Get Busy Learning New Cervico-cerebral Imaging, Re-imagined
It’s time to re-evaluate your cervico-cerebral imaging coding for new concepts and codes in 2013.
By David Zielske, MD, CPC-H, CIRCC, CCC, CCS, RCC
For 2013, CPT® has developed an entirely new concept and set of codes for imaging of the cervico-cerebral (head and neck) arteries. These codes do not apply to selective venous head and neck procedures, but do include the venous follow-through imaging often performed with selective cerebral angiography.
Codes 36221-36228 include catheter placements for the vessels selected and imaged. Catheter placements can be in:
- The aortic arch (36221 Non-selective catheter placement, thoracic aorta, with angiography of the extracranial carotid, vertebral, and/or intracranial vessels, unilateral or bilateral, and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed)
- The innominate or common carotid (either 36222 Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral extracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed or 36223 Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed).
- The internal carotid (36224 Selective catheter placement, internal carotid artery, unilateral, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed).
Code 36221 for arch imaging is bundled with all selective cervico-cerebral imaging codes, and cannot be reported with any codes in the 36222–36228 range; carotid code 36222 describes placement of the catheter selectively into the innominate or common carotid artery with unilateral imaging of the cervical carotid artery; code 36223 includes imaging of the intracranial vessels, as well; and code 36224 requires catheter placement in the internal carotid artery for carotid cerebral imaging.
All three selective codes include arch imaging, if performed, while the cerebral codes 36223 and 36224 include the cervical carotid imaging, if performed. Only one code from this group can be reported per side imaged, with a hierarchy of 36224 > 36223 > 36222.
Example 1: A 75-year-old patient with carotid stenosis identified on Doppler ultrasound is here for angiographic evaluation. Via a right femoral puncture, a catheter is advanced into the arch and cervicocerebral arch imaging is performed (36221). The catheter is advanced into the right innominate artery, and imaging of the cervical and cerebral carotid arterial distribution is performed (delete 36221, add 36223).
Severe stenosis of the right common carotid precludes selective advancement of the catheter into the carotid artery. A catheter is then placed into the left common carotid artery and left cervical carotid imaging is performed (36222-59). The catheter is then advanced into the left internal carotid artery for cerebral imaging of possible aneurysm (delete 36222-59, add 36224, append modifier 59 to 36223 for the right carotid, above). The catheter is removed.
New Codes Bundle Imaging
Code 36221 includes catheter placement in the aorta and imaging of the arch, and the innominate, proximal subclavian, and common carotid arteries (as in the past). This year, imaging from an arch injection also includes complete imaging of the cervical carotid and vertebral arteries, along with the intracranial carotid and vertebral cerebral arteries, when performed. Last year, the imaging codes for these specific regions could be reported; this year, a single code describes all regions imaged via an arch injection.
The new codes are unilateral. If bilateral carotid imaging with selective catheterization is performed, report the appropriate code with modifier 50 Bilateral procedure appended.
If a higher-level diagnostic study is performed on one side, report both sides with accurate codes and modifier 59 on the lesser unilateral procedure (e.g., 36224 for internal carotid selection and intracranial imaging on the right, and 36223-59 for cervical and cerebral imaging on the left, with the catheter in the common carotid artery).
Similar guidelines apply to unilateral vertebral artery imaging (36225 Selective catheter placement, subclavian or innominate artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed) to report unilateral vertebral artery imaging with a catheter placed in the innominate or subclavian artery; as well as to imaging via a catheter selectively placed into the vertebral artery (36226 Selective catheter placement, vertebral artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed).
Both 36225 and 36226 include imaging of the neck and head. These codes are unilateral, and follow similar guidelines as the carotid arteries for bilateral procedures. Selective vertebral codes include imaging of the arch (if done), and have a hierarchy of 36226 > 36225.
Example 2: The patient is 57-years-old with possible vertebro-basilar insufficiency. Via a right common femoral puncture, a catheter is advanced into the arch and cervico-cerebral arch angiography is performed (36221). A catheter is advanced into the right subclavian artery and vertebral artery imaging is performed (delete 36221, add 36225). This injection fails to show retrograde flow down the left vertebral. The catheter is then placed into the left subclavian and advanced further into the left vertebral artery, and selective left vertebral artery imaging is performed (add 36226, append modifier 59 to 36225, above). The left vertebral ends in the posterior inferior cerebellar artery (PICA).
Add-ons Paint a Complete Picture
Report add-on code +36227 Selective catheter placement, external carotid artery, unilateral, with angiography of the ipsilateral external carotid circulation and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure) with codes 36222–36224 when the external carotid artery is selectively catheterized, and imaging is performed of the external carotid artery and any additional branches. Report +36227 only once per side. Do not report +75774 Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation (List separately in addition to code for primary procedure) for any additional super-selective external carotid branch selection and imaging.
Use +36228 Selective catheter placement, each intracranial branch of the internal carotid or vertebral arteries, unilateral, with angiography of the selected vessel circulation and all associated radiological supervision and interpretation (eg, middle cerebral artery, posterior inferior cerebellar artery) (List separately in addition to code for primary procedure) when an intracranial artery is super-selectively catheterized, with imaging performed of any intracranial artery (e.g., anterior cerebral, posterior cerebral, middle cerebral, callosal marginal, peri-callosal, basilar superior cerebellar, PICA, AICA, etc.). Code +36228 may be reported twice per side (right cerebral, left cerebral, and posterior fossa), but only with 36224 and 36226; however, the medically unlikely edit (MUE) for +36228 is four units. It would be an unusual case that requires super-selective intracranial arterial catheterization and imaging from all three territories.
Variant Anatomy & Diagnostic Cervico-cerebral Angiography Coding
The new cervico-cerebral arterial imaging code set is not influenced by variant anatomy. This means, the codes for selective bilateral common carotid and bilateral selective vertebral imaging with catheter placement in the common carotid and vertebral arteries, in a patient with a normal arch, are the same codes as reported for a patient with variant anatomy consisting of a bovine arch, or with an aberrant right subclavian artery.
These codes only apply to cervico-cerebral imaging performed as a diagnostic study (with or without neuro-intervention). If a neuro-interventional procedure is performed without diagnostic imaging (e.g., diagnostic study of stable aneurysm done on the prior day, here for intervention only today), the “selective above diaphragm” catheter placement codes (36215–36218) are appropriate, along with the interventional codes for the procedure performed. If diagnostic imaging and neuro-intervention are performed at the same session, do not submit selective catheter placements. Instead, report only 36221-36228 because catheter selections are included.
Example 3: The patient is 41-years-old with wide-mouthed, supra-clinoid internal carotid aneurysm. The patient had complete diagnostic angiography performed one day earlier and now consents to embolization with Pipeline™ device for therapy. Via a right femoral puncture, a guiding sheath is advanced into the right common carotid artery. The device catheter is then advanced to the level of the aneurysm (36217 Selective catheter placement, arterial system; initial third order or more selective thoracic or brachiocephalic branch, within a vascular family) and the Pipeline™ device successfully deployed for flow diversion and aneurysm embolization (61624 Transcatheter permanent occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method; central nervous system (intracranial, spinal cord) and 75894 Transcatheter therapy, embolization, any method, radiological supervision and interpretation). Completion angiography demonstrates flow diversion and successful procedure with patency of the native vessel (75898 Angiography through existing catheter for follow-up study for transcatheter therapy, embolization or infusion, other than for thrombolysis). The catheter is removed.
Example 4: Same patient as example 3; however, the patient had bilateral internal carotid arterial catheter placements with carotid cerebral imaging (add 36224-50 to prior example) on the same day as the intervention (delete 36217 from prior example).
Example 5: The patient is 60 years old with transient ischemic attacks (TIAs). Via a transfemoral approach, a catheter is placed to the aortic arch and imaging of the arch is performed. Proximal carotid and brachiocephalic ulcerated stenoses preclude selective catheter placements, so repeat arch injection is performed with imaging focused on the cervical and cerebral carotids. Excellent detail is obtained, demonstrating 90 percent right internal carotid artery (ICA) stenosis, 60 percent left ICA stenosis, and normal intracranial vessels. The entire right vertebral artery is imaged and appears normal. Code 36221 describes all imaging of the cervico-cerebral vasculature via this non-selective arch injection.
Example 6: Same case as example 5, but the proximal arch vessels do not have stenoses, so the right common carotid, right vertebral, and left common carotid arteries are selected and images of the cervical and cerebral carotids, as well as the vertebral artery, are obtained. Code 36223-50 describes bilateral carotid imaging. Code 36226 describes selective right vertebral imaging. Arch imaging (36221) is bundled in both the selective carotid and vertebral codes, and is not separately reported.
David Zielske, MD, CPC-H, CIRCC, CCC, CCS, RCC, is an interventional radiologist and president of ZHealth Consulting and ZHealth Publishing in Brentwood, Tenn.