General Surgery Coding Alert

Report catheter placement according to location and vessel

In general surgery practice, catheter placement goes hand in hand with many surgical procedures, but differentiating a second-order from a third-order (or first-order) placement can be a challenge. To help you navigate the families and branches of arterial catheter coding, we offer this basic how-to lesson.

You should select catheter placement codes according to the vascular family, and the branches within that family, that the surgeon accesses. To understand these codes, however, you must first learn about vascular anatomy.

You can think of the patient's aorta (the primary vessel leading from the heart) as the trunk of a tree. Each "branch" that arises from the aorta is considered a first-order vessel. When this branch splits, you have two second-order vessels or branches, says Jackie Miller, MA, CPC, senior consultant at Coding Strategies Inc., a healthcare reimbursement consulting firm in Dallas, Ga.

The brachiocephalic is a first-order vessel that arises form the aorta. It splits into the right subclavian and the right common carotid, each of which is a second-order vessel, Miller says. The right common carotid further splits into the right internal carotid and right external carotid, both of which are third-order vessels.

All of the arteries fed by a first-order vessel are part of the same vascular family. In the explanation above, both the right common carotid and the right subclavian are part of the same vascular family. These definitions are very important in determining which catheter placement code to choose, Miller says.

Selective catheterizations are distinct from other types of vascular catheterizations because in selective caths, the surgeon moves the catheter from a larger blood vessel into a smaller one. The aorta is the largest blood vessel in the body, so movement into the aorta is never a selective catheterization.

However, after the catheter enters the aorta and the surgeon advances the catheter into an artery in a vascular family other than the family in which the catheter placement gained vascular access, you should consider that catheter placement as selective, says Jim Collins, ACS-CA, CHCC, CPC, president of Compliant MD Inc. in Matthews, N.C.

Coding solution: When the catheter first enters the vascular family, you should report it as a first-order selective catheter placement using 36245 (Selective catheter placement, arterial system; each first-order abdominal, pelvic, or lower-extremity artery branch, within a vascular family) or 36215 (Selective catheter placement, arterial system; each first-order thoracic or brachiocephalic branch, within a vascular family), depending on where the vascular family originated (below or above the diaphragm), Collins says.

When the surgeon advances the catheter tip through a bifurcation or trifurcation, the selectivity increases and the catheterization becomes second-order selective and then third-order selective, Collins says.

Coding solution: You should bill a second-order catheter placement with 36246 (... initial second-order abdominal, pelvic, or lower extremity artery branch, within a vascular family) or 36216 (... initial second-order thoracic or brachiocephalic branch, within a vascular family). You report third-order (or more selective) catheter placements with 36247 (... initial third-order or more selective abdominal, pelvic, or lower-extremity artery branch, within a vascular family) or 36217 (... initial third-order or more selective thoracic or brachiocephalic branch, within a vascular family). When reporting 36247 or 36217, remember that choosing the correct code depends on the origin of the vascular family (in other words, above or below the diaphragm).

Example: The surgeon gains vascular access in the right common femoral artery. He advances the catheter into the aorta and then into the left leg where the catheter first becomes selective at the point it leaves the aorta and enters the left common iliac. He then navigates the catheter through the bifurcation. This refers to the point where the common iliac splits into the internal and external iliac.

The surgeon positions the catheter in the left internal iliac where he then performs percutaneous transluminal angioplasty, or PTA(35473, Transluminal balloon angioplasty, percutaneous; iliac). Because he navigated through two bifurcations, and the vascular family originated below the diaphragm, you should report 36246 for second-order catheter placement below the diaphragm within a vascular family.

Caution: "The most common problem I see in reviewing peripheral vascular reports is that doctors don't clearly document exactly where they placed the catheter," Collins says. "Without this specificity, coders must default to lower-paying codes, which are frequently nonselective catheter positionings that reimburse hundreds of dollars less."