Cardiology Coding Alert

Think you can capture every element of a peripheral vascular procedure and keep straight CPT's all-inclusive codes? Test yourself by working your way through this real report and determine which CPT codes you would use. Then check your answers below.

Heads up: "A coder should always review the patient's anatomy, the physician's intentions and indication, the procedural description, and the outcome of the procedure -- before coding the procedure itself," says Christina Neighbors, MA, CPC, ASC-CA, charge capture reconciliation specialist and coder at St. Joseph Heart & Vascular Center in Tacoma, Wash.

First, Read the Procedure Note

Report: Right femoral artery punctured. Catheter used to cross over the aortic bifurcation into the left iliac system. Left common iliac artery was selected. Subselection was made of the left internal iliac artery. DSA performed in two projections. Embolization was carried out using Gelfoam. Completion angiography was performed in the left internal iliac artery.

The catheter was pulled back into the right common iliac, followed by selection of the right internal iliac artery. Right internal iliac angiography was performed in two projections. Embolization was carried out using Gelfoam as well. Completion angiography was performed.

Review Selective Catheterization Rules

You have to work your way through the report's first few sentences to find the first reportable code. You should submit 36246 (Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family) to reflect the left internal iliac artery subselection, says Cheryl Scott, CPC, CPC-H, CCS, CCS-P, a coding consultant with HealthTexas in Dallas.

Reason: You should choose second-order code 36246 because the first-order artery is the common iliac, says Kim French, CIC, director of interventional coding and reimbursement at Crouse Radiology Associates in Syracuse, N.Y.

And the CPT guidelines for vascular injection procedures instruct you that "selective vascular catheterization should be coded to include introduction and all lesser order selective catheterization used in the approach." Translation: Don't separately report the right femoral artery puncture and left common iliac artery selection.

You should report 75736 (Angiography, pelvic, selective or supraselective, radiological supervision and interpretation) for the DSA performed in two projections, French says. Term tip: "DSA" stands for "digital subtraction angiography."

Don't forget: If you're reporting only the physician's services, append modifier 26 (Professional component) to the radiological supervision and interpretation (RS&I) services, Scott says.

As you work your way through the report, you'll next come to the left internal iliac embolization. You should report this embolization with 37204 (Transcatheter occlusion or embolization [e.g., for tumor destruction, to achieve hemostasis, to occlude a vascular malformation], percutaneous, any method, non-central nervous system, non-head or neck) and 75894 (Transcatheter therapy, embolization, any method, radiological supervision and interpretation), French says.

Remember: You should code embolizations that a cardiologist performs in one operative field, even if accomplished through multiple vessels, only once, Neighbors says.

For the completion angiography in the left internal iliac artery, you should report 75898 (Angiography through existing catheter for follow-up study for transcatheter therapy, embolization or infusion), French says.

Again, append modifier 26 to the RS&I codes (75894 and 75898) if you report the professional component only, Scott says.

For the left internal iliac artery selection, you should report 36245 (Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family), French says. This is a separate vascular family from the right leg (which you reported earlier), so you should code a second catheter placement. You should report a first-order code because it's a branch of the vessel punctured, she says.

CPT guideline: The notes for vascular injection procedures state that you should separately code "additional first-order or higher catheterization in vascular families supplied by a first-order vessel different from a previously selected and coded family."

Tip: Append modifier 59 (Distinct procedural service) to 36245 to prevent payers from bundling it into 36246, which you reported for the left internal iliac. Without modifier 59, payers may assume that both codes refer to the same vascular family and won't cover the lesser code.

You should report 75736 for the left internal iliac angiography, French says.

Again, append modifier 26 if you provide only the professional component. Because this is the second occurrence of this code, you'll list this as two units of 75736-26.

The rule: According to CPT guidelines for aorta and artery procedures, you should report diagnostic angiography performed with an interventional procedure only if you meet one of the following two requirements:

1. No prior catheter-based angiography is available, the provider performs a full diagnostic study and decides to intervene based on the diagnostic study; or

2. A prior study is available, but documentation shows one of the following three requirements:

a. the patient's condition has changed

b. the prior study offers inadequate visualization

c. a clinical change during the procedure requires new evaluation outside the intervention area.

Before you report 75736 for our sample report, you need to look further into the documentation, French says. Check the history and findings to determine whether 75736 is appropriate, she says.

You should not charge the second Gelfoam embolization and completion angiography separately, French says. You should report them only once per operative field per session. "This is a recent change for the follow-up angiography," she says. But the AMA confirmed it in the December 2007 CPT Assistant.

Remember: Payers and the AMA, which publishes CPT codes, offer authoritative guidance. Professional societies' advice is not authoritative, but it does indicate what they believe is clinically correct and can guide you in the absence of authoritative guidance.

Assuming the history and findings support reporting 75736 twice, you should submit the following codes on your claim:

• 37204 for the transcatheter occlusion

• 36246 for the second-order arterial system

• 36245-59 for the first-order arterial system

• 75898-26 for the follow-up angiography

• 75894-26 for the transcatheter therapy supervision and interpretation

• 75736-26 x 2 for the pelvic artery S&I.