Radiology Coding Alert

Inclusive services include catheterization, imaging, and interpretation of report.

When your physician performs an intracranial angiography, confirm if there was an angioplasty that followed. Make sure you identify the number of vessels and location for ballooning and confirm whether your physician placed any stents. Do not forget to check if a neurosurgeon also contributed to some services.

Look for Diagnostic Arteriogram

Take a look at the following procedure note for balloon angioplasty services:

Example: You determine that your physician located a stenosis and dilated it by inflating a balloon. Below is a procedure note:

 “Cerebral ischemia was confirmed on a baseline CT scan, and brain perfusion was assessed using CT xenon perfusion imaging. A four vessel diagnostic arteriogram was done to define the stenosis, assess collateral circulation. There was no other associated vascular pathology. With adequate anticoagulation, a microguidewire (0.014 inches) and balloon angioplasty catheter matching the vessel’s luminal diameter were introduced under fluoroscopic guidance. The balloon was inflated for 5 to 10 seconds across the narrowing. The inflation was maintained until the plaque was adequately dilated…..” 

When your physician performs a percutaneous intracranial angioplasty, you’ll report code 61630 (Balloon angioplasty, intracranial [e.g., atherosclerotic stenosis], percutaneous).

Know What to Do When the Note Indicates Stenting

Since the carotid artery has intracranial and extracranial segments, you confirm the precise location of stent placement before you proceed to select the right codes. When your physician places an internal carotid stent in the intracranial segment of the vessel, remember that the location of stent placement is critical in choosing the right code. 

You report code 61635 (Transcatheter placement of intravascular stent[s], intracranial [e.g., atherosclerotic stenosis], including balloon angioplasty, if performed) when your physician places the stent in the intracranial segment of the carotid artery.

On the other hand, you report placement of an internal carotid artery stent in the cervical region (extracranial) with code 37215 (Transcatheter placement of intravascular stent[s], cervical carotid artery, open or percutaneous, including angioplasty, when performed, and radiological supervision and interpretation; with distal embolic protection) or 37216 (Transcatheter placement of intravascular stent[s], cervical carotid artery, open or percutaneous, including angioplasty, when performed, and radiological supervision and interpretation; without distal embolic protection), depending on whether distal embolic protection is used.

Review the following operative note that clearly describes the stent placement:

Example: “A stable guiding catheter platform was established and the balloon was advanced to the level of the narrow segment in the carotid artery. A microcatheter was then advanced to the narrowed area and a coil was introduced. The balloon was gently inflated across the narrowing while the coil was introduced. The coil acquired the convex configuration along the balloon interface. The balloon was deflated after the coil was well placed. The coil was then observed to confirm stability.”

What to report: Since you can confirm the stent placement, you’ll report code 61635.

2 physicians? You may read that your radiologist worked with the neurophysician for the ballooning and stenting, one maneuvering the balloon and another introducing the coil. In this case, you append modifier 62 (Two Surgeons) to 61635 to indicate that two physicians in the same practice worked during the procedure.  “However, CMS payment policy requires documentation of the need for two co-physicians to perform this and many other percutaneous procedures before they will allow payment,” says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison. You need to make sure you document what each physician did and why the services of each were needed.

Do Not Separately Report Inclusive Services

Codes 61630 and 61635 are inclusive of the following services that your physician performs in a specified vascular family:

• Any selective vascular catheterization
• Any diagnostic imaging for arteriography
• Any related radiological supervision and interpretation

If you read that your physician did a diagnostic imaging and selective catheterization and the arteriogram necessitated an angioplasty or stent placement, you report codes 61630 and 61635 as these codes are inclusive of these services.

Also note: Codes 37215 and 37216 are also inclusive of carotid access, diagnostic imaging, supervision and interpretation.

If, however, your physician did an arteriogram which did not indicate any need for angioplasty or stenting, then you do not report 61630 or 61635. Instead, you report the appropriate codes for selective catheterization and radiological imaging.  “While in the past, component coding was the norm in CPT^® to describe each step of a diagnostic and therapeutic vascular procedure, new and revised codes have instead bundled all of the typical services into one code,” says Przybylski.

Beware the bundles: Some procedure codes are bundled in 61630 and 61635. You cannot report these codes with either 61630 or 61635. These procedure codes include codes for transcatheter introduction of intravascular stent (75960), fluoroscopy (76000, 76001) and needle placement guidance (76942, 77002, 77012, 77021).

Editor’s Note: Refer to the sidebar for more on coding the balloon angioplasty for vasospasms.