Radiology Coding Alert

Question: How would the following case be coded, based on these notes provided by the radiologist:

Placement of GDC coil [Guglielmi detachable coil] to repair an aneurysm. A micro catheter with the coil inside is threaded into the area. The coil is released inside the aneurysm to close it off. This would be a two- or four-vessel cerebral angiogram done first, followed by placement of the micro catheter.

Arizona Subscriber

Answer: Your question relates to cerebral embolization, which is comprised of three distinct components that need to be considered when coding: the embolization, catheterization and angiography. Specific codes will vary, depending on the precise nature of the embolization and the catheterization route.

Embolization: There are two major distinctions in cerebral embolization codes, which relate directly to the anatomical structure of cranial vessels. You would choose the code that most accurately reflects the vessels embolized. Code 61624 (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]) is assigned for embolizations of intracranial vessels. Code 61626 (non-central nervous system, head or neck [extracranial, brachiocephalic branch]) is assigned for embolizations of extracranial vessels.

As a general rule, extracranial vessels are those that feed the face in 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. The radiological supervision and interpretation code that accompanies either embolization code is 75894 (transcatheter therapy, embolization, any method, radiological supervision and interpretation). Coders should note that embolization codes are assigned once per operative field and not for each coil that is deployed.

Catheterization: Correctly identifying and coding the first-, second- and third-order vessels that the physician accesses to advance the catheter is vital to ensure appropriate reimbursement. In this case, you would choose one of the following selective catheter placement codes: 36215, 36216 or 36217, depending on the catheter point of entry and its destination. In addition, 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 recognized as an add-on code to be assigned if additional second or higher order branches within a family are accessed.

Angiography: Angiography is the third important component of cerebral embolizations and may be billed multiple times during the procedure, if the physician dictates each time it is performed. It is typically performed before the procedure to locate the bleed. The radiology codes most often assigned include angiography procedures 75660, 75662, 75665, 75671, 75676, 75680 and 75685, depending on which vessels are selected and injected with contrast. 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 to the initial angiography. It is used to describe angiography performed on vessels that extend from the main branches deep into the brain that are not specifically noted in the CPT manual.

Finally, the interventionalist may perform additional angiograms after the embolization has been completed to see if it was successful. Code 75898 (angiogram through existing catheter for follow-up study for transcatheter therapy, embolization or infusion) describes these follow-ups. Follow-up angiograms should be coded and billed as many times as performed after the completed embolization.