Neurosurgery Coding Alert

You can report +36227 in conjunction with codes 36222, 36223, or 36224.

Coding for head and neck angiography procedures in the head and neck region can be challenging. You must know where the neurosurgeon positioned the catheter, understand where the neurosurgeon performed the imaging, and grasp which arteries were involved.

Read the following tips to always submit clean head and neck angiography claims in your office.

Tip 1: Choose the Correct Territory

You should select the appropriate code for angiography procedures in the head and neck region based upon where the neurosurgeon positioned the catheter and the territory in which the surgeon performed the imaging.

Read the medical documentation to see if your neurosurgeon placed the catheter in the aorta or the common carotid artery. Then look to the following choices:

• 36221: Report 36221 (Non-selective catheter placement, thoracic aorta, with angiography of the extracranial carotid, vertebral, and/or intracranial vessels, unilateral or bilateral, and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed) when your surgeon places the catheter in the aorta and advances no further. Code 36221 includes diagnostic imaging of the aortic arch and great vessel origins.
• 36222: Report 36222 (Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral extracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed) when the neurosurgeon places the catheter in the innominate or common carotid arteries and does imaging of extracranial vasculature (external carotid artery circulation).
• 36223: Report 36223 (Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed) when the surgeon places the catheter in the innominate or common carotid artery and does imaging of the intracranial vasculature (internal carotid artery circulation).
• 36224: Report 36224 (Selective catheter placement, internal carotid artery, unilateral, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed) when the surgeon places the catheter in the internal carotid artery.

Tip 2: Rely on These Codes for Subclavian and Vertebral Arteries

When the surgeon positions the catheter in the subclavian or the vertebral arteries, you have specific codes to choose from.

Code 36225: When the surgeon positions the catheter in the subclavian or innominate artery, you should report 36225 (Selective catheter placement, subclavian or innominate artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed).

Code 36226: When the surgeon places the catheter in the vertebral artery, you should report 36226 (Selective catheter placement, vertebral artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed).

Tip 3: Don’t Forget These Add-On Codes

You can consider two add-on codes for external and internal carotid circulation angiography.

Code +36227: You should report +36227 (Selective catheter placement, external carotid artery, unilateral, with angiography of the ipsilateral external carotid circulation and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure) for “unilateral selective arterial catheter placement and diagnostic imaging of the ipsilateral external carotid circulation,” according to CPT^®.  Code +36227 includes assessing the additional vessel, placing the catheter, contrast injections, fluoroscopy, and radiological supervision and interpretation.

Don’t miss: You can report +36227 in conjunction with codes 36222, 36223, or 36224.

Code +36228: You should report +36228 (Selective catheter placement, each intracranial branch of the internal carotid or vertebral arteries, unilateral, with angiography of the selected vessel circulation and all associated radiological supervision and interpretation (eg, middle cerebral artery, posterior inferior cerebellar artery) (List separately in addition to code for primary procedure) for the “unilateral selective arterial catheter placement and diagnostic imaging of the initial and each additional intracranial branch of the internal carotid or vertebral arteries,” according to CPT^®.

Don’t miss: You should report +36228 in conjunction with 36223, 36224, 36225, or 36226.

“Code +36228 describes the further advancement of the catheter into smaller branches beyond the internal carotid artery or vertebral artery and is reported for each smaller vessel that the catheter is placed in with performance of subsequent imaging of the circulation beyond the selected vessel,” says Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey. “Therefore, this add-on code could be reported multiple times, once for each additional selective catheterization beyond the vessel included in 36223-36226.”

Tip 4: Be Careful of Included Services

Codes 36221-36226 include the following, so you should not report these services separately, according to CPT^®:

• Accessing the vessel
• Catheter placement
• Contrast injections
• Fluoroscopy
• Radiological supervision and interpretation
• Closure of the arteriotomy by pressure or application of an arterial closure device

The National Correct Coding Initiative (CCI) Edits Policy Manual further identifies services that are included in these angiography codes, so you should not report them separately.

Codes 36221-+36227 include angiography of the thoracic aortic arch, according to the CCI Policy Manual. So, you should not separately report 75600 (Aortography, thoracic, without serialography, radiological supervision and interpretation) or 75605 (Aortography, thoracic, by serialography, radiological supervision and interpretation) “unless it is medically reasonable and necessary to additionally examine the descending thoracic aorta.”

Tip 5: Code to the Highest Hierarchical Level

If you’re familiar with the world of selective catheterization coding, you know the rules surrounding progressive hierarchies. Basically, it’s just a fancy way of saying that some lesser procedures bundle into more comprehensive ones.

Take this explanation from the CPT^® manual: “Codes 36221-36226 are built on progressive hierarchies with more intensive services inclusive of less intensive services. The code inclusive of all of the services provided for that vessel should be reported (ie, use the code inclusive of the most intensive services provided).”

“This is the most important part of cerebral angiography to understand,” says Przybylski. “Another way of stating this is that your code choice is based on the furthest vessel in which the catheter is positioned for the angiography. Imaging performed prior to this is included in the service of the angiography at the furthest catheter position.”

Code +36227 allows for capturing the additional work of an external carotid artery catheter placement and resulting external circulation angiography for 36223 or 36224 in addition to the internal circulation angiography performed in 36223 or 36224, according to Przybylski. When +36227 is added on to 36222, this reflects advancing the catheter further for the external carotid circulation imaging. Code +36228 refers to each additional intracranial vessel that the catheter is advanced to beyond the carotid or vertebral artery.

From an anatomical perspective, the rule of hierarchies makes complete sense. If contrast has to pass through one site to get to another, you’re only going to code the last level, not each step in-between.

Do this: You should report only one code in the 36222-36224 range for each ipsilateral carotid artery, per CPT^®. To select the appropriate code, select the choice that “represents the most comprehensive service suing the following hierarch of complexity (listed in descending order of complexity): 36224>36223>36222.”

Important: The rules for reporting ipsilateral vertebral angiography are similar to reporting ipsilateral carotid artery angiography. You should only report one code (either 36225 or 36226) for each ipsilateral vertebral territory. You should never report 36225 and 36226 together. You should “select the code that represents the more comprehensive service using the following hierarch of complexity (listed in descending order of complexity): 36226>36225.”