Radiology Coding Alert

Ace add-on coding with this guide to 2 new selective catheter codes.

Taking in all of the CPT® 2013 changes for cervicocerebral angiography is no easy task, but the two add-on codes have raised questions in particular. Avoid mix-ups with a breakdown of when to use the codes, what’s included, and tactics for proper use.

+36227 Is the Go-To Code for ECA

The code: The first add-on code in the range is +36227 (Selective catheter placement, external carotid artery, unilateral, with angiography of the ipsilateral external carotid circulation and all associated radiological supervision and interpretation [List separately in addition to code for primary procedure]).

When to use +36227: Code +36227 represents catheter placement and diagnostic imaging of external carotid circulation on one side of the body. You should use +36227 only when the service is performed at the same session as one of the following angiography services (bold added):

• 36222, Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral extracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed
• 36223, Selective catheter placement, common carotid or innominate artery, unilateral, any approach, 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
• 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.

What’s included: Code +36227 represents accessing the external carotid artery (ECA), catheter placements, contrast injections, fluoroscopy, and radiological supervision and interpretation, including imaging in multiple projections.

Symposium takeaways: The designated primary codes for +36227 are carotid codes 36222-36224, which makes sense if you consider the anatomy. Code +36227 requires selection of the ECA, which "is always selected after the common carotid artery is selected," explained Sean P. Roddy, MD, FACS, of the Society for Vascular Surgery and an AMA CPT® Advisory Committee member in the presentation "Vascular Surgery and Interventional Radiology" at the AMA’s CPT® and RBRVS 2013 Annual Symposium.

Further catheter selection, meaning higher order catheterizations, are included in +36227, so you should not code them separately, Roddy explained.

+36227 example: The physician images the intracranial carotid from the internal carotid (36224) and then advances the catheter to the external carotid and images that vessel (+36227).

+36228 Is for Additional Intracranial Branches

The code: The next add-on code to review is +36228 (Selective catheter placement, each intracranial branch of the internal carotid or vertebral arteries, unilateral, with angiography of the selected vessel circulation and all associated radiological supervision and interpretation [e.g., middle cerebral artery, posterior inferior cerebellar artery] [List separately in addition to code for primary procedure]).

When to use +36228: Code +36228 represents catheter placement and diagnostic imaging of initial and additional intracranial branches of the internal carotid and vertebral arteries on one side of the body. You should use +36228 only when the service is performed at the same session as one of the following services (bold added):

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

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.

What’s included: Code +36228 represents accessing the designated intracranial branches, catheter placements, contrast injections, fluoroscopy, and radiological supervision and interpretation, including imaging in multiple projections. CPT® guidelines instruct that additional selective catheter placement is included if it’s in "the same primary branch of the internal carotid, vertebral, or basilar artery."

Symposium takeaways: From the previous paragraph, you know that +36228 includes further selection of the same primary branch. But if the physician selects a separate branch off of the internal carotid or vertebral, you may report +36228 more than once for the same session. In fact, you may report +36228 up to twice per side for a maximum of four times per encounter, Roddy stated.

Example: The physician places the catheter in the right vertebral artery to image the vertebral circulation (36226). He then moves the catheter to the right posterior inferior cerebellar for imaging and to the anterior spinal artery for imaging (+36228 x 2).

Don’t Overlook Additional Guidelines

Although codes +36227 and +36228 relate to imaging of different vessels, there are some rules that apply to both codes.

Work on 2 sides: You may report services performed on opposite sides of the head separately. If the same services are performed on both sides, append modifier 50 (Bilateral procedure). But if separate territories are imaged on each side, then you should append modifier 59 (Distinct procedural service).

No +75774: Don’t report +75774 (Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation [List separately in addition to code for primary procedure]) to indicate additional diagnostic angiography of the extracranial and intracranial cervicocerebral vessels. Further selection is included in the carotid codes.

3D rendering: You may report 3D rendering separately using 76376-76377 (3D rendering with interpretation and reporting …).

US guidance: Ultrasound guidance for vascular access is separately reportable using +76937 (Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting [List separately in addition to code for primary procedure]).

But remember that +76937 is not appropriate for US guidance to mark a vessel for access. The physician must meet the code definition’s requirements to capture this service.

Modifier 51: Both codes are modifier 51 (Multiple procedures) exempt, meaning that you don’t need to append this modifier to the codes.