Cardiology Coding Alert

Question: Are the internal iliacs and external iliacs different vessels from common iliacs? I'm confused about how to report peripheral procedures.


Illinois Subscriber

Answer: Yes, the common iliac artery starts where the aorta ends and the vascular pathway splits to reach down into each of the lower extremities.

The common iliac ends at the point where the vascular pathway spits again and turns into the internal iliac (angling toward the groin) or the external iliac (continuing down the patient's leg). Although the internal and external iliacs are separate vessels from the common iliacs, they are still in the same "vascular family." 
  
Do: You should code each vascular family separately. Determine the highest order branch the cardiologist accesses in each vascular family.

You should assign all additional second- and third- order branches within the same vascular family either +36218 (Selective catheter placement, arterial system; 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]) or +36248 (Selective catheter placement, arterial system; additional second-order, third-order, and beyond, abdominal, pelvic, or lower-extremity artery branch, within a vascular family [list in addition to code for initial second- or third-order vessel as appropriate]).

Don't: You shouldn't code the branches traversed as a pathway to the second- or third-order branches beyond.

You should also separately code all supervision and interpretation (S&I) services, when your documentation supports it. Sometimes, you should not separately code the imaging S&I.

Example: You should not separately report contrast injections that the cardiologist specifically performs to obtain a map of the vascular territory (to facilitate catheter manipulation).

Always assign the appropriate S&I code for the vessel the cardiologist studies. If your cardiologist does a further selective catheterization in a higher order branch after the basic study, and CPT offers no more specific code, use +75774 (Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation [list separately in addition to code for primary procedure]) to denote the S&I.

You should use this code for additional studies of the same basic vessel (additional runs/images). 

Example: The cardiologist places a sheath in the right femoral artery and, using a guide catheter, manipulates to the abdominal aorta to perform abdominal aortogram. He then repositions the catheter at the bifurcation of the common iliacs for separate runoff injection, followed by a selective study of the left common iliac (which would then be considered an "additional study" to the runoff study).

You should report 36245 for the selective, contralateral catheter placement in the left common iliac artery, 75625-26 (Aortography, abdominal, by serialography, radiological supervision and interpretation; professional component), 75716-26 (Angiography, extremity, bilateral, radiological supervision and interpretation; professional component) and +75774-26 (Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation [list separately in addition to code for primary procedure]; professional component).

Note: If the cardiologist provides a selective and nonselective placement through the same vascular access site, you lose the nonselective placement because payers would consider this "in route" to the selective catheter position.
 
But if two access sites are involved in the procedure (one of which was selective and the other nonselective), you should report both selective catheter placement (such as 36245) and nonselective catheter placement (such as 36140, Introduction of needle or intracatheter; extremity artery).

Remember to attach modifier 59 (Distinct procedural service) to the nonselective catheter placement code to illustrate that it was through a different access site.