Radiology Coding Alert

Pay attention:  Not every procedure follows the normal treatment path

Interventional radiology reports offer up a triple challenge: multiple anatomic areas, numerous steps, and combinations of surgical and RS&I codes. Make sure you're ready for the next procedure note that lands on your desk with this detailed look at coding a PTA (percutaneous transluminal angioplasty).

Good idea: Read the full report on later in this issue and determine which codes you would use before reading our expert's solution.
 
Take the Report Step-by-Step

We've broken down the procedure note into sections to walk you through the correct coding.

History: "A 73-year-old male with insulin-dependent diabetes and heart disease had a percutaneous transluminal coronary angioplasty (PTCA) three years ago. He now has drug-resistant hypertension, and noninvasive testing indicates probable renal artery stenosis." 

Part 1: "Physician draped and prepped right groin area and introduced a pigtail catheter to the aorta through a retrograde right common femoral artery puncture. Then performed a flush abdominal aortogram."

Solution: Your catheter placement at this point merits 36200 (Introduction of catheter, aorta), says Anne Karl, RHIA, CCS-P, CPC, coding and compliance specialist at a clinic in Mendota Heights, Minn.

But you need to read the full report before you commit to this code.

Reason: According to interventional radiology component coding conventions, you should include nonselective catheter placement codes in subsequent selective catheterizations codes if they're performed via the same access route. You won't report 36200 because there's a selective renal catheter placement later in the report.

You're also going to include the flush aortogram (75625, Aortography, abdominal, by serialography, radiological supervision and interpretation) in the selective renal study the physician performs later, Karl says.

Why? Certain RS&I codes include nonselective aortogram services within the selective catheterization code--carefully read the code descriptor to know for sure. Selective renal angiography includes any accompanying nonselective aortogram.

Tip: Make a presumptive coding list now, but don't assign your final code choices yet.
 
Part 2: "The initial study of the right and left renal systems revealed potential high-grade stenosis of the mid-left renal artery, while the right renal arterial system looked essentially normal with no focal stenoses. This was consistent with previous noninvasive testing. The physician then performed a left renal arteriogram using a curved catheter by way of a left renal artery cannulation. Selective diagnostic study of the left renal artery confirmed a high-grade preocclusive stenosis suggestive of fibromuscular dysplasia (FMD). The right renal artery was only visualized from the flush abdominal aortogram. The artery and its branches were within normal limits, as noted previously."

Solution: "Here we have the selective left renal artery catheter placement (36245, Selective catheter placement, arterial system; each first-order abdominal, pelvic, or lower-extremity artery branch, within a vascular family) and selective unilateral renal study 75722-26-59 (Angiography, renal, unilateral, selective [including flush aortogram], radiological supervision and interpretation; professional component; distinct procedural service)," Karl says.

Selective catheter placements include nonselective catheter placements from the same access. So, in this case, code 36245 includes the catheter placement in the aorta (36200). Also, you don't need to code for the aortogram (75625) because this procedure is included in the selective renal study (75722).

Heads up: You need to append modifier 59 to 75722 because you will also be reporting an intervention (the angioplasty) during the same operative setting. The modifier will signify that this procedure is a true diagnostic renal angiogram rather than an angiogram for preoperative planning or postoperative documentation. Translation: The interventional radiologist hasn't performed a prior catheter angiogram, and this isn't a guiding angiogram to support a previously planned intervention.

Part 3: "The physician gave the patient 5,000 units of intravenous heparin. She then introduced a 5-mm PTA balloon catheter over the guidewire into the area of blockage in the left renal artery. She performed initial angioplasty with the balloon. She then upsized the balloon to a 6-mm balloon catheter and performed another dilation at the mid-vessel stenosis site in the left renal artery. She performed a final arteriography, which showed no residual stenosis and smoothly flowing contrast through left renal artery and parenchymal bed with no significant intimal disruption or distal embolization. Following removal of the catheters and sheath, hemostasis was achieved."

Solution: "The intervention takes place here," Karl says. You should report 35471 (Transluminal balloon angioplasty, percutaneous; renal or visceral artery) and the companion supervision and interpretation code 75966-26 (Transluminal balloon angioplasty, renal or other visceral artery, radiological supervision and interpretation).

Code 35471 is for the percutaneous transluminal balloon angioplasty (PTA) of the left renal.

Code 75966 represents the radiological interpretation and report for the PTA. "You should not bill the post-procedure angiogram because it is included in the procedure," Fuller says. Remember: For embolization and infusion interventions, you may separately code follow-up angiography.

Important: Differentiate among the various transvascular treatments for renal artery stenosis.

Although in this case the lesion was treated by angioplasty alone, in other cases "treatment for renal artery stenosis is to stent (37205, Transcatheter placement of an intravascular stent[s] [except coronary, carotid, and vertebral vessel], percutaneous; initial vessel; and 75960, Transcatheter introduction of intravascular stent[s] [except coronary, carotid and vertebral vessel], percutaneous and/or open, radiological supervision and interpretation, each vessel)," says Sandy Fuller, CPC, compliance officer in Athens, Texas.

Note: Patients with FMD present perhaps the most common clinical scenario in which angioplasty alone is used rather than stenting, but this is far from universal.

Sample report: History: A 73-year-old male with insulin-dependent diabetes and heart disease had a percutaneous transluminal coronary angioplasty (PTCA) three years ago. He now has drug-resistant hyper-tension, and noninvasive testing indicates probable renal artery stenosis.

Procedure note: Physician draped and prepped right groin area and introduced a pigtail catheter to the aorta through a retrograde right common femoral artery puncture. Then performed a flush abdominal aortogram.

The initial study of the right and left renal systems revealed potential high-grade stenosis of the mid-left renal artery, while the right renal arterial system looked essentially normal with no focal stenoses. This was consistent with previous noninvasive testing. The physician then performed a left renal arteriogram using a curved catheter by way of a left renal artery cannulation. Selective diagnostic study of the left renal artery confirmed a high-grade preocclusive stenosis suggestive of fibromuscular dysplasia (FMD). The right renal artery was only visualized from the flush abdominal aortogram. The artery and its branches were within normal limits, as noted previously.

The physician gave the patient 5,000 units of intravenous heparin. She then introduced a 5-mm PTA balloon catheter over the guidewire into the area of blockage in the left renal artery. She performed initial angioplasty with the balloon. She then upsized the balloon to a 6-mm balloon catheter and performed another dilation at the mid-vessel stenosis site in the left renal artery.

She performed a final arteriography, which showed no residual stenosis and smoothly flowing contrast through left renal artery and parenchymal bed with no significant intimal disruption or distal embolization. Following removal of the catheters and sheath, hemostasis was achieved.