Cardiology Coding Alert

Some cardiology coders, accustomed to the familiar pathways of the heart, may view the noncoronary vessels in the abdomen as a strange and unrecognizable territory. But learning a few basic coding techniques will help you navigate these conduits with ease.

Indeed, the key to finding your way through this apparent maze of abdominal aortic vessels and accurately coding diagnostic procedures is keeping track of catheter placement during angiography and distinguishing between first-, second- and third-order vessels. You must know the difference between selective and nonselective codes and be able to pair the appropriate radiological supervision and interpretation (S/I) codes with the procedure codes, coding experts say.

Increasingly, cardiologists are performing more noncoronary diagnostic imaging, including imaging the abdominal aortic vessels. In the past, however, interventional radiologists imaged these vessels, so cardiology coders will need more and more expertise in reporting the correct codes for abdominal aortic vessel procedures to avoid payment denials.

When coding angiography in noncoronary arteries, you need two basic components: the procedural code and a code for the S/I, stresses Cynthia Swanson, RN, CPC, a cardiology coding consultant with Seim, Johnson, Sestak and Quist in Omaha, Neb. The codes in combination allow for billing accuracy, whether one physician performs all the services or multiple physicians provide portions of services, she says.

If a cardiologist finds vascular disease in the coronary arteries, he or she may image the rest of the arteries in the body, including the abdominal arteries. For instance, a patient may have a Doppler echocardiography (93320 or 93325) that shows cardiovascular stenosis (429.2), and the cardiologist will decide to check for atherosclerosis of the extremities (440.20) as well, says Sheldrian Wayne, CPC, a cardiology coding specialist with Coding Strategies Inc. of Atlanta.

Remember that if the physician does not own his own equipment and performs the angiography in the hospital rather than in the office, you should append modifier -26 (Professional component) to the radiological S/I codes, says Kathy Pride, CPC, CCS-P, a coding consultant for QuadraMed in Port St. Lucie, Fla.

Where the cardiologist directs the catheter determines whether you use a nonselective or selective procedure code in the 36200-36248 range.

If the cardiologist inserts a catheter from a femoral artery puncture site into the abdominal aorta and the catheter never leaves this primary vessel, then you would report 36200 (Introduction of catheter, aorta) for nonselective catheter placement in the aorta, Swanson and Wayne say.

Report 75630 (Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision and interpretation) for the lower-extremity radiological S/I, which includes imaging the renal arteries and the iliacs, Swanson says.

Frequently, after a patient has had a cardiac catheterization, the cardiologist will advance the catheter a little further down in the aorta, Wayne says. The physician then performs a run-off study to assess the lower-extremity arteries such as the renals and the iliacs.

In this situation, the coder cannot assign 36200 as the catheter placement code, Wayne says, because the catheter started out as a cardiac catheter and was advanced to the level of the renal arteries where the physician injects dye and images the renals and the peripheral arteries to evaluate them. If that catheter never entered any peripheral artery, a coder cannot report 36200 when followed by a cardiac catheterization.

If the physician repositions the catheter within the aorta, however, and pulls the catheter down to the area called the bifurcation, where the aorta splits and forms the left and right common iliacs, you would report 36200 for selective aortic catheter placement.

You would also report 75716 (Angiography, extremity, bilateral, radiological supervision and interpretation) for the bilateral angiography and 75625 (Aortography, abdominal, by serialography, radiological supervision and interpretation) for the abdominal aortographs. The physician's documentation must specify that the catheter advanced to the bifurcation before you can report 75716 and 75625, Wayne says.

When the physician actually directs the catheter into the renal arteries, which are first-order vessels off the abdominal aorta, you should report codes that indicate which renal arteries the catheter entered or "selected."

Use 36245 (Selective catheter placement, arterial system; each first-order abdominal, pelvic, or lower extremity artery branch, within a vascular family) as the procedure code because renals are first-order selective vessels, Wayne says.

The radiological S/I code you choose for renal imaging will depend on whether the cardiologist imaged one renal artery (unilateral) or renal arteries on both sides of the abdominal aorta (bilateral).

Report 75722 (Angiography, renal, unilateral, selective [including flush aortogram], radiological supervision and interpretation) if the physician performs angiography on one renal artery. If the physician selects both renal arteries and images both, report 75724 (Angiography, renal, bilateral, selective [including flush aortogram], radiological supervision and interpretation).

When the cardiologist directs the catheter into both renal arteries, thereby selecting both, you should report 36245 twice and 75724 once, but check with your payer to verify this, coding consultants advise. You only need 75724 once because the code description already has "bilateral" in it, Wayne says. Even if the cardiologist uses different catheters to select the renals, as long as the report states that both renals were selectively engaged, then you can report 36245 twice to indicate a bilateral selection, she adds.

If the physician selectively engages second-order vessels off the renals or iliac arteries, report 36246 ( initial second-order abdominal, pelvic, or lower extremity artery branch, within a vascular family). And if the catheter travels even further into a third-order vessel, which branches off a second-order artery, report 36247 ( initial third-order or more selective abdominal, pelvic, or lower extremity artery branch ...), Swanson says.

When the physician selects additional second- or third-order vessels, add +36248 ( additional second-order, third-order, and beyond [list in addition to code for initial second- or third-order vessel as appropriate]).

Coding iliac artery catheterization and imaging is even more complex than coding renal catheterization because coders have to know whether the physician selected the right or left common, external, or internal iliacs.

CMS considers the common iliac a first-order vessel, so report 36245 if the physician selectively engages it. The internal and external iliacs, which branch off the common iliacs, are second-order vessels, so report 36246 if the catheter enters these. Wayne says the internal iliacs are also known as the hypogastric arteries, so coders should know that if documentation references hypogastric arteries, the physician is referring to the internal iliacs.

The key to coding the iliac system is having a clear understanding of whether the catheter placement for the imaging is ipsilateral on the same side of the body as the puncture site or contralateral on the opposite side of the body from the puncture site, Wayne says.

For example, if the physician punctures the right femoral artery and advances the catheter down the leg into the aorta and does not cross the bifurcation, this is an ipsilateral study. You would report 36140 (Introduction of needle or intracatheter; extremity artery) for the femoral artery catheterization and 36245 for selective catheter placement of a second-order vessel.

If the physician performs a contralateral study of the superficial femoral artery (SFA), you would use 36247 to indicate that this is a third-order vessel on the opposite side from the puncture site, but if the physician performs an ipsilateral SFA study, you would use 36245 because the catheter selects only the SFA, Wayne says.

Occasionally, the cardiologist decides to correct a problem detected during imaging arteries in the abdominal region immediately following the imaging. If this is the case, report the therapy code and the radiological S/I code, Wayne and Pride say.

For instance, if the patient has an angioplasty of the iliac, report 35473 (Transluminal balloon angioplasty, percutaneous; iliac) for the angioplasty procedure and 75962 (Transluminal balloon angioplasty, peripheral artery, radiological supervision and interpretation) for the radiological S/I for a peripheral artery. You would report 35471 (Transluminal balloon angioplasty, percutaneous; renal or visceral artery) and 75966 for angioplasty S/I, Wayne notes.

Note: For more on interventional radiology, go to the Society of Interventional Radiology's Web site, www.sirweb.org. To order texts on interventional radiology, visit www.medlearn.com or call (800) 252-1578.