneous approach

03L63DZ Occlusion of left axillary artery with intraluminal device, percutaneous approach

03L73DZ Occlusion of right brachial artery with intraluminal device, percutaneous approach 03L83DZ Occlusion of left brachial artery with intraluminal device, percutaneous approach 03L93DZ Occlusion of right ulnar artery with intraluminal device, percutaneous approach 03LA3DZ Occlusion of left ulnar artery with intraluminal device, percutaneous approach 03LB3DZ Occlusion of right radial artery with intraluminal device, percutaneous approach 03LC3DZ Occlusion of left radial artery with intraluminal device, percutaneous approach 04LK3DZ Occlusion of right femoral artery with intraluminal device, percutaneous approach 04LL3DZ Occlusion of left femoral artery with intraluminal device, percutaneous approach 04LM3DZ Occlusion of right popliteal artery with intraluminal device, percutaneous approach 04LN3DZ Occlusion of left popliteal artery with intraluminal device, percutaneous approach 04LP3DZ Occlusion of right anterior tibial artery with intraluminal device, percutaneous approach 04LQ3DZ Occlusion of left anterior tibial artery with intraluminal device, percutaneous approach 04LR3DZ Occlusion of right posterior tibial artery with intraluminal device, percutaneous approach 04LS3DZ Occlusion of left posterior tibial artery with intraluminal device, percutaneous approach 04LT3DZ Occlusion of right peroneal artery with intraluminal device, percutaneous approach 04LU3DZ Occlusion of left peroneal artery with intraluminal device, percutaneous approach

Occlusion Procedures, Peripheral Veins

06L03DZ Occlusion of inferior vena cava with intraluminal device, percutaneous approach

Note: Per the ICD-10-PCS Body Part Key, the inferior vena cava code is used for the right testicular vein and the

right ovarian vein, which are tributaries of the inferior vena cava.

06LB3DZ Occlusion of left renal vein with intraluminal device, percutaneous approach

Note: Per the ICD-10-PCS Body Part Key, the left renal vein code is used for the left testicular vein and the left

ovarian vein, which are tributaries of the left renal vein.

06L83DZ Occlusion of portal vein with intraluminal device, percutaneous approach

06LH3DZ Occlusion of right hypogastric vein with intraluminal device, percutaneous approach

06LJ3DZ Occlusion of left hypogastric vein with intraluminal device, percutaneous approach



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ICD-10-PCS Procedure Codes – continued

ICD-10-PCS

Code

Code Description

Restriction Procedures, Peripheral Arteries

04V33DZ Restriction of hepatic artery with intraluminal device, percutaneous approach Note: Per the ICD-10-PCS Body Part Key, the hepatic artery code is also used for the gastroduodenal artery,

which is a branch of the hepatic artery.

04V43DZ Restriction of splenic artery with intraluminal device, percutaneous approach 04V53DZ Restriction of superior mesenteric artery with intraluminal device, percutaneous approach 04V93DZ Restriction of right renal artery with intraluminal device, percutaneous approach 04VA3DZ Restriction of left renal artery with intraluminal device, percutaneous approach 04VB3DZ Restriction of inferior mesenteric artery with intraluminal device, percutaneous approach 04VE3DZ Restriction of right internal iliac artery with intraluminal device, percutaneous approach 04VF3DZ Restriction of left internal iliac artery with intraluminal device, percutaneous approach Revision Procedures, Peripheral Arteries

03WY3DZ Revision of intraluminal device in upper artery, percutaneous approach 04WY3DZ Revision of intraluminal device in lower artery, percutaneous approach


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HCPCS II Device Codes

HCPCS II codes are used to capture the device itself. They are assigned by the provider that supplied the device. In

the case of embolization procedures, that is typically the hospital rather than the physician. HCPCS II codes are

submitted on hospital outpatient bills only, not inpatient.

For devices, there are two types of HCPCS II codes for implanted devices: L-codes and C-codes. L-codes are

accepted by all payers. C-codes are a special type of HCPCS II code and were established by Medicare in 2001 to

identify devices eligible for hospital pass-through payments when used in outpatient procedures being billed under

APCs. Although other payers may accept C-codes, their use is generally reserved for Medicare bills. There are also

HCPCS II A-codes, which are assigned for supplies.

No HCPCS II codes, including L-codes, C-codes and A-codes, can be submitted on hospital bills for inpatient

procedures. For this reason, HCPCS II codes do not exist for all devices and supplies, particularly those used in

procedures primarily performed on an inpatient basis. However, some hospitals desire HCPCS II codes for internal

tracking purposes on all cases, including inpatient.

The full list of HCPCS II codes can be found at: www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/

Alpha-Numeric-HCPCS

Note there are no L-codes, C-codes or A-codes specifically defined for peripheral vascular embolization products

such as coils and plugs. Miscellaneous codes are not available for C-codes but are available for L-codes and A-codes.

Some hospitals may choose to use code L8699 if they consider that coils constitute a prosthetic device. Prosthetic

devices are those that "replace all or part of an internal body organ…or replace all or part of the function of a

permanently inoperative or malfunctioning internal body organ". Some hospitals may choose to use code A4649 if

they consider that coils constitute a supply. Other hospitals may choose not to assign a HCPCS II code at all for

peripheral embolization coils and plugs.

Miscellaneous

HCPCS II Code

Code Description

No C-code No C-Code available

L8699 Prosthetic implant, not otherwise specified

A4649 Surgical supply, miscellaneous

https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html

https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html


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CPT Codes

CPT codes are used by physicians for all procedures and by hospitals for outpatient procedures. CPT embolization

codes are differentiated by the vessel (venous vs arterial) and the indication. In general, the codes are mutually

exclusive. For example, if there are overlapping indications, the code for the immediate, ie, acute, indication is used.

Embolization codes are assigned once per "surgical field", which is defined as the area immediately surrounding and

directly involved in a treatment/procedure. The number of vessels embolized is not a factor in identifying separate

surgical fields. For example, when multiple feeding vessels must be embolized to occlude a single tumor, only one

code is assigned. Bilateral organs constitute separate surgical fields so, for example, two codes are assigned for

embolization of an AVM in the left lung and embolization of an AVM in the right lung. Notably, Medicare's Medically

Unlikely Edits allow two units for code 37241 and two units for code 37242. For practical purposes, the number of

times an embolization can be coded for the same patient during the same encounter is limited to two.

The embolization codes include all radiologic guidance, roadmapping, and completion angiography. However, truly

diagnostic angiography can be coded separately. Selective catheterization of the vessel for embolization is coded

separately. One or more codes may be assigned depending on the vessels catheterized, the vascular families

involved, and the number of separate puncture sites.

CPT Code &Description Scenarios Embolization

37241 Vascular embolization or occlusion, inclusive of

all radiological supervision and interpretation,

intraprocedural roadmapping, and imaging guidance

necessary to complete the intervention; venous, other

than hemorrhage (e.g., congenital or acquired venous

malformations, venous and capillary hemangiomas,

varices, varicoceles)

• Embolization for varicocele

• Embolization for pelvic congestion syndrome (pelvic

varices)




necessary to complete the intervention; arterial, other

than hemorrhage or tumor (e.g., congenital or acquired

arterial malformations, arteriovenous malformations,

arteriovenous fistulas, aneurysms, pseudoaneurysms)

• Embolization of non-target vascular beds (prior to

Yttrium-90 radioembolization of liver cancer)

• Embolization of AAA endoleak (type 2, type 1)

• Embolization of collateral vessel(s) in conjunction

with placement of AAA endograft

• Embolization of pulmonary arteriovenous

malformation

• Embolization of uterine arteriovenous malformation

• Embolization of renal arteriovenous malformation

• Embolization to exclude unruptured peripheral

aneurysms from circulation




necessary to complete the intervention; for tumors,

organ ischemia, or infarction

• Embolization of portal vein to increase the size of

the remaining left lobe of liver (prior to resection of

the right lobe of the liver for liver cancer)

• Embolization for uterine fibroids




necessary to complete the intervention; for arterial or

venous hemorrhage or lymphatic extravasation

• Embolization to occlude ruptured peripheral

aneurysms with hemorrhage

• Embolization to occlude vessels with hemorrhage

due to trauma or vessel injury



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CPT Codes – continued

CPT Code &Description Examples (from femoral puncture) Catheterization

Arterial Catheterization

36215 Selective catheter placement, arterial system,

each first order thoracic or brachiocephalic branch,

within a vascular family

36216 Selective catheter placement, arterial system;

initial second order thoracic or brachiocephalic branch,


• Left axillary artery


initial third order or more selective thoracic or

brachiocephalic branch, within a vascular family

• Right axillary artery

• Brachial artery

• Ulnar artery

• Radial artery

+36218 Selective catheter placement, arterial system;

additional second order, third order, and beyond,

thoracic or brachiocephalic branch, within a vascular

family (List in addition to code for initial second or third

order vessel as appropriate)


each first order abdominal, pelvic, or lower extremity

artery branch, within a vascular family

• Superior mesenteric artery


• Renal artery, lumbar artery

• Lumbar artery, median (middle) sacral artery


initial second order abdominal, pelvic, or lower

extremity artery branch, within a vascular family

• Splenic artery

• Internal iliac (hypogastric) artery (contralateral)

• Common hepatic artery

• Common femoral artery (contralateral)


initial third order or more selective abdominal, pelvic,

or lower extremity artery branch, within a vascular

family

• Right gastric artery


• Uterine artery

• Superior gluteal artery

• Obturator artery

• Internal pudendal artery

• Superficial femoral artery (contralateral)

• Popliteal artery (contralateral)

• Tibial artery

• Peroneal artery



abdominal, pelvic, or lower extremity artery branch,

within a vascular family (List in addition to code for

initial second or third order vessel as appropriate)

+ represents add-on code Continues on next page


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CPT Codes – continued

CPT Code &Description Examples (from femoral puncture) Venous Catheterization

36011 Selective catheter placement, venous system,

first order branch (e.g., renal vein, jugular vein)

• Right testicular vein

• Right ovarian vein

36012 Selective catheter placement, venous system;

second order, or more selective, branch (e.g., left

adrenal vein, petrosal sinus)

• Left testicular vein

• Left ovarian vein

• Internal iliac vein (contralateral)

Pulmonary Artery Catheterization

36015 Selective catheter placement, segmental or

subsegmental pulmonary artery

• Segmental pulmonary artery

Portal Vein Catheterization

36481 Percutaneous portal vein catheterization by any

method

• Portal vein


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Physician Coding and Payment Effective January 1, 2021 – December 31, 2021

For Medicare, physicians are reimbursed using the RBRVS methodology. Each CPT code is assigned a relative value

unit (RVU) which is then converted to a flat payment amount.

The RVUs and payment for each code differ depending on the site of service. "Non-Facility" is for services in the

physician office and "Facility" is for services in a hospital (inpatient or outpatient). "Facility" RVUs and payments to the

physician are usually lower because the hospital incurs many of the costs, while "Non-Facility" RVUs and payments to

the physician are higher because the physician incurs all costs in the office.

When an embolization code is submitted together with one or more catheterization codes, as is usually the case,

payment for the highest-weighted code is made at 100% of the rate and payment for all lower-weighted codes is

made at 50% of the rate. The one exception is add-on codes (+) which are always paid at 100% of the rate.

Private payers often follow the same RBRVS methodology or a variation on it. Alternately, some payers may contract

to use other payment methodologies.

CPT Code & Description Medicare

RVU Medicare

National

Average

Medicare

RVU Medicare

National

Average Non-Facility Facility

Embolization

37241 Vascular embolization or occlusion, venous, other


malformations, venous and capillary hemangiomas,

varices, varicoceles)

147.86 $5,159 12.55 $438

37242 Vascular embolization or occlusion, arterial, other




231.27 $8,069 13.79 $481

37243 Vascular embolization or occlusion, for tumors,

organ ischemia, or infarction 284.68 $9,932 16.14 $563

37244 Vascular embolization or occlusion, for arterial or

venous hemorrhage or lymphatic extravasation 213.35 $7,444 19.15 $668

Catheterization

Arterial Catheterization


each first order thoracic or brachiocephalic branch, within

a vascular family

32.75 $1,143 6.15 $215


initial second order thoracic or brachiocephalic branch,


34.19 $1,193 7.88 $275



16

Physician Coding and Payment – continued

CPT Code & Description Medicare

RVU Medicare

National

Average

Medicare

RVU Medicare

National

Average Non-Facility Facility


initial third order or more selective thoracic or

brachiocephalic branch, within a vascular family

56.71 $1,979 9.52 $332


additional second order, third order, and beyond, thoracic

or brachiocephalic branch, within a vascular family (List in

addition to code for initial second or third order vessel as

appropriate)

6.51 $227 1.46 $51


each first order abdominal, pelvic, or lower extremity


40.13 $1,400 6.84 $239


initial second order abdominal, pelvic, or lower extremity


26.13 $912 7.36 $257


initial third order or more selective abdominal, pelvic, or

lower extremity artery branch, within a vascular family

45.55 $1,589 8.72 $304



abdominal, pelvic, or lower extremity artery branch,

within a vascular family (List in addition to code for initial

second or third order vessel as appropriate)

3.85 $134 1.42 $50

Venous Catheterization

36011 Selective catheter placement, venous system,

first order branch (e.g., renal vein, jugular vein)

26.14 $912 4.59 $160

36012 Selective catheter placement, venous system;

second order, or more selective, branch (e.g., left adrenal

vein, petrosal sinus)

26.57 $927 5.04 $176

Pulmonary Artery Catheterization

36015 Selective catheter placement, segmental or

subsegmental pulmonary artery

27.24 $950 4.96 $173

Portal Vein Catheterization

36481 Percutaneous portal vein catheterization by any

method

56.44 $1,969 9.47 $330

+ represents an add-on code


17

Hospital Outpatient Coding and Payment Effective January 1, 2021 – December 31, 2021

For Medicare, hospitals are reimbursed using the APC methodology. Each CPT code is assigned to one of

approximately 800 ambulatory payment classes. Each APC has a relative weight which is then converted to a flat

payment amount. Embolization procedures are paid via Comprehensive APCs (C-APCs) in which hospitals receive a

single all-inclusive payment. There is no separate payment for other procedures performed or devices used. Instead,

the C-APC payment for the embolization procedure is set to include the costs of any other procedures as well as any

devices. C-APCs are identified by Status Indicator (SI) J1.

Private payers may follow the same APC methodology or a variation on it. Alternately, some payers may contract to

use other payment methodologies and some may pay for devices separately.

Note: CPT codes for catheterization are not shown because this component is not paid separately. Likewise,

diagnostic angiography is also not paid separately with embolization.

CPT Code and Description APC Title SI Relative Weight

Medicare National Average

Embolization

37241 Vascular embolization or occlusion, venous, other


malformations, venous and capillary hemangiomas, varices,

varicoceles)

5193 Level 3

Endovascular

Procedures

J1 121.2960 $10,043




arteriovenous fistulas, aneurysms, pseudoaneurysms) 37243 Vascular embolization or occlusion, for tumors, organ

ischemia, or infarction 37244 Vascular embolization or occlusion, for arterial or

venous hemorrhage or lymphatic extravasation

Refer to the following page for details about the combination of two embolization procedures involving different

surgical fields, which can lead to a “complexity adjustment” that re-maps the encounter to a different APC.


18

Complexity Adjustment In some very specific circumstances, the combination of two procedures leads to a “complexity adjustment” in which

the entire encounter is re-mapped to a single higher-level APC. For embolization, this typically involves additional

embolization procedures performed during the same outpatient encounter, although it may also involve certain

types of stenting and tumor ablation.

The example below is coded for embolization of two separate arteriovenous malformations in the right and left lungs,

which are separate surgical fields. Modifier -59, Distinct Procedural Service, can be added to the second iteration of

code 37242 to show the code represents a second surgical field.

CPT Code and Description APC Title SI Relative Weight






5194 Level 4

Endovascular

Procedures

J1 194.0167 $16,064

Plus

37242-59 Vascular embolization or occlusion, arterial, other





19

Hospital Inpatient Coding and Payment Effective October 1, 2020 – September 30, 2021

For Medicare, hospitals generally receive a single all-inclusive payment, which includes devices, for each hospital

inpatient admission. Each inpatient stay is assigned to an MS-DRG based on the ICD-10-CM diagnosis and ICD-10-

PCS procedure codes. The DRGs shown below are those that are most commonly assigned for the specific indication

when embolization is the most significant procedure performed during the stay.

Private payers may follow the same MS-DRG methodology or a variation on it. Alternately, some payers may contract

to use other payment methodologies, and some may pay for devices separately. Although many peripheral

embolization procedures, other than those for ruptured aneurysms and trauma, are performed in the hospital

outpatient setting, DRGs and payment for all indications are shown for those occasions when the procedures are

performed as inpatient.

Note: Several of the scenarios group to the "mismatch" DRGs 981-983 and 987-989. This happens when the principal

diagnosis and the procedure are classified in different body systems. For example, liver cancer is a Hepatobiliary

diagnosis, but embolization is a Vascular procedure. The "mismatch” DRGs are valid and payable.

Note: If other significant procedures are also performed during the same stay, DRGs other than those shown may be

assigned.

MS-DRG

MS-DRG Description Relative Weight

Average Geometric

LOS


Embolization of non-target vascular beds via gastric artery (prior to Yttrium-90 radioembolization of liver cancer)

987 Non-Extensive OR Procedure Unrelated to Principal

Diagnosis W MCC

3.2621 7.7 $20,967


Diagnosis W CC

1.6807 4.3 $10,803


Diagnosis WO CC/MCC

1.1159 2.3 $7,172

Embolization of non-target vascular beds via gastroduodenal artery (prior to Yttrium-90 radioembolization of liver

cancer)

423 Other Hepatobiliary or Pancreas OR Procedures W MCC 4.1790 8.4 $26,861

424 Other Hepatobiliary or Pancreas OR Procedures W CC 2.2816 4.7 $14,665

425 Other Hepatobiliary or Pancreas OR Procedures WO CC 1.5433 2.2 $9,920

Embolization of portal vein to increase the size of the remaining left lobe of liver (prior to resection of the right lobe

of the liver for liver cancer)

981 Extensive OR Procedure Unrelated to Principal Diagnosis W

MCC

4.6078 8.4 $29,617


CC

2.5412 4.7 $16,334

983 Extensive OR Procedure Unrelated to Principal Diagnosis WO

CC/MCC

1.6548 2.3 $10,636



20

Hospital Inpatient Coding and Payment – continued

MS-DRG


Average Geometric

LOS


Embolization for varicocele

717 Other Male Reproductive System OR Procedure Except

Malignancy W CC/MCC

1.7985 3.7 $11,560

718 Other Male Reproductive System OR Procedure Except

Malignancy WO CC/MCC

1.2362 2.2 $7,946

Embolization for uterine fibroids

749 Other Female Reproductive System OR Procedures W

CC/MCC 2.7074 5.6 $17,402

750 Other Female Reproductive System OR Procedures WO

CC/MCC 1.4659 2.3 $9,422

Embolization for pelvic congestion syndrome (pelvic varices)

749 Other Female Reproductive System OR Procedures W

CC/MCC

2.7074 5.6 $17,402

750 Other Female Reproductive System OR Procedures WO

CC/MCC

1.4659 2.3 $9,422

Embolization of AAA endoleak type 2 from branch vessels, except lumbar artery and median (middle) sacral artery

270 Other Major Cardiovascular Procedures W MCC 5.1816 6.6 $33,305

271 Other Major Cardiovascular Procedures W CC 3.5646 4.3 $22,912

272 Other Major Cardiovascular Procedures WO CC/MCC 2.6888 2.0 $17,282

Embolization of AAA endoleak type 2 from branch vessels, lumbar artery and median (middle) sacral artery

Embolization of collateral vessel(s) in conjunction with placement of AAA endograft

268 Aortic and Heart Assist Procedure Except Pulsation Balloon W

MCC

6.9546 6.3 $44,701

269 Aortic and Heart Assist Procedure Except Pulsation Balloon

WO MCC

4.3146 1.6 $27,732

Note: When embolization of collateral vessel(s) is performed in conjunction with placement of the AAA endograft

during the same inpatient admission, DRG assignment is driven by the endograft diagnosis and procedure codes

and is generally be assigned to DRGs 268-269.

Embolization of pulmonary arteriovenous malformation

252 Other Vascular Procedures W MCC 3.3207 5.2 $21,344

253 Other Vascular Procedures W CC 2.6537 4.1 $17,057

254 Other Vascular Procedures WO CC/MCC 1.8095 2.1 $11,631



21


MS-DRG


Average Geometric

LOS


Embolization of uterine arteriovenous malformation


MCC

4.6078 8.4 $29,617


CC

2.5412 4.7 $16,334

983 Extensive OR Procedure Unrelated to Principal Diagnosis WO

CC/MCC

1.6548 2.3 $10,636

Embolization of renal arteriovenous malformation




Embolization to exclude unruptured peripheral aneurysms from circulation

Unruptured aneurysm of renal artery

673 Other Kidney or Urinary Tract Procedures W MCC 3.4631 7.7 $22,259

674 Other Kidney or Urinary Tract Procedures W CC 2.3804 5.9 $15,300

675 Other Kidney or Urinary Tract Procedures WO CC/MCC 1.7520 2.7 $11,261

Unruptured aneurysm of other peripheral arteries




Embolization to occlude ruptured peripheral aneurysms

Ruptured aneurysm of renal artery

673 Other Kidney or Urinary Tract Procedures W MCC 3.4631 7.7 $22,259

674 Other Kidney or Urinary Tract Procedures W CC 2.3804 5.9 $15,300

675 Other Kidney or Urinary Tract Procedures WO CC/MCC 1.7520 2.7 $11,261

Ruptured aneurysm of other peripheral arteries






22


MS-DRG


Average Geometric

LOS


Embolization to occlude vessels with hemorrhage due to trauma or vessel injury

Injuries in a single body system

907 Other OR Procedures for Injuries W MCC 3.9571 6.9 $25,434

908 Other OR Procedures for Injuries W CC 2.0404 3.9 $13,115

909 Other OR Procedures for Injuries WO CC/MCC 1.3746 2.4 $8,835

Major injuries in two or more different body systems

957 Other OR Procedures for Multiple Significant Trauma W MCC 7.4208 9.1 $47,697

958 Other OR Procedures for Multiple Significant Trauma W CC 4.2054 6.7 $27,030

959 Other OR Procedures for Multiple Significant Trauma WO

CC/MCC

2.7342 4.2 $17,574


23

ASC Coding and Payment Effective January 1, 2021 – December 31, 2021

Medicare payment for procedures performed in an ambulatory surgery center (ASC) is generally based on Medicare’s

APC methodology for hospital outpatient payment. Each CPT code designated as a covered procedure in an ASC is

assigned a relative weight which is then converted to a flat payment amount specific to ASCs. In general, there is no

separate payment for devices because the payment amount for the procedure is adjusted to incorporate device cost.

For Payment Indicators P2 and G2, payment is based on hospital outpatient rate adjusted for ASC. Payment Indicator

J8 designates a device-intensive procedure.

Comprehensive APCs are used only for hospital outpatient services and are not applied to procedures performed in

ASCs. This allows multiple procedures performed during the same ASC encounter to be paid separately. When

multiple procedures are coded and billed, payment is usually made at 100% of the rate for the first procedure and

50% of the rate for the second and all subsequent procedures. These procedures are marked “Y.” Procedures marked

“N” are not subject to this discounting and are paid at 100% of the rate regardless of whether they are submitted with

other procedures.

Note: CPT codes for catheterization are not shown because this component is not paid separately in ASCs. Likewise,

diagnostic angiography is also not paid separately with embolization in ASCs.

CPT Code &Description Payment

Indicator Multiple

Procedure

Discount

Relative

Weight Medicare

National

Average Embolization

37241 Vascular embolization or occlusion, venous,

other than hemorrhage (e.g., congenital or acquired

venous malformations, venous and capillary

hemangiomas, varices, varicoceles)

P2 Y 87.5421 $4,285

37242 Vascular embolization or occlusion, arterial,

other than hemorrhage or tumor (e.g., congenital or

acquired arterial malformations, arteriovenous

malformations, arteriovenous fistulas, aneurysms,

pseudoaneurysms)

J8 Y 130.0490 $6,366

37243 Vascular embolization or occlusion, for

tumors, organ ischemia, or infarction G2 Y 87.5421 $4,285

37244 Vascular embolization or occlusion, for arterial

or venous hemorrhage or lymphatic extravasation

J8 Y 125.2488 $6,131


24

References

ICD-10-PCS Procedure Codes

ICD-10-PCS Official Guidelines for Coding and Reporting 2021, B3.12: Occlusion vs. Restriction for vessel embolization procedures.

Coding Clinic for ICD-10-CM and ICD-10-PCS, 3rd Q 2020

Coding Clinic for ICD-10-CM and ICD-10-PCS, 1st Q 2014

HCPCS Codes - Definition of "Prosthetics"

Medicare Benefit Policy Manual, Chapter 15: Covered Medical and Other Health Services, section 120: Prosthetic Devices. Available at www.cms.gov/Regulations-and-Guidance/ Guidance/Manuals/Downloads/bp102c15.pdf.

CPT Codes - Mutually Exclusive, Surgical Fields,

Catheterization

CPT 2021, Surgery, Cardiovascular System: Vascular Embolization and Occlusion, instructional notes.

Interventional Radiology Coding Update 2014, Society of Interventional Radiology and American College of Radiology, p.27-34.

CPT Assistant, November 2013, p.6-8.

New Embolization Codes for 2014, Katharine Krol, MD, Endovascular Today, April 2014, p.75-77.

Information on the Medically Unlikely Edits is available at www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/ MUE.

Medicare National Average Amounts

The average national allowable amounts shown include patient cost-sharing amounts, such as any applicable coinsurance, deductible, and other amounts that are patient obligations. The allowable amounts shown also do not reflect the impact of sequestration, by which all Medicare fee-for-service claims are subject to a 2 percent across-the-board cut to the final amount.

Physician Coding and Payment

Centers for Medicare & Medicaid Services. Medicare Program; CY 2021 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies. Final Rule, CMS-1734-F. 85 Fed. Reg. 84472-85377. Published December 28, 2020. Available at www.govinfo.gov/content/ pkg/FR-2020-12-28/pdf/2020-26815.pdf.

Medicare national average payment is determined by multiplying the sum of the three RVUs by the conversion factor. The conversion factor for CY 2021 is $34.89 as amended by CY 2021 Physician Fee Schedule Update, available at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched. Final payment to the physician is adjusted by the Geographic Practice Cost Indices (GPCI).

Hospital Outpatient Coding and Payment

Centers for Medicare & Medicaid Services. Medicare Program; Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs. Final Rule, CMS-1736-FC. 85 Fed. Reg. 85866-86305. Published December 29, 2020. Available at www.govinfo.gov/content/pkg/FR-2020-12-29/pdf/2020-26819.pdf.

Medicare national average allowable is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2021 is $82.797. This conversion factor assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Data Reporting Program. The allowable amount will be adjusted by the Wage Index for each hospital’s geographic locality. Therefore, the allowable amount for a specific hospital will vary from the Medicare national average allowable shown.

Hospital Inpatient Coding and Payment

Centers for Medicare & Medicaid Services. Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals…Fiscal Year 2021 Rates. Final Rule. CMS-1735-F. 85 Fed. Reg. 58432-59107. Published September 18, 2020. Available at www.govinfo.gov/content/pkg/FR-2020-09-18/pdf/2020-19637.pdf. Correction Notice, CMS-1735-CN. 85 Fed. Reg. 78748-78769. Published December 7, 2020. Available at www.govinfo.gov/content/pkg/FR-2020-12-07/pdf/2020-26698.pdf.

Medicare national average allowable is based on the DRG weight multiplied by the average standardized operating amount $5,961.31 plus the capital standard amount $466.21 for 2021. The allowable amount shown uses the standardized amounts for hospitals with a wage index of 1.000. The amount shown also assumes that hospitals submitted quality data. The allowable will be adjusted by the Wage Index for each hospital's geographic locality. Therefore, the allowable amount for a specific hospital will vary from the Medicare national average allowable shown.

ASC Coding and Payment

Centers for Medicare & Medicaid Services. Medicare Program; Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs. Final Rule, CMS-1736-FC. 85 Fed. Reg. 85866-86305. Published December 29, 2020. Available at www.govinfo.gov/content/pkg/FR-2020-12-29/pdf/2020-26819.pdf.

Medicare national average allowable is determined by multiplying the ASC weight by the ASC conversion factor of $48.952 for 2021. The conversion factor assumes ASCs meet quality reporting requirements. Payment is adjusted by the wage index for each ASC’s specific geographic locality, so payment will vary from the stated national average Medicare payment levels displayed.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE

https://www.govinfo.gov/content/pkg/FR-2020-12-28/pdf/2020-26815.pdf


http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched

http://www.govinfo.gov/content/pkg/FR-2020-12-29/pdf/2020-26819.pdf

http://www.govinfo.gov/content/pkg/FR-2020-12-29/pdf/2020-26819.pdf







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