Op Reports Show How to Code Selective Catheter Placement
To claim correctly consider the codes that should be assigned for these cases.
Nancy G. Higgins, CPC, CPC-I, CIRCC, CPMA, CEMC
Determining correct selective catheter placement codes is an integral part of coding any interventional procedure. For a better understanding, code these two operative (op) reports demonstrating common coding scenarios.
PATIENT: John Doe
SURGEON: John Smith, MD
PROCEDURE: Abdominal and pelvic angiography with bilateral lower extremity runoff, selective runoff of left lower extremity.
INDICATIONS: Mr. Doe is a 70-year-old gentleman who presents with worsening bilateral lower extremity claudication. CT angiogram had demonstrated severe atherosclerotic disease of the infrarenal aorta but there did not appear to be a focal high-grade stenosis. He had bilateral patent iliac stents and left SFA occlusion.
DESCRIPTION OF PROCEDURE: The patient was brought to the angiography suite and placed on the table in supine position. We accessed the right femoral site with use of a SonoSite. A Magic Torque™ wire was advanced in a retrograde fashion under fluoroscopic guidance. A 5-French sheath was positioned over the wire and the wire and dilator were withdrawn. A pigtail catheter was then advanced up to the upper abdominal aorta over a wire and flush aortography was performed in an AP projection. The catheter was then brought down to the lower abdominal aorta and AP views of the pelvis were taken. Using a step-table technique, bilateral subtraction angiography of the lower extremity was performed. We then exchanged catheters for a universal flush catheter, which was used with the Glidewire to select the left common iliac artery. A Glidewire was then advanced down to the superficial femoral artery and catheter exchange was performed over the wire for an angled taper catheter. Pressures in the left femoral artery distally were 80/40. There did not appear to be any focal high-grade stenosis proximal to that. The catheter was then utilized to perform selective angiography of the left lower extremity.
FINDINGS OF THE DIAGNOSTIC EXAMINATION: There was atherosclerotic disease involving the entire infrarenal segment from the renal arteries to the bifurcation; however, this did not appear to result in a focal high-grade stenosis. There were duplicated renal arteries on the right. The left renal artery did not demonstrate any significant stenosis. Bilateral common iliac stents were patent. The left lower extremity runoff demonstrates a patent common femoral artery. The superficial femoral artery is occluded at its origin. Despite the fairly rapid filling of the profunda femoris, there was very poor distal runoff and very slow filling of the above-knee popliteal segment on that side. On the selective angiograms, we were able to identify three-vessel runoff. Distally, there is a short focal dissection in the proximal superficial femoral artery that does not appear to be flow limiting. The superficial femoral artery appears patent down to the popliteal segment. He appears to have three-vessel runoff preserved on the right.
This report indicates the catheter was introduced at the right femoral artery, advanced to the aorta, then to the left common iliac, and finally to the left superficial femoral artery. The correct catheter placement code is 36247 Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family because the superficial femoral artery is considered a third-order branch and the code assignment is based on the final destination of the catheter.
To help with your coding, you may refer to the CPT® Appendix L , which shows the assignment of branches to first, second, and third order for various vascular families, assuming the starting point is the aorta. From this appendix, we can follow the progression from common iliac to superficial femoral. The appendix indicates that this is a third-order branch, confirming the correct catheter placement code is 36247.
Through various vendors, including Z Health Publishing (www.zhealthpublishing.com) and Medical Assets Management (www.medicalassetsmanagement.com), you can obtain color diagrams that show codes for various catheter placements by vessel. When using such a diagram, you also can determine, at a glance, 36247 is the appropriate code.
In example 2, the catheter is introduced at the left common femoral artery and advanced in an antegrade fashion to the left superficial femoral artery. This case differs from the first one because the aorta was not crossed, and the catheter was moved down the leg from one branch to another.
PATIENT: Jane Doe
SURGEON: John Smith, MD
PROCEDURES PERFORMED: Left femoral angiogram by antegrade access, left angioplasty and stent of superficial femoral artery.
DESCRIPTION OF PROCEDURE: The patient was brought to the angiography suite where both groins were prepped and draped in the usual manner. Skin overlying the left common femoral artery was infiltrated with 1 percent Xylocaine. Left common femoral artery was cannulated with a 21-gauge perc needle in an antegrade manner. The wire was confirmed to be in the superficial femoral artery. The micropuncture sheath was then exchanged for a 5-French sheath. The 5-French sheath in place, angiographic images were acquired of the left superficial femoral artery. She was noted to have a total occlusion at the level of the adductor canal as well as other multiple, relatively minor stenoses. The vessel was reconstituted at the level of the adductor canal. Popliteal artery is widely patent. Anterior tibial and posterior tibial arteries are patent, although there is some mild atherosclerotic disease at the tibioperoneal trunk. A 5-French sheath was then exchanged for a 6-French sheath. With 6-French sheath in place, the lesion was crossed using a subintimal dissection technique. The superficial femoral artery was reentered well above the knee joint. The lesion was angioplastied with a 5 mm x 40 mm angioplasty balloon. Residual occlusion remained so a decision was made to place a stent. A 6 x 150 mm Viabahn stent was then deployed across the diseased segment. The stent was then angioplastied with a 6 x 40 Powerflex balloon that did not adequately expand the stent through its proximal portion. A 6 x 40 Dorado balloon was then used to complete the angioplasty proximally. Follow-up angiography revealed some contour irregularities in the distal component of the stent deployment. This area was then covered with a 5 mm x 5 cm Viabahn extension. Completion angiography showed the stent to be widely patent. I showed excellent flow through the stent. The angiogram shows the popliteal artery and proximal tibial vessels were unchanged from the preprocedure angiograms. The patient tolerated the procedure without difficulty and was returned to the holding area in satisfactory condition.
Here, CPT® Appendix L is not as easy to use. Recall that Appendix L assumes the starting point for the catheterization is the aorta. In this case, the catheter was not moved to the aorta—so that assumption does not hold true. But you can still use the appendix if you are careful with your interpretation. The appendix indicates that if the catheter is in the common femoral and is moved to the superficial femoral, the catheter has moved from one branch to a different branch. If we consider the common femoral as the starting point, the superficial femoral artery would be a first-order branch. This scenario would support the use of 36245 Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family for the catheter placement.
Note: If you have access to color diagrams (as mentioned above), you will find them to be more intuitive when coding a case such as this.
To sum it up, you can determine the correct catheter placement code by always considering the location of the starting point, whether the catheter was advanced to the aorta, and the final destination of the catheter.
Keep reading: In future months, we will consider the other codes that should be assigned for these cases, and will look at other op reports and their coding.