Cardiology Coding Alert

Don’t miss CPT^®’s specific instructions for selective catheterization.

Catheterization is a challenging topic to wrap your head around, no matter how long you’ve been coding. You have to learn about concepts like vascular families, vessel order, selective, and nonselective catheterization. It’s no wonder this can be such a confusing section of the CPT^® manual.

A new cardiology coder recently wrote in and asked about the difference between nonselective and selective catheter placement. Read on to learn more and brush up on your catheter know-how.

Tackle This Nonselective Catheterization Scenario

With nonselective catheterization, the cardiologist places the catheter into the desired blood vessel. There is no manipulation, and the cardiologist does not advance the catheter into other branches of the vascular family or he only negotiates the catheter into a vessel like the thoracic or abdominal aorta or vena cava and then he removes it.

Coding scenario: The cardiologist introduces a catheter into the patient’s common femoral artery and advances it into his aorta. Then the cardiologist he removes the catheter. You would report 36200 (Introduction of catheter, aorta) for this service.

Delve Into Selective Catheterization

Selective catheterization occurs when the cardiologist manipulates the catheter from the vessel entered, from the aorta, or vena cava into a branch vessel — first, second, third, or higher order. Regardless of the approach (from the arm, leg or neck), once the aorta or vena cava is entered and a branch is selected, a selective catheter placement code must be used, and the non-selective catheter position is included.

Remember to always code to the furthest catheter placement within a vascular family, and each vascular family is coded independently.

Per the CPT^® manual, the vascular injection procedure section, which encompasses 36000 (Introduction of needle or intracatheter, vein) through 36598 (Contrast injection(s) for radiologic evaluation of existing central venous access device, including fluoroscopy, image documentation and report) also offers some additional guidelines for selective catheterization.

When reporting selective catheterization, you will need to make sure of the following:

• »You should code selective vascular catheterizations “to include introduction and all lesser order selective catheterizations used in the approach ….,” per CPT^®.
• You should report any “additional second and/or third order arterial catheterizations within the same family of arteries or veins supplied by a single first order vessel” with 36012 (Selective catheter placement, venous system; second order, or more selective, branch (eg, left adrenal vein, petrosal sinus), +36218 (…, 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)), or +36248 (…, arterial system; additional second order, third order, and beyond, 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)), according to CPT^® when appropriate.
• You should separately report any additional first order or higher catheterizations when medically necessary of different vascular families supplied by a first order vessel, using the conventions described above, per CPT^®, when appropriate.

Don’t miss: “Some vessels can only be selected by the “pull back method,” which requires the physician to maneuver the catheter in a reverse motion to access a different route in the same vascular family,” says Christina Neighbors, MA, CPC, CCC, Coding Quality Auditor for Conifer Health Solutions, Coding Quality & Education Department, and member of AAPC’s Certified Cardiology Coder steering committee. “This is where additional second or higher selective catheter position codes apply. When the physician provides additional work to get to a branch vessel after a second or third order selection has been performed, the ‘each additional’ code should be used.”

Decipher Vascular Order for Catheterization Success

When it comes to catheterization, you must understand the concept of vessel order to code correctly. Take a look at the following for clarification:

First order: The first order vessel is the primary branch off the main trunk of a vascular system.

Second order vessel: The secondary branch, which comes off the first order vessel.

Third order and higher vessels: The tertiary branch and further. This comes off the second order vessel. Any branch higher than a third order is also coded as a third order or additional second or third order.

Rule of thumb: Follow this additional advice from Neighbors:

• Never code according to wire placements.
• Do code to the furthest point where the tip of the sheath, catheter, or interventional catheter/tool (excluding wires) ends within a singular vascular family.
• Do code when the physician uses the “pull back method” to access a branch vessel after an initial, second and/or third order section has been performed within the same family. Don’t forget to always code to the furthest point.
• Do code from each approach from different access points.

Reminder: Some procedures bundle catheter placements within the interventional procedure(s), Neighbors adds.