Cardiology Coding Alert

Hint: Watch catheter shaping procedures When cardiologists catheterize peripheral vascular (PV) vessels, you should use the catheter tip rather than guidewire placement to determine the level of selectivity. Guidewires Pave the Way Frequently, physicians advance the guidewire into a higher-order vessel than the tip of the catheter. Moving the wire ahead of the catheter tip may be necessary to ease catheter advancement and/or intervention in a lesser-order vascular branch, coding experts say.

Be aware: Although the cardiologist may navigate an additional bifurcation/trifurcation with the guidewire, you should code these catheterizations to the level of the catheter tip.

Billing the tip placement correctly is crucial to reimbursement. Specifically, when the physician performs a first-order selective cath procedure, you can recoup about  $250 for 36215 (Selective catheter placement, arterial system; each first-order thoracic or brachiocephalic branch, within a vascular family) or 36245 (... each first-order abdominal, pelvic, or lower-extremity artery branch, within a vascular family), according to national averages in the 2004 Medicare Physician Fee Schedule.

Coding example: "During a diagnostic carotid catheterization procedure, the physician may track the guidewire way up into the left external carotid artery and then place the catheter into the left common carotid to shoot an angiogram," says Roseanne R. Wholey, president of Roseanne R. Wholey and Associates in Oakmont, Pa.

In this situation, you would report the most selective catheter placement, not the most selective position of the guide wire, Wholey says. Specifically, you would report 36215 for a first-order catheter placement and the appropriate angiographic code for the carotid evaluation, she adds. Don't Let the 'Loop' Throw You Off Track Be on the lookout when the cardiologist advances the catheter tip into one vascular family just to shape the tip of the catheter and facilitate catheterization of a different family.

For instance, your physician may use a technique called a "Waltman loop." During this procedure, the physician catheterizes the superior mesenteric artery to form a loop that will facilitate ipsilateral internal iliac artery catheterization. (The "Simmons-type" catheter procedure is similar.)

Even though the physician advances the catheter into a different family (the superior mesenteric) to shape the tip, you should report only the catheter placement in the ipsilateral internal iliac artery (36245) because this is the vessel the physician actually catheterized.

The bottom line: You should not code catheterizations to form catheter shapes such as the Waltman loop separately, Wholey says. SIR Says Keep Your Eye on the Tip If you're following the catheter tip for PV cath procedures, you're falling in line with Society for Interventional Radiology (SIR) current coding guidelines for these procedures.

"SIR does support that catheter tip placement is typically the determining factor in coding catheter selectivity," says Dawn R. Hopkins, SIR's senior manager [...]