Keep Vascular Coding in the Family
Each branch of the “family tree” can help you determine additional vessel orders.
By Kimberly Engel, CPC
Previously, we looked at how best to determine the order of vessels (“In the Journey Through Vessels, Code Destinations, Not Waypoints,” November 2010) and reviewed the basics of catheter placement (“Catheter Location, Not Wire, Decides Proper Interventional Coding,” December 2010). Now, let’s expand on those topics to explain more advanced concepts, such as coding for additional second- and third-order vessels and the dreaded “bypass configurations.”
Coding Second- and Third-order Vessels
A vascular family is just that: a family, with vessels branching from a common origin to form a “family tree.” As an example, the brachiocephalic is a first-order vessel, or a “child” of the aorta (in this example, the aorta is our Eve). The brachiocephalic has two children, the right axillary and right common carotid, which are second-order vessels. From this point, each branch of the family stems out again, with third-order vessels (grandchildren/cousins), such as the right mammary, right costo trunk, right vertebral, right internal and external carotid, etc.
In a case scenario, documentation may look something like: “The right common femoral artery was accessed. Guidewire was manipulated through the vessels up to the thoracic arch. Catheter was selectively placed in the arch and angiography was performed. The guidewire was then moved into the right internal carotid and catheter followed. Angiography was performed and the vessel was widely patent. I then selectively engaged the right external carotid performing angiography also showing a widely patent vessel.”
In this example, the catheter was placed in the right internal carotid (a third-order vessel), and also a “sister” third order vessel, the right external carotid. Code 36217 Selective catheter placement, arterial system; initial third order or more selective thoracic or brachiocephalic branch, within a vascular family and 36218 Selective catheter placement, arterial system; 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).
Now, let’s use the same scenario, but change one placement:
“The right common femoral artery was accessed. Guidewire was manipulated through the vessels up to the thoracic arch. The catheter was selectively placed in the arch and angiography was performed. The guidewire was then moved into the right internal carotid and catheter followed. Angiography was performed and the vessel was widely patent. I then moved the catheter back and selectively engaged the right vertebral performing angiography, also showing a widely patent vessel.”
In this case, we have “cousin” vessels: Code 36217 for the right internal carotid and 36218 for the right vertebral. These vessels share a common “grandparent” so they are still in the same family, but they arise from different “parents,” or branches, off of the right common femoral artery.
Beware of the Bovine Arch
In cases where there is a bovine arch, you need clear documentation of where the arch branches from. Often, it will branch from the right brachiocephalic, making it part of this family. In such a case, the left common carotid becomes a child (second order), and the left internal and external carotids are the grandchildren/cousins (third order) of the right branch. Remember that not all anatomy is the same—if the provider states “bovine arch,” ask from where the arch originates to ensure proper coding.
Count Your Way to Bypass Codes
Bypass vessels are like man-made paths, and can be confusing to report. There are two types of bypasses:
The first is to bypass an injured or diseased portion of a vessel. Common types are aortofemoral, femoral-popliteal, and popliteal-tibial, but these are not the only kinds that bypass a diseased portion of a vessel. Remember to use basic concepts of counting the order by how many bifurcations (road name changes) you pass in these types of bypasses (see, “In the Journey Through Vessels, Code Destinations, Not Waypoints,” November 2010).
For example, a previously-placed left aortofemoral bypass is present. The provider enters at the right common femoral artery, then moves the catheter up the aorta (zero order) and into the bypass. This is a first-order placement (36245 Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family) from this route because only one bifurcation was passed. Another route into this bypass, from the place of access, through and over the aortic bifurcation (zero order), past the left iliac (first order) and into the femoral artery (second order), and then into the bypass vessel, makes this a third-order placement (36247 Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family). Three bifurcations were passed to get to this point.
In documentation, an example of a fem-pop bypass might be: “Access was obtained in the right common femoral artery. Catheter was moved over the aortic bifurcation, down to the left common femoral and into the fem-pop bypass. Angiography of the bypass was obtained, showing diffuse stenosis.”
How many bifurcations or roads did we pass? We know the aorta and aortic bifurcation is a zero order. After that is the iliac (first order). Next is the femoral (second order), to which the graft was anastomosed. Lastly, we turn to enter the bypass (third order).
The second type of bypass is when a vessel is passed completely, with the bypass as a replacement road. In this case, the catheter placement would be just as if this was the original vessel. For example, the patient has a femoral-axillary bypass, completely passing the aorta. The provider places the catheter from the left femoral artery into the bypass at any point; this is zero order (the aorta always is zero order, as reported by 36200 Introduction of catheter, aorta).
To make coding such difficult cases much more manageable and less confusing, ask and answer these questions:
- Did I take a detour (bypass)?
- What was the detour rerouting me from?
- Was the entire road or just a portion of a road under construction?
- How many bifurcations did I pass; or how many roads did I drive on?
And that completes our journey!
Kimberly J. Engel, CPC, is owner of Decision Medical Management Solutions, LLC, in Atlanta, Ga. (www.decisionmedicalmanagementsolutions.com). She has been a Certified Professional Coder (CPC®) for nearly a decade and also is former coding management for Duke University Medical Center and Aurora-Advanced. She has been an instructor for state technical colleges and does speaking engagements on various coding concepts.