Radiology Coding Alert

Distinguish between evaluation of vessel origin and selective imaging.

Reporting arteriograms can be an arduous task if your physician administers multiple contrast injections during the procedure. The best bet in such cases is to adopt a stepwise approach to trace the vessels studied during the procedure. Here is a case that will help you gain insights for reporting common carotid and cerebral arteriograms.

Example: You may read that in a patient with history of transient ischemic attacks and intracranial aneurysm, your physician wanted to rule out an aneurysm and subjected the patient to arteriogram. 

Overview of procedure: Your physician will use a micropuncture needle set to access the right common femoral artery. Your physician will then selectively catheterize, using a 5 French catheter, the right and left common carotid arteries, right and left internal carotid arteries, right and left vertebral arteries, innominate artery, and the left subclavian artery.

Step 1: Spot the Specific Findings in Procedure Note

When reporting vascular procedures, you should look for details of findings that your physician records for each artery catheterized and injected. In the procedure described in example above, you may gather the following details from the clinical document:

Left common carotid injection: No significant stenosis of the left common carotid bifurcation or internal carotid artery.

Left internal carotid artery injection: Aneurysm of size 5 mm x 5 mm, projecting superolaterally, in the bifurcation of left middle cerebral artery bifurcation. Another aneurysm in the origin of left posterior communicating artery.

Right common carotid artery injection: No significant stenosis of the right common carotid bifurcation or internal carotid artery.

Right internal carotid artery injection: Good intracranial circulation with patent internal carotid circulation. No aneurysm in the anterior communicating artery or right middle cerebral artery. Fetal type of posterior communicating artery seen but this is a normal variant. 

Right and left vertebral injections: No aneurysm of the vertebrobasilar system.

Innominate artery injection: Normal origin of subclavian artery and right common carotid artery.

Left subclavian artery injection: Normal origin of left vertebral artery. Good patency of the cervical segment of left vertebral artery.

Step 2: Do Not Miss the Final Impressions

Your physician will document the final impressions from the arteriogram that will guide your coding for the procedure. In this example, you may come across the following final diagnoses:

1. Left middle cerebral artery bifurcation.

2. Aneurysm in the origin of the left posterior communicating artery (differential diagnosis: bone aneurysm).

3. Normal vertebrobasilar system.

4. Normal subclavian arteries.

5. Normal patency and tortuosity of the right and left common carotid arteries.

6. No dural or pial arteriovenous malformations.

Basics of Brain Circulation

The main arteries that supply the brain include the vertebral arteries, basilar artery, and the anterior, middle, and posterior cerebral arteries. Figure 1 shows how the arteries on the two sides are joined by the anterior and posterior communicating arteries to complete the arterial circle in the brain called the ‘Circle of Willis.’

Step 3: Define Codes That You Can Submit

You report codes: 

• 36224 (Selective catheter placement, internal carotid artery, unilateral, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed) with modifier 50 (Bilateral procedure) and 
• 36226 (Selective catheter placement, vertebral artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed) with modifier 50.

Your physician is placing the catheter into the bilateral common and internal carotid arteries with imaging of cervical and cerebral arteries. This imaging is included in 36224-50. For imaging of the bilateral vertebral arteries from the catheter that your physician placed in the vertebral arteries, you submit code 36226-50.

Tip: In this procedure, you do not report the injections into the innominate and left subclavian arteries as your physician administers these injections to evaluate vessel origin. This is bundled into selective imaging. Hence, you do not submit code 36225 (Selective catheter placement, subclavian or innominate artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed).