Cardiology Coding Alert

The next time your report reveals an aortogram on a patient with a bovine arch, you've got important decisions to make: Should you choose a second- or third-order catheter code? How will you determine which imaging code to use? When should you report a bovine arch ICD-9 code?

Our experts reveal the answers to all these questions and more in these three steps.

Scenario: Your cardiologist gains access from the right femoral artery and performs an ascending aortogram on a patient with a bovine arch. He places a catheter in the right common carotid with selective angiogram of the right common carotid and obtains intracerebral angiogram on the right side.

Step 1: Report a Third-Order Code

One school of thought defends coding a third-order catheter placement for this scenario.

Reason: In a patient with a bovine arch, the left common carotid rises from the innominate artery, so the left carotid is a second-order branch and the right carotid becomes a third-order branch, says Dawn Hopkins, senior manager for reimbursement with the Society of Interventional Radiologists (SIR).

How to code: Report 36217 (Selective catheter placement, arterial system; initial third-order or more selective thoracic or brachiocephalic branch, within a vascular family).

You should always choose your code based on accuracy, not payment. If your payer agrees that 36216 (... initial second-order thoracic or brachiocephalic branch, within a vascular family) and 36217 are equally accurate for this procedure, however, you should choose 36217. Why: The higher the vessel order, the higher the relative value units (RVUs), and consequently the higher the payment.

Remember: Your payer will have the final word on whether you may code this as second- or third-order catheter placement, says Deepa Malhotra, MS, CPC, president of Healthcare Education Resource (HERS Inc.) in Chicago.

Caution: Whenever you report a third-order code for a vessel that's normally second-order (including the left internal and left external arteries), be sure the cardiologist specifically documents the bovine arch or states that the left common carotid originates from the innominate.
 
This documentation proves to the payer why the physician could not take the normal route to the vessel, Malhotra says.

Step 2: Develop Your Imaging Coding

Although you may code only the highest level of catheterization, you may report any diagnostic imaging your cardiologist documents along the way, as long as the cardiologist does not perform it exclusively for guiding purposes. 

Example: You should report an ascending aorta study with 75650-26 (Angiography, cervicocerebral, catheter, including vessel origin, radiological supervision and interpretation; professional component) if it was diagnostic (in other words, you have a documented indication and the report reflects the findings of the diagnostic study).

But if the study was for guiding purposes (in other words, your cardiologist did this procedure to obtain a "road map" to facilitate innominate artery catheterization), you should not separately report this study.

In the above scenario, you should report 75676 (Angiography, carotid, cervical, unilateral, radiological supervision and interpretation) for the angiogram of the right common carotid.

You should also submit 75665 (Angiography, carotid, cerebral, unilateral, radiological supervision and interpretation) for angiogram of the right internal carotid and the cerebral distribution.

You should not report a supervision and interpretation (S&I) code for the right external carotid. Why: The imaging codes for the external carotids (75660-75662) are defined as selective--the physician must place the catheter within that vessel to code for the S&I portion of the angiogram, experts say.

The exam codes for most other vessels above the diaphragm are nonselective, so the catheter doesn't have to be in the imaged vessel for you to report S&I.

Helpful: Picture the procedure as a road trip, Malhotra says. Driving along the expressway, you have many exits. You don't have to take an exit (vessel) to get a great view (image) of where it goes, she says.

Step 3: Leave 747.21 for Later

When choosing the appropriate ICD-9 code, look through the cardiologist's report to determine the medical necessity for the arch study and the diagnostic findings, such as 433.10 (Occlusion and stenosis of precerebral arteries, carotid artery; without mention of cerebral infarction).

You should report pertinent findings from the exam first for your diagnoses. If there are no pertinent findings, you may code the reason behind the exam--just be sure you don't code the diagnosis that the test was meant to "rule out" unless the study confirms that diagnosis.

The diagnosis code for the bovine arch--747.21, Anomalies of aortic arch--should only be used as a secondary or tertiary code, says Stacy Gregory, RCC, CPC, charge capture and reconciliation specialist for Franciscan Health Systems' Imaging Support Services in Tacoma, Wash. It isn't appropriate as a primary diagnosis for a carotid angiography.

Finally, be sure the cardiologist documents the bovine arch in the report to support your diagnosis choice.