Cardiology Coding Alert

It all comes down to vascular families, experts say

You know you can't report nonselective catheter placement with selective placement from the same access site. But how should you report situations in which the physician inserts the catheter multiple times in selective locations from the same access site?

The key to coding these peripheral vascular (PV) studies correctly is knowing whether the cardiologist catheterized more than one vascular family during the procedure, PV coding experts say.

Don't Bill for Catheter Exchanges

Frequently, a physician will perform a diagnostic study with the catheter in a selective location and exchange the diagnostic catheter for an interventional catheter before treating the lesion.

What to do: When the cardiologist performs a cath placement for a selective left renal artery study from a femoral access site, you would report 36245 (Selective catheter placement, arterial system; each first-order abdominal, pelvic, or lower-extremity artery branch, within a vascular family) for the selective renal artery study.

If the imaging shows a high-grade stenosis in the left renal artery and the physician decides to perform a percutaneous transluminal angioplasty (PTA), he would need to remove the diagnostic catheter and completely advance an interventional catheter to the same location. Even though the physician advanced a second catheter into the same selective location, you cannot report this service separately.

"You would only bill one catheter placement unless there is more than one access site," says Roseanne R. Wholey, president of Roseanne R. Wholey and Associates in Oakmont, Pa.

Track Cath Progress Through Vascular Families

Even so, when the physician catheterizes more than one vascular family -- a network of arterial branches supplied by the same artery with a proximal connection to the aorta -- you may be able to bill multiple catheter positions. Here are the guidelines for two situations:

1. Separate Families: Code Highest-Order Cath

If the physician selectively positions the catheter in two different vascular families, such as the contralateral lower-extremity and the left renal artery, you should code the highest-order selective catheterization in each vascular family separately.

Indeed, the Society of Interventional Radiology's (SIR) 2003 Coding Guide confirms that within each vascular family "the highest-order catheterization is coded."

This means that the highest-order cath placement code includes all lesser-order cath positions necessary to reach the target destination.

In addition, the procedure "will include all of the work involved puncturing the artery, negotiating any anomaly or stenosis, and advancing the catheter into the lumen of the target," the SIR guide states.

Coding example 1: From a femoral puncture site, the physician selectively places a catheter in both renal arteries. "These are two different vascular families, and the first-order catheter code, 36245, can be billed twice," Wholey says. "But since the procedure is bilateral, you would use modifier -50 (Bilateral procedure) with this code."

Helpful: Check with your carrier/payer for modifier guidelines. "Some carriers want 36245 listed once with modifier -50, while others want 36245 listed twice with modifier -59 (Distinct procedural service) or a modifier    -50 on one of them," says Jim Collins, CHCC, CPC, president of Compliant MD Inc. and compliance manager for several cardiology groups around the country. "Despite the standardized code set requirements established by HIPAA, there is little consistency among payers in many areas, especially PV billing."

Coding example 2: The physician may need to puncture both femoral arteries. For instance, on one side, he places the catheter into the aorta for an aortogram but cannot advance the catheter over the aortic bifurcation. So, he must puncture the other femoral artery and place the catheter in the popliteal.

In this situation, you can code both catheter placements, Wholey says. The second-order cath placement in the popliteal would be 36246 (...initial second-order abdominal, pelvic or lower-extremity artery branch, within a vascular family), and you would bill the catheter to the aorta with 36200 (Introduction of catheter, aorta), she says. "This is one case where you can bill a nonselective cath placement, as well as a selective one, because there are two puncture sites."

Be sure to add modifier -59 to 36200, says Rhonda Burge, CPC, coding and billing supervisor for Mid-Ohio Cardiology and Vascular Consultants in Columbus. "Otherwise, 36200 will be bundled into 36246," she says.

Indeed, appending modifier -59 in this instance aligns with CMS guidance regarding using the modifier with selective catheter procedures. (For more on these CMS
uidelines, see "How to Bill Selective and Nonselective Caths Together" in the February 2004 Cardiology Coding Alert.)

2. Same Family: Check Multiple Cath Positions

The physician may place the catheter in two selective positions that are in the same vascular family. In some of these cases, you can bill for multiple cath placements, but in other situations you cannot. The following examples illustrate how to report these services:

Coding example 1: From a right femoral access point, the cardiologist positions the catheter in the right subclavian artery, performs imaging and then repositions the catheter in the right common carotid artery. Both of these vessels are branches of the brachiocephalic/ innominate artery that arises at the arch of the aorta, and they both represent second-order selective catheter positions, coding experts say.

For the initial second-order catheter position above the diaphragm, you should report 36216 (Selective catheter placement, arterial system; initial second-order thoracic or brachiocephalic branch, within a vascular family). Report the second cath position with +36218 (...; 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]).

Here's why: CPT indicates that you should bill for one of the selective catheter placement services with the regular code that indicates the initial/selective catheter placement (36215, 36216 or 36217 for vascular families above the diaphragm; or 36245, 36246 or 36247 for vascular families below the diaphragm).

The other selective catheter placement should be reported with 36218 or 36248, depending on whether the vascular family arises above or below the diaphragm, respectively.

Don't miss: The key to being able to bill for multiple cath positions in the same vascular family is that the multiple positions cannot be along the same path, Collins says. For such procedures, the physician would have to retract the catheter tip proximally through the bifurcation/trifurcation and then advance the catheter down a different pathway so it is distal to the bifurcation/trifurcation, he says.

Coding example 2: The cardiologist positions the catheter tip in the right vertebral and then in the brachiocephalic artery. In this case, you would report only one code (36217), assuming a femoral puncture site. You would not need to report the additional vessel code (36218) because the physician navigated the brachiocephalic artery en route to the right vertebral.