Radiology Coding Alert

Question: Our interventional radiologist positioned a catheter in the patient's aortic arch and performed an aortic angiogram, which showed normal anatomy. The angiogram indicated stenosis in the left common carotid artery, left subclavian artery and beyond the internal mammary. Next, the physician selectively engaged the left common carotid artery and accomplished selective angiographies in multiple oblique views, including intracranial injections. The angiography indicated stenosis in the distal left common carotid and left external carotid artery. The left internal carotid at the bifurcation site had a calcification. 
  Intracranial injections demonstrated some left-to-right flow through the middle cerebral artery. The physician then used a catheter to selectively engage the right common carotid artery. He performed multiple injections and obtained intracranial views, and determined that the distal right common carotid was 90 percent stenosed, the right internal and right external carotids were normal, and intracranial flow was also normal. Which codes should we report?

Wisconsin Subscriber
Answer: First, you should report 36215 (Selective catheter placement, arterial system; each first-order thoracic or brachiocephalic branch, within a vascular family) for the catheter placement in the left common carotid artery. Append modifier -59 (Distinct procedural service) or modifier -LT (Left side) to 36215 to indicate that the physician placed a separate catheter into a first-order vessel in a different family from the right common carotid artery.
 
Next, report 36216 (... initial second-order thoracic or brachiocephalic branch, within a vascular family) for the catheter placement in the right common carotid artery. If you appended modifier -LT to code 36215, you should append modifier -RT (Right side) to 36216.
  While the physician indicates that "intracranial injections" were performed, there is no documentation to state that the catheter was advanced beyond the common carotid on either the right or the left.
 
You should report 75650 (Angiography, cervicocerebral, catheter, including vessel origin, radiological supervision and interpretation) for the aortic arch aortogram, with 75680 (Angiography, carotid, cervical, bilateral, radiological supervision and interpretation) and 75671 (Angiography, carotid, cerebral, bilateral, radiological supervision and interpretation) for the supervision.
  Keep in mind that you cannot report the external carotid interpretations because the radiologist did not selectively catheterize them.