Radiology Coding Alert

It's not enough for coders reporting pulmonary angiography studies to know only the proper code assignments within the pulmonary system. For full reimbursement, coders must also understand unique service situations when they may report venous system codes as well.

During a PA, "radiologists advance the catheter through the venous system to access the pulmonary system," says Stacey Hall, RHIT, CPC, CCS-P, director of corporate coding for Medical Management Professionals Inc., a national billing and management firm for hospital-based practices in Chattanooga, Tenn. "On occasion, the radiologist stops in the vena cava and performs an inferior vena cavagram. When this occurs, you would assign additional codes."

Typically, the radiologist accesses the venous system at the groin and advances the catheter to the inferior vena cava. Images may be obtained to allow visualization of the blood flow from the renal vein. If completed and documented, Hall says, coders should assign 36010 (Introduction of catheter, superior or inferior vena cava) with CPT 75825 (Venography, caval, inferior, with serialo-graphy, radiological supervision and interpretation). "Remember, however, that if the radiologist doesn't actually stop here and take the images, these codes can't be used," she warns.

From this point, the radiologist moves the catheter further into the system to access the main pulmonary artery. If the radiologist stops the catheter within this vessel, angiography is reported with CPT 36013 (Introduction of catheter, right heart or main pulmonary artery) and 75746 (Angiography, pulmonary, by nonselective catheter or venous injection, radiological supervision and interpretation).

In other cases, the radiologist may advance into the right and/or left branches of the pulmonary artery, says Donna Gullikson, CPC, division director for Medical Computer Business Systems, a national coding and billing company based in Augusta, Ga. This scenario is coded with 36014 (Selective catheter placement, left or right pulmonary artery). If both the left and right sides are catheterized, report 36014 twice. Depending on payer preference, you would assign modifier -50 (Bilateral procedure) to the second occurrence of the repeated code or add the RT/LT designation.

Gullikson adds that you should choose one of two radiological supervision and interpretation (RS&I) codes for angiography of the right and left pulmonary branches. If angiography is performed only on one side, use 75741 (Angiography, pulmonary, unilateral, selective, radiological supervision and interpretation). "If images are obtained from both sides, use 75743 (Angiography, pulmonary, bilateral, selective, radiological supervision and interpretation)," she says.

The radiologist may progress further into the pulmonary system, selecting arteries that branch into the upper, middle or lower lobes of the lung. "This additional selection is described in 36015 (Selective catheter placement, segmental or subsegmental pulmonary artery)," Hall says. "You can report this code once for each artery accessed." Code 75741, therefore, is assigned for angiography within the right or left pulmonary arteries, while add-on code +75774 (Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation [List separately in addition to code for primary procedure]) is assigned for subsequent supraselective imaging studies.

Remember to report only the level of access code that represents the final catheter placement. For example, you would not report both 36013 and 36014 for selective catheter placement within the same vascular family. "A first-order placement includes advancing the catheter through the main branch to reach the first-order branch. By the same token, a second-order code includes both the main branch and first order," Hall says.

But all imaging studies performed should be captured and billed, since each of these procedures represents a unique service. Because the segmental and subsegmental pulmonary arteries represent different families, 36015 can be reported multiple times once each for the lobes catheterized on both the right and left sides, although this would be "highly unusual," Hall says.

Angiography may be performed at multiple points within the pulmonary system. Following are examples of common coding situations.

Scenario A

The radiologist gains access to the venous system at the groin and advances the catheter into both the left and right pulmonary arteries, where angiography is performed.

36014-RT catheter placement in right pulmonary artery
36014-LT catheter placement in left pulmonary artery)
75743 bilateral angiography

Scenario B

The radiologist gains access to the venous system at the groin and advances the catheter into the inferior vena cava, where he performs angiography. He then proceeds to the main pulmonary artery and obtains images once again.

36010 catheter placement in inferior vena cava
75825 venography at inferior vena cava
36013 catheter placement in main pulmonary artery
75746 angiography in main pulmonary artery

Scenario C

The radiologist gains access to the venous system at the groin and advances the catheter, selecting the right main pulmonary artery and then subselecting the upper and middle lobes of the patient's right lung. Angiography of all is performed.

36015 catheter placement in upper lobe artery of right lung
36015 catheter placement in middle lobe artery of right lung
75741 angiography in right main pulmonary artery
75774 angiography in upper and middle lobes of right lung x 2.