Cardiology Coding Alert

Training tip: Documentation needs to state where the catheter terminates.

You may want to grab a little caffeine before diving into 2013’s new cervicocerebral angiography codes. Your attention to detail needs to be at its best to pick out the key differences in the code definitions.

Anatomically, these codes relate to vessels in the neck and head, says Terry A. Fletcher, BS, CPC, CCS-P, CCS, CEMC, CCC, CMSCS, CMC, of California-based Terry Fletcher Consulting.

2012 comparison: The new codes each include angiography and radiological supervision and interpretation (RS&I). This is a significant shift from 2012 coding, which required separate codes for catheter placement and RS&I, Fletcher notes. Because of this change, CPT® 2013 deletes angiography codes 75650 and 75660-75685 for the carotid, cerebral, vertebral, and cervical arteries.

What’s included: New codes 36221-36226, which are primary rather than add-on codes, include vessel access, related catheter placement and contrast injections, fluoroscopy, RS&I, and arterial closure by pressure or device, as noted in the Vascular Surgery and Interventional Radiology presentation by Sean P. Roddy, MD, FACS, of the Society for Vascular Surgery and AMA CPT® Advisory Committee, at the CPT® and RBRVS 2013 Annual Symposium.

If the physician performs any arterial, capillary, or venous phase imaging, you shouldn’t report that separately. That imaging is included in each of the new codes (36221-+36228). Below you’ll find details to help you choose among the different possibilities.

36221: Know the Non-Selective Option

The first new code is specific to non-selective catheter placement:

• 36221, Non-selective catheter placement, thoracic aorta, with angiography of the extracranial carotid, vertebral, and/or intracranial vessels, unilateral or bilateral, and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed.

Code 36221 applies only when the catheter goes as far as the thoracic aorta and no farther. Imaging of the aortic arch and origin of the great vessels is also included in this code, CPT® guidelines state. It is not appropriate to report non-selective code 36221 with selective codes 36222-36226, described below.

Note that 36221 is the only code that specifies "unilateral or bilateral." All of the others are unilateral. This makes sense because imaging from the thoracic aorta allows visualization of both sides from that single catheter position. In contrast, the other codes require selective placement of the catheter in either a right-side or left-side vessel.

36222-36224: Choose the Most Comprehensive Service

The first three selective codes in the new range are 36222-36224. To select the proper code, you must watch for where the catheter terminates (common carotid, innominate, internal carotid) and which vessels are imaged (extracranial carotid, intracranial carotid). Imaging of the cervicocerebral arch will not change your coding because all of the codes include that service when performed.

• 36222, Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral extracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed
• 36223, Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed
• 36224, Selective catheter placement, internal carotid artery, unilateral, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed

Guidelines instruct that these codes are hierarchical, so you may report only one code from 36222-36224 for each same-side carotid territory. In other words, if the physician places the catheter in the left common carotid and images the extracranial circulation, and then places the catheter in the left internal carotid and images the intracranial circulation, you should report only 36224. You should not report 36222, as well. Code 36224 represents the most selective catheter placement and all of the angiography services performed.

36225-36226: Catheter Position Is the Key

The next two new codes are also hierarchical, only varying based on the placement of the catheter:

• 36225, Selective catheter placement, subclavian or innominate artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed
• 36226, Selective catheter placement, vertebral artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed.

As you might expect, you should report only one of these codes per same-side vertebral territory. Vertebral artery placement is more selective than subclavian or innominate. So you should report 36226 if the physician images the vertebral circulation from the subclavian or innominate in addition to from the vertebral artery.

+36227: Limit This Add-On to 3 Primary Codes

The first new add-on code in the series is +36227:

• +36227, Selective catheter placement, external carotid artery, unilateral, with angiography of the ipsilateral external carotid circulation and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure).

CPT® guidelines state that this code includes artery access, catheter placement, contrast injection, fluoro, and RS&I. Add-on codes are designed to be reported in addition to primary procedure codes. In this case, you should report +36227 in addition to 36222, 36223, or 36224.

+36228: Don’t Take ‘Each Branch’ at Face Value

The final new code in the range is also an add-on code. The primary code options are 36224 and 36226 for this add-on code:

• +36228, Selective catheter placement, each intracranial branch of the internal carotid or vertebral arteries, unilateral, with angiography of the selected vessel circulation and all associated radiological supervision and interpretation (e.g., middle cerebral artery, posterior inferior cerebellar artery) (List separately in addition to code for primary procedure).

Although the definition states "each intracranial branch," you shouldn’t get carried away with units. Guidelines clarify that you should not report the code "more than twice per side regardless of the number of additional branches selectively catheterized."

A single unit of the code includes the usual list of vessel access, cath placement, contrast injection, fluoro, and RS&I. But for proper application of the code, you also need to understand that once you’ve coded cath placement in a primary branch of the internal carotid, vertebral, or basilar artery, then any additional second or third order cath placement in that branch is included in the code, too.

Resource: You can access Roddy’s slides, including helpful anatomic diagrams, from www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt/cpt-rbrvs-symposium.page. Watch for an article in a future issue focusing on the guidelines accompanying these codes.