Radiology Coding Alert

Question: I am brand new to coding endovascular, and I’m not sure which codes I need to use to properly document the patient’s visit.

The following is listed in the report:

Pre-operative diagnosis: Exertional pain and edema right upper extremity

Post-operative diagnosis: Same

Procedure:

1. Catheter placement in the innominate artery from a right radial approach.
2. Catheter placement in the right innominate vein from a right basilic vein approach.
3. Right upper extremity venogram in the neutral and steep arm abduction positions.
4. Right upper extremity arteriogram in the neutral and steep arm abduction positions.

What CPT^® codes should be used to document the procedures?

Arizona Subscriber

Answer: Part of getting started is recognizing the accesses are from the arm, which is called out in the documentation. According to the report, it appears the doctor went up the arm, and it wasn’t a selective process.

You will code the catheter placement in the artery from the right side with 36140 (Introduction of needle or intracatheter, upper or lower extremity artery). You would report CPT^® code 75710 (Angiography, extremity, unilateral, radiological supervision and interpretation) to document the right upper extremity arteriogram.

For the catheter placement in the right innominate vein, you’ll use code 36005 (Injection procedure for extremity venography (including introduction of needle or intracatheter)). You will then use 75820 (Venography, extremity, unilateral, radiological supervision and interpretation) to code the right upper extremity venogram in the neutral and steep arm abduction positions.

Modifier: The radiologist performed each of these procedures on the right side of the patient’s body, so you will need to apply modifier RT (Right side (used to identify procedures performed on the right side of the body)) to each code.