Neurosurgery Coding Alert

Define discrete territories for vertebral, subclavian, and carotid arteries.

Coding for head and neck angiography has never been easy as there is a myriad of vessels involved. The secret to clean claims lies in getting the vascular territory right. Learn more about coding for head and neck angiographic procedures.

The head and neck angiography codes are inclusive of the following services:

• Establishing access to the target vessel.
• Placement of catheter(s) in the vessel.
• Injections of contrast for imaging. Arterial contrast injections include the arterial, capillary, and venous phase imaging.
• Fluoroscopic guidance.
• Radiological supervision and interpretation.
• Closure of the arteriotomy.

Confirm the Territory for Imaging

When reporting angiography procedures in the head and neck region, you select the right code depending upon where the catheter was positioned and the territory in which the imaging was done. “Identifying the territory will be based upon the artery that is being evaluated and the distance along that vessel,” says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison.

Your physician may place the catheter in the aorta or common carotid artery. You submit code 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 provider places the catheter in the aorta and advances no further. This code includes the imaging of aortic arch and vessel origins.

You submit code 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 your provider places the catheter in the innominate or common carotid arteries and does an imaging of common carotids and code 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 your physician places the catheter in the innominate or common carotid artery. The imaging spans over the internal carotids including the aortic arch and the common carotid arteries.

When your physician places the catheter in the internal carotid artery, you submit code 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). Here again, the imaging spans over the internal carotids including the aortic arch and the common carotid arteries.

Look For Specific Codes for Subclavian and Vertebral Arteries

When you read that the catheter was positioned in the subclavian or innominate artery, you submit code 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). Similarly, you submit code 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) when your physician places the catheter in the vertebral artery. The imaging is done for the vertebral arteries. These codes are inclusive of imaging of the aortic arch when performed.

Check Two Add-On Codes

Here are two add-on codes you should consider for external and internal carotid circulation angiography:

• For external carotid circulation: +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 internal carotid and vertebral circulation: +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 (e.g., middle cerebral artery, posterior inferior cerebellar artery) (List separately in addition to code for primary procedure). This code includes any additional second or third order catheter placement as well as the imaging in any additional vessels in the same primary branch of the internal carotid, vertebral, or basilar artery.

Ready Reckoner with Handy Tips

Here are few handy tips for reporting of codes 36222-36228.

• You report only one code from 36222-36224 for each ipsilateral carotid territory.
• You report one code from 36225-36226 for each ipsilateral vertebral artery territory.
• You can report 36221 for unilateral as well as bilateral procedures.
• You submit codes 36222-36228 for unilateral procedures. When your physician does a bilateral carotid and/or vertebral catheterization and imaging, you append modifier 50 to 36222-36228.
• When your physician does imaging on different territories on each side, you append modifier 59 to the lesser code.
• You do not report the cervical carotid stenting codes (37215 and 37216) along with codes 36222-36224.

Make note of the following for correct reporting of +36227 and +36228:

• You can report code +36227 in conjunction with 36222, 36223, and 36224
• You can report code +36228 in conjunction with 36223, 36224, 36225 or 36226
• Do not report 36228 more than twice per side

“Since the more distal arterial branches are either from the internal carotid or vertebral arteries, there are only a maximum of two arteries from which distal branch evaluations can be performed,” Przybylski says.

Revisit code +75774: You do not report +75774 (Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation [List separately in addition to code for primary procedure]) for diagnostic angiography of intracranial or extracranial cervicocerebral vessels. You report code +75774 for angiography in upper extremities or another vascular bed, when done in the same session. “With the CPT^® trend to bundle procedures that are typically performed together, these new codes include diagnostic imaging,” Przybylski says.