Transcatheter intra-cranial chemotherapy for retinoblastoma
By C. Matthew Hawkins, MD, FSIR Spring 2018
Q: Ophthalmic artery catheter-directed chemotherapy for retinoblastoma with melphalan has become the standard of care in many instances for this tumor. Is this procedure considered a CNS embolization (CPT code 61624) that can be reported with a supervision and interpretation (S&I) code (CPT code 75984) as well as selective catheter placement in a branch of the internal carotid artery (CPT code +36228)?
61624 Transcatheter permanent occlusion or embolization (e.g., for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method, central nervous system (intracranial, spinal cord).
A: The short answer is “no.” The dictionary definition of embolization is “the process or state in which a blood vessel or organ is obstructed by the lodgment of a material mass.” To report 61624, there must be permanent occlusion of the vessel. The intra-arterial ophthalmic artery chemotherapy procedure includes subselection of the ophthalmic artery with infusion of the chemotherapeutic agent without permanent embolization. In fact, many of these patients require multiple treatments. Thus, permanent occlusion/embolization should be avoided, to allow for future treatments. In some instances, balloon occlusion of the internal or external carotid artery (and branches) may be performed to assist in diverting flow into the ophthalmic artery. However, this type of occlusion is only temporary and thus it is not appropriate to report 61624.
Instead, the appropriate code to report catheter directed ophthalmic artery chemotherapy is 61650, which includes arterial access, ipsilateral selective intracranial catheterization, all diagnostic angiography in the vascular territory (including arch) and access vessel, follow-up angiography and vessel closure (if performed), all imaging guidance and supervision and interpretation. Therefore, it is also not appropriate to report 36223, 36224, 36228 or 75894 for this procedure.
61650 Endovascular intracranial prolonged administration of pharmacologic agent(s) other than for thrombolysis, arterial, including catheter placement, diagnostic angiography, and imaging guidance; initial vascular territory.
For intra-arterial ophthalmic artery chemotherapy in the setting of retinoblastoma, then, only 61650 should be reported.
Clarification: Self-compounded foam venous sclerotherapy
In the last issue’s “Coding Q&A” (IR Quarterly, Winter 2018, p. 34), SIR representatives reported their view that, when IRs self-compound their own venous sclerosant, the procedure should be coded with CPT code 37799 (unlisted, vascular surgery) and that IRs should clarify or seek pre-authorization from their patents’ carrier. In the March 2018 edition of the American Medical Association’s coding newsletter, CPT Assistant, the AMA opined, that selfcompounded venous foam procedures intended to treat incompetent lower-extremity truncal veins, and other lower extremity veins, may be coded with 36470 (sclerosant injection, single incompetent vein) or 36471 (multiple incompetent veins, same leg). If performed, code 76942 (ultrasound guidance, needle placement) may also be reported.
After review, the SIR Economics Committee amends its previous opinion and recommends that SIR members adhere to the AMA guidance, reporting codes 36470, 36471 and 76942 (if performed). Local carrier policies may have specific instructions for coding this procedure but, in general, using the Category I codes is appropriate.