General Surgery Coding Alert

Vascular coding basics tell you not to report nonselective catheter placement with selective placement from the same access site. But what if the surgeon positions the catheter in multiple vascular families from the same access site? Our experts have outlined what you should (and shouldn-t) do when coding these tricky procedures.

You should code separately each vascular family the surgeon accesses separately, first determining the highest-order branch the physician accesses in each family, says Sheri Bernard, CPC, CPC-H, CPC-P, AAPC vice president of member relations.

Crucial: Pay attention to whether the physician catheterized more than one vascular family during the procedure.

Example: From a right femoral access point, the physician positions the catheter in the right subclavian artery, performs imaging and then repositions the catheter in the right common carotid artery. Both of these vessels are branches of the brachiocephalic/innominate artery that arises at the aortic arch, and they both represent second-order selective catheter positions.

For the initial second-order catheter position above the diaphragm, you should report 36216 (Selective catheter placement, arterial system; initial second-order thoracic or brachiocephalic branch, within a vascular family). Report the second cath position with +36218 (... 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]).

Don't miss: You should assign all additional second- and third-order branches within the same vascular family using either 36218 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]).

Important distinction: You-ll use 36215-36218 to report thoracic and brachiocephalic selective arterial procedures, and 36245-36248 to report abdominal, pelvic and leg selective arterial procedures.

In other words, you should use 36215-36218 for arteries above the diaphragm and 36245-36248 for arteries below the diaphragm, says Jackie Miller, RHIA, CPC, senior consultant with Coding Strategies Inc. in Powder Springs, Ga. You should look to 36014-36015 for selective pulmonary artery catheterization.
Great resource: CPT Appendix L, "Vascular Families," lists the first, second, third and higher order branches for each vascular family. This is a simple way to determine whether the surgeon is addressing more than one vascular family -- identify individual vessels and determine the order of each vessel treated.

Avoid Coding -on the Way- Services

Be aware, however that you should not code for any branches the surgeon must cross as a pathway to the second- or third-order branches beyond. In other words, you should code only the highest-order catheter placement the physician achieved within each vascular family, Bernard says. Avoid coding the lower-order catheter placements that are "on the way to" the higher-order position.

If the physician performs a selective and nonselective catheter placement through the same vascular access site, you should not separately report the nonselective placement because payers would consider this "en route" to the selective catheter position, Bernard says.

But if two access sites are involved in the procedure (one selective, the other nonselective), you should report both the selective catheter placement (such as 36245) and the nonselective catheter placement (such as 36140, Introduction of needle or intracatheter; extremity artery).

Remember: You should attach modifier 59 (Distinct procedural service) to the nonselective catheter placement code to illustrate that it occurred by way of a different access site.

Translation: Use modifier 59 whenever you report a lower-order catheter placement with a higher-order catheter placement.