Part B Insider (Multispecialty) Coding Alert

Learn the most overlooked services experts say you should be reporting

Vascular coding basics tell you not to report nonselective catheter placement with selective placement from the same access site. But how should you report situations when the physician positions the catheter in multiple vascular families from the same access site?

Our peripheral vascular (PV) experts have outlined what you should--and shouldn-t--do when coding these tricky procedures.

Key: Pay attention to whether the physician catheterized more than one vascular family during the procedure, PV coding experts say.

Use 2 Codes for Additional Second-, Third-Order Branches

You should code each vascular family separately. Determine the highest-order branch the physician accesses in each vascular family.

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 arch of the aorta, 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]).

Important: 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]).

Know the difference: 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.

Avoid Coding -On The Way- Services

On the other hand, you shouldn't code the branches traversed 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. You should avoid coding the lower-order catheter placements that are -on the way to- the higher-order position.

Learn When You Should Report S&I Codes

You should also separately code all supervision and interpretation (S&I) services when your documentation supports it. Sometimes, you should not separately code the imaging S&I. For instance, you should not separately report contrast injections that the physician specifically performs to obtain a map of the vascular territory (to facilitate catheter manipulation).

But you should always assign the appropriate S&I code for the vessel the physician studies. If your physician does a further selective catheterization in a higher-order branch after the basic study, and CPT offers no more specific code, use +75774 (Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation [list separately in addition to code for primary procedure]) to denote the S&I.

You should use this code for additional studies of the same basic anatomic region (additional runs/images). -Make sure to share these guidelines with your physicians,- says Jim Collins, CPC-CARDIO, ACS-CA, CHCC, president of The Cardiology Coalition in Saratoga Springs, N.Y. -Unless physicians realize that these additional studies are separately billable, they may not document appropriately. This is one of the most commonly undocumented and unbilled services that I identify during physician training programs.-

Example: The physician places a sheath in the right femoral artery and, using a guide catheter, manipulates to the supra-renal abdominal aorta to perform an abdominal aortogram. He then repositions the catheter at the bifurcation of the aorta into the common iliacs for separate runoff injection of the lower extremities, followed by a selective study of the left common iliac (which would then be considered an -additional study- to the initial lower extremity study).

You should report 36245 for the selective, contralateral catheter placement in the left common iliac artery, 75625-26 (Aortography, abdominal, by serialography, radiological supervision and interpretation; professional component), 75716-26 (Angiography, extremity, bilateral, radiological supervision and interpretation; professional component) and +75774-26 (Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation [list separately in addition to code for primary procedure]; professional component).

Watch Your Access Site(s)

If the physician performs a selective and nonselective catheter placement through the same vascular access site, you lose the nonselective placement because payers would consider this -en route- to the selective catheter position.

But if two access sites are involved in the procedure (one of which was selective and the other nonselective), you should report both selective catheter placement (such as 36245) and 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 was through a different access site.  

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