Radiology Coding Alert

"Radiology coders must have a clear understanding of the various steps involved with angiography to diagnose a pulmonary embolism (PE) and subsequent intervention to restore blood flow. This will ensure correct coding and proper reimbursement for this multistep procedure.

In many cases, patients are elderly, previously have been hospitalized for other conditions or are experiencing acute symptoms including complete cardiopulmonary arrest. Interventional radiologists often may be called upon to perform the pulmonary angiography on an urgent basis. These circumstances may require them to customize the examination significantly, allowing them to respond to unusual or emerging symptoms. During the course of the procedure, the interventionalist also may provide additional ancillary services such as thrombolysis and/or IVC (inferior vena cava) filter placement.

In patients where PE is suspected, pulmonary angiography is performed to confirm or exclude the possibility of an embolism. Diagnosis codes that support pulmonary angiography include shortness of breath (786.05), painful respiration (786.52), primary pulmonary hypertension (416.0), chronic cardiopulmonary disease (416.9) and cardiorespiratory arrest (427.5). If a PE has been confirmed, the appropriate ICD-9 415.19 415.19ICD-9 Codes for the patients underlying medical or surgical condition unless it is also the reason for the pulmonary angiogram. For example, should a patient with recent orthopedic surgery or trauma need an angiogram to rule out PE, do not use the diagnosis code of the orthopedic procedure or of trauma to justify the angiogram.

According to Lisa Grimes, RT (R), radiology special procedures technologist and reimbursement specialist for the University of Texas/Houston Health Science Center, the procedure typically involves multiple steps, each of which may be billed. In most instances, these steps include catheter placement, angiography, transcatheter therapy, placement of filters to entrap clots and the appropriate supervision and interpretation codes.

Pulmonary Embolism Case Study

Procedure: A 68-year-old male, five days postoperative for total hip replacement, complains of chest pain and severe shortness of breath. Within minutes, the patient loses consciousness and suffers cardiopulmonary arrest. The patient is resuscitated, placed on a ventilator and transferred to the catheterization lab.

The interventional radiologist then performs pulmonary angiography. The patients right groin is prepped and the patient is draped. A 7-French sheath is placed into the right femoral vein, and a pigtail catheter is advanced to the confluence of the iliac veins. A hand injection with fluoroscopic monitoring of the IVC is performed to rule out IVC clot. The catheter is advanced into the right atrium. Using a guide-wire, the catheter is placed through the atrium, right ventricle and pulmonary outflow tract into the right pulmonary artery. Right pulmonary artery pressures are obtained. Right pulmonary angiography is performed using 40 cc of contrast. The catheter is then repositioned into the left pulmonary artery followed by a similar pulmonary angiogram of the left pulmonary artery. The angiogram indicates extensive pulmonary emboli as detailed in the findings. Thrombolysis is performed through the catheter. The radiologist then performs a vena cavagram, and a Braun filter is deployed below the renal veins entry to prevent further embolization.

Findings: The right and left pulmonary artery pressures were normal. The main right and left pulmonary arteries appear to be unobstructed and without thrombus. But there is a thrombus in the right upper lobe artery and one to the right middle lobe artery. The right lower lobe artery is almost totally thrombus-filled with very little contrast getting past. There is amputation of some of the vessels to the right upper lobe. The pulmonary arteriogram in the left main pulmonary artery shows extensive pulmonary emboli, very similar to that described above distributed throughout all the major tributaries. After the lysis procedure, there was significant decrease in thrombus burden bilaterally.

Coding Solution

Catheterization and angiography: During this procedure, the interventionalist selectively placed a catheter to examine both the right and left pulmonary arteries. This is reported with 36014 (selective catheter placement, left or right pulmonary artery), assigned twice.

Because the radiologist documented that both the right and left side were catheterized, 36014 is reported twice, Grimes points out. However, coders should refer to their local carriers requirements when reporting a bilateral procedure. Some may require that modifier -50 (bilateral procedure) be appended to the second code, while others prefer the -RT/-LT (right side/left side) designation.

In rare instances, some carriers stipulate that the code be reported only once with the -50 modifier. But unless specifically instructed to use this coding method, coders should avoid it and, if instructed to report the procedure in this manner, they should review reimbursement received closely to ensure that the radiology practice has been properly paid for both catheterizations.

Code 75743 (angiography, pulmonary, bilateral, selective, radiological supervision and interpretation) would be assigned to describe the angiography service itself. Unlike the codes describing catheter placement, which are unilateral, 75743 is a bilateral code and would be reported only once.

Editors note: Coders should be aware that the fluoroscopic IVC inspection and the pulmonary artery pressure measurements are not coded separately. In this example, a separate inferior vena cavagram is performed prior to IVC filter placement and that IVCgram is coded (below). But there is no additional catheter placement code for this fluoroscopic examination because a more selective code (36014) already has been charged.

Gary Dorfman, MD, FACR, FSCVIR, representative to the American Medical Associations CPT Advisory Board, points out that in some cases, coders may be able to assign 36015 (selective catheter placement, segmental or subsegmental pulmonary artery), rather than 36014.

Code 36015 can be used only when the medical record clearly indicates that the radiologist advanced the catheter into the next level of the pulmonary branch. This case study does not include documentation that would justify assigning 36015, explains Dorfman, who is also president of Health Care Value Systems Inc. in Rhode Island, an organization that provides practical management services as well as revenue optimization through coding and billing support, and past president of the Society for Cardiovascular and Interventional Radiology (SCVIR). While the payment for the more selective code is higher, it can not be reported unless medically indicated and justified by the operative report.

He adds that coders should note that the use of the higher level of selectivity is right and left dependent and precludes the use of the less selective code on the side where the more selective catheterization was performed and coded.

Likewise, Dorfman points out, if the documentation had stated that additional angiography of the left and right lower lobe was performed during the angiogram, coders could assign add-on code 75774 twice (angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation [list separately in addition to code for primary procedure]). Again, the documentation in this case study does not justify the addition of this code.

Infusion of thrombolytic agent: During this procedure, the radiologist clearly indicated that he infused a lytic agent to dissolve the emboli and hasten the restoration of blood flow. This service is reported with 37201 (transcatheter therapy, infusion for thrombolysis other than coronary), along with 75896 (transcatheter therapy, infusion, any method [e.g., thrombolysis other than coronary], radiological supervision and interpretation).

Vena cavagram: In addition, the radiologists report states that he performed vena cavagraphy prior to deploying a Braun filter. The IVCgram allowed the visualization of the ingress of renal vein blood flow to help determine placement of the filter at the appropriate level, as well as to determine the IVC size prior to filter placement. For this stage of the procedure, coders would assign only the radiological supervision and interpretation (RS&I) code 75825 (venography, caval, inferior, with serialography, radiological supervision and interpretation).

As stated above, a catheter placement code for the IVCgram could not be used because a more selective code for the pulmonary angiogram had been assigned already. The one exception to this rule would be if a separate access route had been used and clearly documented in the operative report. If this were the case, 36010 (introduction of catheter, superior or inferior) would be reported, appended with modifier -59 (distinct procedural service).

Placement of inferior vena cava filter: The radiologist placed a Braun filter one of many varieties of filters at the point just below where the renal veins enter the inferior vena cava. This device serves to trap any future emboli to prevent them from entering the pulmonary arteries. Coders would use 37620 (interruption, partial or complete, of inferior vena cava by suture, ligation, plication, clip, extravascular, intravascular [umbrella device]), along with 75940 (percutaneous placement of IVC filter, radiological supervision and interpretation) to report this part of the procedure."