# Help with new Arch Angiography Coding



## rlj99w (Apr 12, 2014)

I am looking for some guidance on how to code an arch angiogram and upper extremity angiography with selective catheter placement in the subclavian artery. Code 36255 which is selective catheter placement in the subclavian includes vertebral angiography but this was not done. Would I just code the nonselective cerebral arch angiography 36221 and then 36215 and 75710 for the selective catheter placement and radiology? I have included a copy of the report. Any guidance would be greatly appreciated.

Preoperative Diagnosis: Ischemic left hand, possible steal syndrome.

Postoperative Diagnosis: Left radial and ulnar arterial occlusive disease.

Operation:
1. Aortic arch with left upper extremity angiogram. 
2. Mynx closure left common femoral artery access
3. Ultrasound-guided left common femoral artery access.

Anesthesia: TIVA. 

Contrast Used: 45 ml Optiray 240.

Angiographic Findings:
1. With the diagnostic catheter in the descending aorta, the arch aortogram was performed demonstrating type 1 aortic arch with no evidence of significant atherosclerotic occlusive disease or aneurysmal degeneration of the descending and arch aorta with patent innominate artery, left common carotid and subclavian arteries.
2. With the diagnostic catheter in the distal subclavian artery, left upper extremity angiogram was performed demonstrating patent axillary artery and brachial artery with high bifurcation of the radial artery which is chronically occluded in the proximal third with patent left ulnar artery and interosseous artery with diffuse with moderate diffuse atherosclerotic occlusive disease involving the left ulnar artery. There is reconstitution of the distal radial artery at the level of the wrist which supplies the medial side of the digit. The ulnar artery gives the main distal runoff to the palmar arch as well as the lateral 3 that.
3. Patent brachial-cephalic arterial-venous fistula without evidence of hemodynamically significant stenosis

Technique: The patient was identified in the holding area and was brought into the operating room, laid supine on the operating table. After adequate anesthesia was obtained both groins were prepped and draped in the usual sterile fashion. Due to the skin rash on the right side, the left groin was chosen for access. The left femoral head was identified under fluoroscopy guidance. The common femoral artery was palpated. An 11 blade after infiltrating the skin with local anesthetics was made to make a small stab incision overlying the left common femoral artery. Using ultrasound guidance, retrograde arterial access was obtained using micropuncture needle. The micropuncture catheter was then exchanged over a guidewire for 5-French sheath and a diagnostic Omni Flush catheter was advanced up into the descending aorta under fluoroscopy guidance using guidewire technique. The diagnostic catheter was then exchanged for a 4-French angled glide catheter over the guidewire technique and advanced into the distal subclavian artery. The left upper extremity angiogram was then performed with above findings noted. With these findings, with the options for the patient of ligation of the brachiocephalic arteriovenous venous fistula versus brachial to the radial artery bypass determined, the catheter and the guidewire was withdrawn completely. The left common femoral artery access was then closed using Mynx closure device. The sheath was removed once the Mynx closure was assured. Pressure dressing was then applied to the left groin. The patient tolerated the procedure well without any acute intraoperative complications. All surgical counts were correct at the end of the procedure.


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## jkayser (Apr 15, 2014)

The aortic arch angiography documentation does not include extracranial carotid, vertebral, and/or intracranial vessels.  The documentation seems insufficient for billing 36221.  The imaging may have been primarily for guidance for selective catheterization of the subclavian artery. Also, CPT 36221 is for non-selective catheterization but the procedure continued into a selective catheterization of the subclavian artery via the same access site.  Per ZHealth "Non-Selective Catheter Placements" eLearning, "selective catheter placements include non-selective catheter placements performed along the route to the selective catheter placement."

My inclination would be to bill 36215 and 75710 only.  The report also mentions ultrasound guidance for access (+76937) and it would be billable if permanent recording was done per CPT description.  

Someone else may have additional information on this question.

Thanks.

Jean Kayser CPC CIRCC


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## rlj99w (Apr 15, 2014)

Thanks Jean!

That makes sense. I did not want to choose the selective catheter placement in the subclavian due to the inclusion of the ipsilateral vertebral circulation
(36255) but was trying to capture the angiography of the cervicocerebral arch. I don't see any way to capture just the arch and possibly this was just done for guidance. Thanks so much for your input! I am new to the vascular coding field and have much to learn.


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