Radiology Coding Alert

This aortic anomaly opens up your aortogram options

Next time your report reveals an aortogram on a patient with a bovine arch, you've got an important decision to make--will you choose a second- or third- order catheter code?

Our experts reveal the arguments behind the different coding options for this 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.

Place Catheter Code Carefully

Solution 1: Second-order code. One option is to 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).

The argument is that the scenario described above is not affected by the bovine arch, says radiology coding consultant Cheryl Schad, BA Ed, CPC, ACS-RA, owner of Schad Medical Management in Mullica Hill, NJ.
 
"In normal human anatomy, 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," Schad says. "All vessels that originate from the aorta are first-order vessels." The right common carotid branches away from the innominate, making it second-order.

With a bovine arch, found in about 30 percent of the population, 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, Schad says.
 
In the scenario above, the left common carotid doesn't come into play, so you can argue that the physician moved from the first-order innominate into the second-order right common carotid.

How to code: If you choose to code a second-order catheter placement, you should report 36216 for access to the right common carotid, Schad says. You may also append RT (Right side).

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

Reason: In a patient with a bovine arch, the left common carotid rises from the innominate artery, so the left 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.

How to code: Report CPT 36217 (... initial third-order or more selective thoracic or brachiocephalic branch, within a vascular family).

You should always choose your code based on accuracy, not payment. If your payer agrees that CPT 36216 and 36217 are equally accurate for this procedure, you should choose 36217. Why: The higher the vessel order, the higher the RVUs, Schad says.

Remember: Your payer will have the final word on whether you may code this as second- or third-order catheter placement, says radiology coding specialist Deepa Malhotra, MS, CPC, president of Illinois-based HERS Inc.

Caution: 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, Schad says.

This documentation proves to the payer why the physician could not take the normal route to the vessel,  Malhotra agrees.

Develop Your Imaging Coding

While you may only code the highest level of catheterization, you may report any imaging your radiologist documents along the way.

In our scenario, report 75676 (Angiography, carotid, cervical, unilateral, radiological supervision and interpretation) for the angiogram of the right common carotid,  Schad says. Append RT if your payer wants specifics.

You should also report 75665 (Angiography, carotid, cerebral, unilateral, radiological supervision and interpretation) for angiogram of the right internal carotid, Schad says. Again add RT if your payer prefers.

You should not report a supervision and interpretation code for the right external carotid, Schad says. Why: The exam codes for the external carotids (75660-75662) are defined as selective--the physician must place the catheter within that vessel to code for the S&I portion of the angiogram, Schad says.

The exam codes for most other vessels above the diaphragm are nonselective, so the catheter doesn't have to be in the imaged vessel for you to report S&I.

Helpful: Picture the procedure as a road trip, Malhotra says. Driving along the expressway, you have many exits. You don't have to take an exit (vessel) to get a great view (image) of where it goes, she says.

Leave 747.21 for Later

When choosing the appropriate ICD-9 code, look through the radiologist's report to determine the medical necessity for the arch study and the diagnostic findings, such as 433.10 (Occlusion and stenosis of precerebral arteries, carotid artery; without mention of cerebral infarction).

You should report pertinent findings from the exam first for your diagnoses. If there are no pertinent findings, you may code the reason behind the exam--just be sure you don't code the diagnosis that the test was meant to "rule out."

The diagnosis code for the bovine arch--747.21 (Anomalies of aortic arch)--should only be used as a secondary or tertiary code, says Stacy Gregory, RCC, CPC, charge capture and reconciliation specialist for Franciscan Health Systems' Imaging Support Services in Tacoma, Wash. It isn't appropriate as a primary diagnosis for a carotid angiography.

And of course be sure the radiologist documents the bovine arch in the report to support your diagnosis choice.