Radiology Coding Alert

More interventional radiologists are treating stroke patients with thrombolysis, a technique that may minimize damage to the brain and allow for a more complete clinical recovery.

"Catheter-directed thrombolysis is an aggressive therapy that interventionalists provide under emergent conditions," noted Richard Duszak Jr., MD, an interventional radiologist with West Reading Radiology Associates in Reading, Pa., during a presentation at the spring meeting of the Radiology Business Managers Association meeting in Scottsdale, Ariz. "It's an exciting area of practice because it is an emergency procedure and the radiologist is on the front lines of treatment."

Describing a stroke as a "brain attack" similar to a heart attack, he explains that thrombolysis must usually be performed within six hours of the event to be most effective. During the multistep procedure, a catheter is advanced to the site of obstruction or occlusion, and a thrombolytic agent is injected or infused to restore blood flow.
Step One: Locating the Occlusion
Interventional radiologists pinpoint the precise site of an obstruction by inserting a catheter, advancing it through the arterial system and performing angiography, explains Jeff Fulkerson, supervisor of radiology billing at the Emory Clinic in Atlanta. "When a patient presents with symptoms of a stroke, interventionalists won't know precisely where the occlusion has occurred within the brain. Cerebral angiography provides information about what is going on throughout the entire vascular structure."

This process is described by two sets of codes -- one for reporting the catheterization and one for reporting the angiography.
 
Catheter Access

Most often, catheter access is gained through the femoral artery and, depending on the final position of the catheter in the head or neck, one of the following catheterization codes is assigned:

  CPT 36215  -- selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family;

  CPT 36216  -- ... initial second order thoracic or brachiocephalic branch, within a vascular family;

  CPT 36217  -- ... initial third order or more selective thoracic or brachiocephalic branch, within a vascular family.
A fourth arterial access code, CPT 36218 (... additional second order, third order and beyond, thoracic or brachiocephalic branch, within a vascular family [list in addition to code for initial second or third order vessel as appropriate]), is an add-on code that may be assigned if additional second- or higher-order branches within a vascular family are accessed.

When reporting catheterization, coders must avoid two common errors, according to Lisa Grimes, RT [R], radiology special procedures technologist and reim-bursement specialist for the University of Texas/Houston Health Science Center. "First, practices cannot report more than one first-, second- or third-order code within the same vascular family during a single procedure," she says. "Each code includes advancing the catheter through the previous branches. For instance, 36217 includes both the [...]