Endovascular aneurysm repair (EVAR) of an infrarenal abdominal aortic aneurysm is governed by component coding which generally consists of separate CPT codes for catheter, imaging, and intervention. There are five steps to consider when reporting such a repair. These include the appropriate main body description with extensions, arterial catheter placements, open arterial exposure, radiological supervision and interpretation (S&I), and finally any separately reportable service including its associated S&I coding, if appropriate. Unlike open surgery CPT coding, ruptured and elective EVARs are reported similarly.

Endovascular therapies typically allow the provider to bill multiple CPT codes in one claim. The CPT code with the highest RVU content is paid in full. All subsequent non-radiologic codes are paid at 50 % of their independent value. This decrease is termed the “multiple procedure discount” taking into account the overlap in work before, during, and after multiple procedures done on the same date of service. Imaging codes (i.e., the radiology codes that begin with the number 7) are not subject to this discount and are paid in full. Additionally, add-on codes are exempt from this fee reduction since they are created solely for use with other codes.

Occlusive disease may limit endovascular access such that angioplasty is employed to facilitate sheath insertion in the common or external iliac arteries. Any angioplasty performed within the “treatment zone” of the graft to allow for appropriate cannulation, advancement of a sheath, and stent graft deployment is bundled. “Treatment zone” is defined simply as any area of the aorta or iliac arteries where the endoprosthesis is touching the arterial wall after deployment. However, angioplasty or endovascular stent placement in the native artery distal to the “treatment zone” may be billed to the insurance carrier.

EVAR is reported based on the main body graft configuration. The first description is an aorta-to-aorta tube stent graft (CPT code 34800). This type of graft is no longer available for implantation in the United States, and therefore, this code is rarely appropriate in current practice. The next configuration is a modular bifurcated endoprosthesis with one docking limb (CPT code 34802). Reporting this CPT code includes deployment of the ipsilateral graft, cannulation of the contralateral gate, and insertion of the contralateral stent graft docking limb. The third option is a modular bifurcated device with two docking limbs (CPT code 34803). CPT code 34803 contains the work of deploying an initial main body stent graft, cannulation of the contralateral gate, insertion of the contralateral docking limb, and insertion of the ipsilateral stent graft docking limb. In total, three pieces of prosthetic stent graft are contained within this main body description. The fourth in this series comprises the use of a bifurcated unibody graft (CPT code 34804). All manipulation to appropriately seat this single-piece device into both iliac arteries is bundled. The last description is the aorto-uni-iliac endoprosthesis (CPT code 34805). When a bifurcated graft (modular or unibody) is transformed into an aorto-uni-iliac configuration with either a formal graft converter, an aortic cuff placed proximally, or even the deployment of a second main body stent graft, the two devices are collectively reported with this single CPT code. Angioplasty to iron out folds or kinks after deployment is considered inherent to all five of these main body code descriptions.

Additional stent graft extensions both proximally in the aorta and distally after docking limb insertion in the iliac vasculature may be reported separately. Similar to bare metal stent insertion in the superficial femoral artery, they are coded per vessel treated and not per number of devices implanted. This implies a maximum of five extensions (one in the aorta proximally, one in each common iliac artery, and one in each external iliac artery). A single endoprosthesis extension that traverses two vessels is only reported once. Remember that deployment of the docking limb(s) is part of the main body coding. The first endoprosthesis is described by CPT code 34825. Each additional vessel treated by endograft extension is represented by CPT code 34826. If three or more stent graft extensions are necessary, keep in mind that subsequent submissions would require the use of a −59 modifier on the CPT code 34826 to identify that the replication of an identical code is not an accidental duplicate bill.

Next, the arterial catheter placements are considered. Most patients will have two nonselective aortic catheters (CPT code 36200 billed twice): one in each femoral artery that extends into the aorta. If selective catheterization is performed, appropriate component coding rules apply for first-, second-, or third-order selection. Percutaneous access with or without the use of a closure device is bundled and does not allow for additional reporting. However, open arterial access has separate CPT code descriptions. Usually, femoral artery exposure and simple repair are coded with 34812, but complex primary repair (35226), prosthetic patch angioplasty (35286), and common femoral endarterectomy (35371) may supersede an exposure code. CPT code 34820 denotes iliac artery exposure as necessary and 34833 conveys iliac artery exposure with the additional creation of a prosthetic graft conduit to assist in sheath insertion when small or heavily diseased external iliac arteries are encountered.