Cardiology Coding Alert

Bolster your knowledge of coding multiple angiograms with this example

If you're coding for op reports for peripheral vascular procedures, don't be left in a daze. Learn how to code selective catheter placement by the highest order and report multiple angiograms along with an attempted percutaneous transluminal balloon angioplasty (PTA).

Prime Yourself by Reading the Full Procedure

Procedure: The cardiologist accessed the right femoral artery and performed an abdominal bi-iliac angiogram with interpretation of both iliacs and common femoral arteries. He followed with a selective cannulation of left common iliac and runoff of the left lower extremity. Then he performed bilateral selective renal angiography. Next, he performed a selective left CFA angiography with distal arterial runoff for selective visualization of distal vessels. The patient underwent a peripheral angioplasty with cryoplasty balloon of critical stenosis in the distal left SFA and left popliteal artery. He cannulated the left renal and crossed the lesion and performed a peripheral angioplasty (peripheral angioplasty of in-stent restenosis in the left renal artery).

Main point of confusion: "How should I code the selective left common iliac artery with access from the right femoral? Would that be first or second highest order?" asks Josefina Peredo, a coder at New Coast Cardiology in Gulfport, Miss. "Can I report anything for the attempted PTA?"

Here's how to break down this complicated procedure into codes, based on the expert advice of Deborah Ovall, CMA, CCS, CIC, lead coder and data quality analyst with Medical College Hospitals of Ohio at Toledo.

Parcel Out 5 Stops to Pick Correct Codes

Think of it this way: "It's just like taking a car trip - you've got your beginning, your final destination, and sight-seeing stops along the way. Sometimes you just look at stuff as you go by, and sometimes you stop and do something a little more fun," Ovall says.

1. The cardiologist accessed the right femoral artery and performed an abdominal bi-iliac angiogram with interpretation of both iliacs and common femoral arteries. The cardiologist followed with a selective cannulation of the left common iliac and runoff of the left lower extremity.

The abdominal aorto-bi-iliac angiogram includes visualization of the abdominal aorta, bilateral common iliac arteries and distal runoff through the common femoral arteries. You should report 75630-26 (Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision and interpretation; professional component) if the cardiologist took one shot (in other words, shot dye and took a picture) from one position in the aorta.

For the service described by "a selective cannulation of left common iliac and runoff of the lower extremity," you should report +75774-26 (Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation [list separately in addition to code for primary procedure]).

Pitfall: At this point you might be tempted to report 36245 (Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family) as well, but resist the temptation. "This will go away as the cardiologist moves further into the left leg," Ovall says.

2. Then he performed bilateral selective renal angiography.

Because he interpreted both renals, you can report selective left and right renal angiographies with 75724-26 (Angiography, renal, bilateral, selective [including flush aortogram], radiological supervision and interpretation).
 
However, don't forget to code for the catheter placements. You should add 36245-59 and 36245-59 (Distinct procedural service). These codes reimburse your cardiologist for putting the catheter in the renal arteries.

Keep in mind: Carriers often differ on how they want you to report 36245/36245, so check with them to see how they want you to report this, Oval says.

3. Next, he performed a selective left CFA angiography with distal arterial runoff for selective visualization of distal vessels.

If your cardiologist did an interpretation of this shot, you can code another 75774-26.

Don't miss: At this point you may be tempted to code 36246 (Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family) for the second order catheter placement. This catheter placement is the reason the first order code (36245) in this vascular family went away. But hold onto that thought, because 36246 will go away later, too, Ovall says. 
 
4. Then the patient underwent a peripheral angioplasty with cryoplasty balloon of critical stenosis in the distal left SFA and left popliteal artery.

Keep in mind that the cardiologist accessed this vessel from the right femoral artery access site.

For the superficial femoral artery (SFA) intervention, you can report 35474 (Transluminal balloon angioplasty, percutaneous; femoral-popliteal) and 75962-26 (Transluminal balloon angioplasty, peripheral artery, radiological supervision and interpretation).

Watch for: The contralateral SFA cath placement is 36247 (...initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family). So, the second order code (36246) now goes away, Ovall says.

Heads-up: You also need to code for the popliteal PTA, which is 35474-59 (Transluminal balloon angioplasty, percutaneous; femoral-popliteal) and +75964-26 (Transluminal balloon angioplasty, each additional peripheral artery, radiological supervision and interpretation [list separately in addition to code for primary procedure]).

5. He cannulated the left renal and crossed the lesion and performed a peripheral angioplasty (peripheral angioplasty of in-stent restenosis in the left renal artery).

Red flag: You already coded the catheter placement in the left renal artery when you coded the angiogram at the beginning. Therefore, you cannot code this a second time, so don't include 36245, Ovall says.

However, you should report 35471 (Transluminal balloon angioplasty, percutaneous; renal or visceral artery) and 75966-26 (Transluminal balloon angioplasty, renal or other visceral artery, radiological supervision and interpretation).

Tally Up the Op Report Codes

In the end, here are all the codes put together for the procedure described above: