Radiology Coding Alert

See if you can pick out which vessels were simply 'on the way' and which merit coding

In your radiology practice, catheter placement goes hand in hand with interventional procedures, but differentiating a second-order from a third-order placement can be a challenge. To help you navigate the brachiocephalic family of arterial catheter coding, make your way through this how-to lesson, including the four documentation trouble spots you need to watch out for.

You can hone your interventional skills by seeing how to apply the rules to a case that could cross your desk at any time. Review the rules in "Bulletproof Your Coding by Acing Selective Vs. Nonselective" on page 4. Then analyze this report shared by Brenda Cole, CPC, of Dexios Corp. in Greenwood, S.C. Your goal is to determine the appropriate code for each injection procedure performed, assuming the full report meets all documentation requirements.

Procedure: The right femoral artery is utilized for vascular access and a 5 French H1 catheter was introduced into the right vertebral, right internal carotid and right external carotid arteries, and multiple injection runs performed. Images show no vascular abnormality associated with vertebral circulation or the external carotid artery circulation. On internal carotid artery injection there is a small dilated venous structure that corresponds to the abnormality seen on CT angiography performed on [date omitted]. This is in the medial cranial fossa on the right just medial to the tip of the temporal lope. This fills in the normal mid venous phase and has the appearance of a small venous angioma. No other vascular anomalies are identified.

Properly identifying the vascular access site is a common documentation trouble spot, notes interventional coding expert Sheldrian Leflore, BA, CPC, director of revenue management for Integrated Revenue Management of Carlsbad, Calif.

The sample report gets an "A" for identifying the right femoral artery as the vascular access site. You need to know this site as a first step to choosing between selective and nonselective codes.

Three other areas that the radiologist needs to document carefully are the following, Leflore says:

1. where the catheter terminated in each vessel

2. the catheter's location for injection procedures

3. the vessels targeted for angiography.

Benefit: If you know this information, you'll be able to distinguish billable imaging from roadmapping, guiding shots, and other nonbillable services, Leflore says.

Read on to see how knowing this information affects your choice of codes for the sample procedure.

In the sample report, the next site the radiologist documents after femoral access is the right vertebral artery.

You can trace the path from the right femoral artery introduction to the right vertebral artery. The radiologist would advance the catheter through the aorta and then into the brachiocephalic (aka innominate) artery (see the diagram at right).

If the radiologist terminated the procedure in the brachiocephalic, you would report 36215 (Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family).

But the radiologist advanced the catheter into the right subclavian. If he had terminated the procedure here, you would report 36216 (... initial second order thoracic or brachiocephalic branch, within a vascular family).

Instead, though, the radiologist documents moving into the right vertebral artery, performing an injection and finding no vertebral circulation abnormalities in the imaging.

Coding point: With the right vertebral, you have your first reportable codes. You should report the vertebral catheter placement with initial third-order code 36217 (Selective catheter placement, arterial system; initial third order or more selective thoracic or brachiocephalic branch, within a vascular family), says Leflore.

RS&I: The appropriate code for the vertebral imaging is 75685 (Angiography, vertebral, cervical, and/or intracranial, radiological supervision and interpretation), Leflore adds. Note that you should append modifier 26 (Professional component) to the imaging code to indicate that the radiologist performed only the professional component of 75685.

The radiologist next documents injection and imaging in the right internal carotid. To reach this artery, he must move the catheter back into the subclavian and then into the brachiocephalic. From here, he moves the catheter into the right common carotid. If he terminated the procedure here, you would report +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]) because the right common carotid is an additional second-order code in the same vascular family (brachiocephalic) as the right subclavian and vertebral arteries.

Careful: The radiologist did not stop in the common carotid, though.

Coding point: He moved the catheter into the internal carotid and for the placement, you should report +36218, says Leflore.

Reason: You reported the right vertebral with an initial code (36217). So you need to report an "additional" code. And +36218 is appropriate whether you're in an additional second- or third-order artery.

RS&I: The appropriate imaging code for intracranial vascular imaging is 75665-26 (Angiography, carotid, cerebral, unilateral, RS&I).

Finally, the radiologist discusses the right external carotid, describing a small venous structure. To reach the right external carotid artery, the radiologist would pull the catheter from the right internal carotid, into the right common carotid, and then would advance into the right external carotid artery.

Coding point: For the right external carotid catheter placement, you should again report +36218, Leflore says.

And follow your payer's preference for reporting the code twice on the same claim.

RS&I: You have a specific code for external carotid circulation imaging: 75660-26 (Angiography, external carotid, unilateral, selective, RS&I).

Coding roundup: The appropriate codes for the procedures performed are the following:

• 36217 for right vertebral artery catheter placement

• +36218 for right internal carotid artery cath placement

• +36218 for right external carotid artery cath placement

• 75685-26 for vertebral imaging

• 75665-26 for intracranial vascular imaging

• 75660-26 for external carotid circulation imaging.