Cardiology Coding Alert

Question: How do I code for a thoracic and abdominal aortogram? The operative report reads, Left brachial artery entered ... pigtail catheter guided into abdominal aorta where an abdominal aortogram was performed with run off into the iliac system. Next, the catheter was exchanged for an internal mammary catheter. This was placed into the abdominal aorta but was unable to be selectively engaged in the right renal artery. Single angiogram was performed. Next, this was exchanged for a pigtail catheter which was placed in the ascending aorta, hooked to power injector, and aortogram with runoff to the iliacs was performed.

I also do not understand the use of the phrase first order artery branch within a vascular family in the description of 36245. What are first and second order branches, and what constitutes a vascular family?

Cheryl Hathorn
Anniston, Ala.

Answer: Without obtaining a copy of the separate radiologic interpretation report, the only procedure that can be coded with certainty in this situation is access code 36200 (introduction of catheter, aorta), says Susan Callaway-Stradley, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C. Although a selective approach to the renals was attempted, it was not successful, and as a result the only access code possible is for the nonselective access to the aorta, Callaway-Stradley says, noting that the same code is used regardless of which portion of the aorta was accessed.

If the cardiologist performed the supervision and interpretation of the aortograms performed, these services also may be billed. Although in this case the correct codes cannot be determined without examining the radiology report, two possible coding scenarios suggest themselves.

According to Medlearns Interventional Radiology Coder, when performing an arteriogram with the catheter in the upper abdominal aorta or studying the full abdominal aorta and lower extremity vessels, (bilaterally, at least through the level of the femoral arteries) in one fluid exam, submit the supervision and interpretation code 75630 (aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision and interpretation). When performing full and complete exams of both the abdominal aorta and lower extremity vessels, code separately each anatomic area imaged using codes 75625 (aortography, abdominal, by serialography, radiological supervision and interpretation) and 75716 (angiography, extremity, bilateral, radiological supervision and interpretation) or 75710 (angiography, extremity, unilateral, radiological supervision and interpretation). Usually this is accomplished by separate nonselective catheter placements, both high (typically at the renal arteries level) and low (catheter at the aortic bifurcation).

If full and complete radiological exams of the extremities were performed, 75625 and 75716 would be the most appropriate choice. It is more likely, however, that only 75630 should be billed because all the angiograms were at the renal arteries level or higher and this code describes a less complete radiological exam of the abdomen and lower extremities. With regard to the second question, the definition of a vascular family is a group of vessels (arteries) fed by the primary branch of the aorta or the vessels punctured. To code arterial procedures, you must know the original puncture site and where the catheter ends, says Andrea Lamb, CPC, a coding and reimbursement specialist with St. Josephs Medical Center, a multispecialty practice in Buckhanon, W.Va.

The aorta has several primary branches from which the secondary and tertiary branches arise. In the arterial system, catheter placement in a primary branch is described as first order. Selective catheterization of a secondary branch is second order, etc.

In essence, code selection is determined by the final position of the catheter. Within each vascular family, the highest order treated is coded. This will include all of the work getting to the artery, including lesser order procedures. Lesser branches of the same family are not separately coded.