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 for reimbursement in Fairfax, Va.

"SIR became aware that some providers were using guidewire placement as the determining factor in coding catheterization selectivity," Hopkins says. Hoping to prevent this misuse, SIR addressed this issue, instructing providers that the "intent" of catheter placement is also a determining factor in coding, she says. 

Old way: Indeed, a statement in SIR's 2003 Coding Guide referencing "catheter tip and/or guidewire," which could be interpreted as being interchangeable when determining the level of selectivity, appears to have caused confusion. "Our 'intent' behind the language as presented in the 2003 edition of the Guide is being misinterpreted," Hopkins says. "This section of the Guide has been rewritten."

Specifically, SIR's 2003 Coding Guide states, "Degree of selectivity may be higher than the order of the vessel targeted for an intervention when medically indicated. For example, the contralateral common iliac artery is a first- order catheterization (36245). In order to perform an angioplasty of the contralateral common iliac artery, it is medically necessary to place a guidewire and/or catheter into the external iliac or common femoral artery, which are second-order vessels (36246); dilating an artery causes controlled trauma, and access beyond the site of therapy is crucial should complications arise. Therefore, the proper selective code to describe the necessary selective catheterization is 36246" (emphasis in original).

New way: In the 2004 Coding Guide, SIR has changed this section: "The site of therapeutic intervention is also not a determining factor in coding catheterization selectivity. It may be medically necessary to place the catheter at a higher degree of selectivity than the site of an intervention" (emphasis in original).