Radiology Coding Alert

Coders who lack a thorough understanding of the heads vascular structures and the various components of cerebral embolizations run the risk of undercoding or incorrectly coding the procedure. This could result in practices not receiving the appropriate reimbursement or the increased risk of fraud and abuse investigations.

Lisa Grimes, RT [R], coding specialist for radiology administration at the University of Texas Houston-Health Science Center, offers two strategies to enhance general understanding of the procedure, as well as an explanation of the three specific components of embolization to help codersnovices and veterans alikeassign the most accurate codes and receive appropriate levels of reimbursement.

Components of a Cerebral Embolization

In addition to understanding the anatomy involved, Grimes notes that coders should recognize that there are three discreet components to a cerebral embolization: the embolization itself, catheterization and angiography. Each exhibits its own set of coding parameters, which must be taken into account to ensure the radiologist receives reimbursement commensurate with the tasks performed.

1. Choosing the Correct Cerebral Embolization. There are two major distinctions in cerebral embolization codes, which relate directly to the anatomical structure of cranial vessels:

A. Code CPT 61624 is assigned for embolizations of intracranial vessels (transcatheter occlusion or embolization [e.g., for tumor destruction, to achieve hemostasis, to occlude a vascular malformation], percutaneous, any method; central nervous system [intracranial, spinal cord]).

B. Code CPT 61626 is assigned for embolizations of extracranial vessels (non-central nervous system, head or neck [extracranial, brachiocephalic branch]).

It is vital that coders recognize this basic distinction, Grimes says. As a general rule, extracranial vessels are those that feed the facein other words, those vessels in the head and neck not considered part of the central nervous system. Conversely, intracranial vessels specifically support the central nervous system, including the brain and the spinal cord.

Intracranial embolization procedures (61624) are most often performed on patients who suffer from conditions such as aneurysms (437.3) and arteriovenous malformations (AVM). Patients for whom extracranial embolization (61626) is most often performed may suffer from vascular tumors, epistaxis (784.7severe nosebleeds) or severe trauma like a gunshot or stab wound.

The radiological supervision and interpretation code that accompanies either embolization code is 75894 (transcatheter therapy, embolization, any method, radiological supervision and interpretation).

According to the Society of Cardiovascular and Interventional Radiologys (SCVIRs) Interventional Radiology Coding Users Guide, cerebral embolization procedures should be billed only one time per operative area, no matter how many vessels are actually embolized. Lets say that a patient has multiple blood vessels, or feeders, supplying an AVM that is embolized. Even though more than one embolization may be performed in different sections of the brain, it can be billed only once (61624). The head is considered a single operative area. Grimes says.

2. Coding catheterization correctly may mean higher reimbursements. Coders may not realize they should be billing a catheter access code in addition to the embolization code, Grimes says. There is time and skill involved with inserting the catheter, advancing it through the vascular system and positioning it correctly.

Correctly identifying and coding the first-, second-and third-order vessels that the physician accesses in order to advance the catheter to the point of embolization is vital.

These codes should be used to describe access as appropriate, she adds:

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

36216initial second-order thoracic or brachio- cephalic branch, within a vascular family

36217initial third-order or more selective thoracic or brachiocephalic branch, within a vascular family

Grimes emphasizes that reimbursement levels are directly tied to identifying the correct branch Undercoding may be prevalent in this area, she says. If the interventionalist has advanced the catheter into a third-order branch, payment is much higher than for first-order access. It makes sense. There is more time, effort and expertise involved in advancing farther into the vascular system. So, if a coder assigns 36215 when the interventionalist actually selected a second- or third-order branch, they will not receive the full reimbursement they are allowed.

Conversely, a second area of confusion regarding first-, second- and third-order access may put an interventional radiology practice at risk for fraud and abuse investigations. Coding professionals must remember that they cant assign multiple first-, second- and third-order codes from one access within the same vascular family during a single procedure, Grimes points out. Code 36216second-orderincludes advancing the catheter through the first-order branch to reach the second-order branch. By the same token, 36217 includes both the first-and second-order.

One additional code is important to understand if a radiologist is to receive appropriate reimbursement: code 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]). This code is recognized as an add-on code to be assigned if additional second- or higher-order branches within a family are accessed.

Although the embolization may be billed only once per operative area, Grimes points out that coders may assign multiple catheterization codes if different access points are used. For instance, if the neurointerventionalist performs bilateral femoral punctures, the highest-order vessels catheterized for each access could be coded separately.

3. Angiography: Clear documentation allows coders to bill for maximum reimbursement allowable. Angiography is the third important component of cerebral embolizations. Although pre-embolization angiograms may be billed only once, follow-up studies may be billed multiple times, but only if the physician dictates each time it is performed.

Angiography is typically performed before the procedure to identify the problem area, says Grimes. The radiology codes most often assigned may include 75660, 75662, 75665, 75671, 75676, 75680 and 75685, depending on which vessels are selected and injected with contrast.

Stacey Hall, ART, CPC, CCS-P, director of corporate coding for Medical Management Professionals in Chattanooga, Tenn., cautions coders to look closely at the CPT descriptions for each of the angiography codes. The description in codes 75660 and 75662 contain the word, selective. This means the radiologist actually has to insert the catheter into this vessel and inject it, she points out. The other codes in this series (75665, 75671, 75676, 75680 and 75685) are not selective. The radiologist doesnt have to inject contrast directly into these vessels, but may be able to read images that result from injections into the selected vessels.

Code 75774 Dubbed Most Underused

In some instances, 75774 (angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation [list separately in addition to code for primary procedure]) may be assigned in addition to the initial angiography, Hall notes. The head contains a lot of vessels that extend off from the main branches deep into the brain. Some of these are not specifically noted in the CPT, so 75774 is assigned to these other vessels.

Grimes agrees with Hall. Code 75774 is one of the most underused codes in angiography, Grimes says. For example, an interventionalist may initially perform angiography of the external carotid, which would be coded 75660. However, to make sure they have pinpointed the entire area thats bleeding, they may take the catheter into the distant branches, like the internal maxillary. This would be a situation where it would be appropriate to assign 75774 to describe further selective angiography.

Each of these initial angiography codes may be assigned only once, since they describe the work of locating the vessel in order to perform the embolization, adds Hall, whose firm provides billing and management services to hospital-based physician practices nationwide.

However, once the embolization has been completed, the interventionalist usually goes back and does another angiogram to see if it was successful. Code 75898 describes this follow-up (angiogram through existing catheter for follow-up study for transcatheter therapy, embolization or infusion), she says.

If the interventionalist finds that the hemorrhage has not ceased, he or she will repeat the embolization and will repeat the angiography until the bleed is stopped. This may take two or three angiograms, or it may take 20. But, if it is clearly documented by the physician in the medical record, 75898 may be assigned each time this follow up is performed.

Knowing Anatomy and Educating Coders The single most important thing for a radiology coder is to understand the anatomy of the head so they are able to identify the blood vessels that feed various areas of the brain, says Lisa Grimes, RT [R], coding specialist for Radiology Administration at the University of Texas Houston-Health Science Center. She recommends that professionals who frequently code cranial embolization procedures keep an anatomical drawing at their fingertips (see insert). Two that she recommends are in the Interventional Radiology Coder Users Guide, published by the Society for Cardiovascular and Interventional Radiology (SCVIR), available at www.scvir.org/Educatn/educpg5.htm, and in the Interventional Radiology Coder, published by MedLearn, which can be ordered at www.medlearn.com/pubalphF.html. Because cerebral embolizations are so complex and involve a wide variety of coding scenarios, Grimes recommends that coding professionals spend time educating their collections staff. If the collections staff understand embolization and why a case has been coded the way it has been, they can more effectively appeal the denial. This could have significant impact on the bottom line, if they are able to appeal successfully. Grimes notes that many payers may be confused by the multitude of codes affiliated with cerebral embolization. They may want to bundle them into one. But the codes are explained in the CPT. The collections staff must be able to walk the payer through the codes. codes.

Related Case Study: Cerebral Angiogram and Embolization This case study demonstrates the correct coding for an intracranial embolization. Indication: Forty-seven-year-old patient with hypertension and multiple intracranial aneurysms, for coil occlusion of a left basilar tip aneurysm. Impression: Successful occlusion of the left basilar tip aneurysm with GDC (Guglielmi Electrolyctically Detachable Coil) and electrothrombosis. The patient will need to have follow-up angiography in six months, eighteen months to two years, three years and five years. Procedure: Under general anesthesia and via a percutaneous right femoral approach, the following procedures were performed: 1. pre-embolization left vertebral arteriogram with filming over the cranium in multiple projections; 2. endovascular coil occlusion of the left basilar tip aneurysm using GDC coils and electrothombosis; 3. postprocedure left vertebral arteriograms with filming over the cranium. Findings: The left vertebral arteriogram demonstrates the aneurysm measuring approximately 5 mm arising from the distal left basilar artery between the origins of the left posterior cerebral artery and the superior cerebellar artery. Slight infundibular dilation is seen on the right at the origin of the right superior cerebellar artery. The endovascular procedure is initiated by placing a guiding catheter in the distal left vertebral artery. Through this guiding catheter, a braided microcatheter is introduced and advanced to the aneurysm where GDC coils are placed with electrothrombosis resulting in greater than 95 percent occlusion of the aneurysm. The postprocedure left vertebral arteriogram demonstrates good occlusion and exclusion of the aneurysm from circulation. Normal branches of the vertebrobasilar system are seen. No branch occlusion or retrograde filling is noted. Coding: Embolization61624: intracranial procedure Catheterization36217: catheter is advanced beyond the left vertebral artery (second order) to the site of the basilar tip aneurysm between the left posterior cerebral artery and the superior cerebellar artery (this area is beyond second ordercoding should always reflect the highest order. Angiography75685: initial arteriogram conducted at left vertebral (*); 75898: follow-up angiogram to confirm embolization (*); 75894: supervision & interpretation of embolization procedure (*). * Note: If coding only for professional services, the RS&I codes should carry a -26 modifier (professional component). If coding for the technical component only, the RS&I code should carry a -TC (technical component) modifier. If coding globally, no modifier is used.