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 [...]