Part B Insider (Multispecialty) Coding Alert

Uncover the difference between using 2nd- and 3rd-order catheter codes

There isn't one set-in-stone way to report an aortogram on a patient with a bovine arch. Our coding experts present two solutions that could work for you--depending on how you view the left common carotid's role in the procedure.

Scenario: Your interventional radiologist gained access from the right femoral artery and performed an ascending aortogram on a patient with a bovine arch. He placed a catheter in the right common carotid with selective angiogram of the right common carotid, and obtained intracerebral angiogram on the right side.

Option 1: Second-order code. Report this procedure with second-order catheter placement code 36216 (Selective catheter placement, arterial system; initial second-order thoracic or brachiocephalic branch, within a vascular family).

Why?: The argument for this option is that the bovine arch does not affect the scenario described above. "There are three 'great vessels' that arise from the aortic arch: the innominate or brachiocephalic artery, the left common carotid artery and the left subclavian artery" explains a radiology coding consultant from New Jersey. With a bovine arch, the left common carotid doesn't branch off from the aorta. Instead, it branches off from the innominate artery, making the left common carotid second-order, the consultant explains.

Do this: If you choose to code a second-order placement, you should report 36216 for access to the right common carotid, notes the consultant. You may also append RT (Right side).

Option 2: Third-order code. Another school of thought defends coding a third-order placement code for this scenario.

Why?: In a patient with a bovine arch, the left common carotid rises from the innominate artery, so the carotid is a second-order branch and the right carotid becomes a third-order branch, says Dawn Hopkins, senior manager for reimbursement specialist with the Society of Interventional Radiologists.

Do this: Report 36217 (...initial third-order or more selective thoracic or brachiocephalic branch, within a vascular family). Choose your code based on accuracy, not payment. If your payor agrees that 36216 and 36217 are equally accurate for this procedure, you should choose 36217. Reason: The higher the vessel order, the higher the RVUs, says the New Jersey consultant.

Key: Check with your payor to be sure it will accept a third-order code for this procedure.

Warning: Whenever you report a third-order code for a vessel that's normally second-order (including the left internal and left external arteries), be sure the radiologist specifically documents the bovine arch or states that the left common carotid originates from the innominate. This documentation proves to the payor why the physician couldn't take the normal route to the vessel, explains Deepa Malhotra, MS, CPC, president of Illinois-based HERS Inc.