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CCS Prep

Expanded FEVAR Codes

More specificity for fenestrated endovascular repair of the visceral and infrarenal aorta

Fenestrated endovascular repair of an abdominal aneurysm provides treatment opportunities for patients who are not acceptable candidates for the traditional open aneurysm repair procedure. The customized openings in the fenestrated endoprosthesis allow the surgeons to accomplish stabilization of the aorta while maintaining blood flow to connecting arteries. These new innovative devices are proving to be a safe and effective treatment of aneurysms in patients with complex medical conditions.

Minimally invasive surgical procedures, such as fenestrated endovascular aortic/aneurysm repair (FEVAR), with their customized devices, continue to advance the medical care available to patients with complicated vascular conditions. Repair of aneurysms, pseudoaneurysms, dissection, penetrating ulcers and intramural hematomas are being accomplished by using customized fenestrated endografts that are placed internally, and often result in a shorter recovery time for the patient. The CPT manual continues to introduce codes that are expanding to include greater detail about procedures. These expanded code descriptions often include the involved anatomy, conditions treated and device used to accurately capture new technology. New CPT codes 34841 - 34848 for fenestrated endovascular repair of the visceral and infrarenal aorta are an example of expanded code descriptors, and will be discussed in this article. Endovascular graft repair of abdominal aortic aneurysm which does not involve fenestrated grafts will continue to be reported within the code range of 34800-34805.

Figure 1

To understand appropriate application of code 34841-34848, we will need to review the anatomy of the aorta, define the visceral arteries, and discuss new terminology associated with these codes. The code set 34841 - 34848 can be divided into two regions: Visceral aorta region and infrarenal abdominal aorta region.

The Aorta
The Aorta is a centrally positioned great vessel in the human body, and its patency is essential to vascular hemostasis. The aortic vessel originates at the top of the heart and flows to the bottom of the spine branching at the pelvis into two iliac arteries which continue downward into the right and left leg. Because of the length and diameter of this vessel, it has the potential to develop aneurysms, pseudoaneurysms, dissection, penetrating ulcers, intramural hematomas, and other traumatic disruptions. Any one of these conditions presenting in the aortic vessel may require intervention to re-stabilize the blood flow to the body from the heart.

Sectioning the aorta into regions, such as thoracic, visceral, and infrarenal abdominal will aid a coder in proper code assignment. The thoracic region contains the heart, lungs and diaphragm. Below that region is the visceral region, which includes the following visceral arteries:  celiac artery, superior mesentery artery and the bilateral renal arteries. These visceral arteries are listed in the code descriptors to identify the arteries in the visceral region. The infrarenal (below the renal arteries) abdominal aorta region includes vessels such as the inferior mesentery artery, and extends into the common iliac arteries (See Figure 1).

Procedure
Repair of an abdominal aneurism in the aorta can be achieved by many methods, but the most common method is applying or inserting a graft in or around the aorta to stabilize the vessel. There are many types of grafts that can be surgically applied externally or internally (endovascular) to the area of the aorta needing repair. This article will discuss the endovascular repair of the aorta with a fenestrated endograft. In 2014, CPT codes 34841-34848 were added to describe endovascular fenestrated graft procedures. These codes are reported for placement of a fenestrated endovascular graft in the visceral aorta, either alone or in combination with the infrarenal aorta for aneurysms, pseudoaneurysms, dissection, penetrating ulcers, intramural hematomas, and other traumatic disruptions.

To perform the procedure access to the patient's femoral artery is obtained through a small incision in the leg. The visceral aortic endoprosthesis is loaded onto a super-stiff wire and advanced into the femoral artery. The aortic endoprosthesis is advanced further through to the iliac arteries and upwards to the abdominal aorta into the visceral aortic target zone. The fenestrations (customized openings) in the graft are aligned with the corresponding native visceral artery origins. The aortic endoprosthesis is then deployed. After this alignment and deployment of the endograft within the visceral aorta, one or several visceral arteries may be treated with endoprosthesis. Balloon angioplasty is performed to appropriately seat and seal the distal end of the visceral endoprosthesis.

Visceral Aorta

Related Content

Clinical Validation

A change in the rules

The visceral aorta includes the superior mesenteric, celiac and two renal arteries. Code 34841-34844 is utilized for repair of an abdominal aortic anomaly such as those listed in the code descriptor. To utilize these codes a patient must have one of the following conditions shown in the code descriptors: aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, and various traumatic disruptions. These codes include fenestrated endovascular repair graft placement in the visceral aorta and endoprosthesis of one or more of the visceral arteries (e.g., superior mesenteric, celiac or renal artery).

Codes and descriptors for Visceral Aorta Repair
34841 Endovascular repair of visceral aorta (e.g., aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including one visceral artery endoprosthesis (superior mesenteric, celiac or renal artery).

34842 ...including two visceral artery endoprostheses (superior mesenteric, celiac or renal artery)
34843 ...including three visceral artery endoprostheses (superior mesenteric, celiac or renal artery)
34844 ...including four visceral artery endoprostheses (superior mesenteric, celiac or renal artery)

Figure 2: Anatomy of the Visceral Aortic Zone

Supporting documentation for code 34841 shown in Figure 2 may be as follows: A radiological image of a 58 year old man's aorta had identified an aortic aneurysm that extends into his right renal artery. A procedure is performed to repair the visceral aorta and includes endoprosthesis placement in one (right renal artery) visceral artery. Code 34841 includes endoprosthesis placement in one (1) visceral artery such as the right renal artery graft, illustrated in red in Figure 2.

Visceral Aorta and Infrarenal Abdominal Aorta
The visceral aorta and infrarenal abdominal aorta codes include all the visceral arteries (e.g., superior mesenteric, celiac or renal artery) and any fenestrated endografts that span from the visceral aorta through the infrarenal aorta into the common iliac arteries (See Figure 3). The infrarenal component may be a bifurcated unibody device, a modular bifurcated docking system with docking limb(s), or an aorto-uniiliac or aorta-unifemoral device. These codes are only used when repair extends past the visceral aortic area and into the area below the renal arteries.

Codes and Descriptors for Visceral Aorta and Infrarenal Aorta Abdominal Repair
34845 Endovascular repair of visceral aorta and infrarenal abdominal aorta (e.g., aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal aortic endograft  and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including one visceral artery endoprosthesis (superior mesenteric, celiac or renal artery).

34846 ...including two visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s])
34847 ...including three visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s])                
34848 ...including four visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s])

Figure 3

Highlights of basic guidelines:

  • Fenestrated aortic repair is reported based on the extent of aorta treated.
  • 34841-34844 describe repair using proximal endoprostheses that span from the visceral aortic component to one, two, three, or four visceral artery origins and distal extent limited to the infrarenal aorta.
  • 34845-34848 are used to report deployment of a fenestrated endoprosthesis that spans from the visceral aorta (including one, two, or three or four visceral artery origins) through the infrarenal aorta into the common iliac arteries.
  • Codes 34841-34848 define the total number of visceral and/ or renal arteries (i.e., celiac, superior mesenteric, and/or unilateral or bilateral renal artery(s) requiring placement of an endoprosthesis (i.e., bare metal or covered stent) through an aortic endograft fenestration.
  • Other interventional procedures performed at the time of fenestrated endovascular abdominal aortic repair may be reported separately. Read the entire guidelines prior assigning in additional codes.

Work included (not separately reported) in the codes 34841-34848:

  • Introduction of guide wires and catheters in the aorta and visceral and/or renal arteries
  • Balloon angioplasty within target treatment zone of endograft, either before or after endograft deployment
  • Fluoroscopic guidance and radiological supervision and interpretation in conjunction with the aortic repair

Understanding and applying the new CPT codes 34841-34848 will require extensive knowledge of the aortic anatomy, and the devices that will be used with fenestrated endograft repair of aortic diseases. This article is a brief overview to help you get started on learning these new CPT codes. It is essential to further study the guidelines for these new codes as they provide many different scenarios that may occur or be documented in the operative report.

Terminology

  • Fenestrated: having one or more open pores or holes
  • Visceral aorta: area which contains the celiac, superior mesenteric and renal arteries
  • Fenestrated Endovascular Aneurysm Repair (FEVAR)

 See Page 2 for quiz questions.


Expanded FEVAR Codes

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