Catheter Placement is Critical to Coding Arterial System Procedures

Use terminology, order placement, and coding guidelines to accurately capture these specialized services.

 
Arterial catheter placement is a ubiquitous part of interventional radiology, cardiology, and endovascular surgery, and affects both facility and physician coding. Because it is such an important part of these specialty procedures, choosing the correct placement codes is essential for accurately capturing the physician’s services, ensuring proper reimbursement, and maintaining compliance.
Learning specific codes for any individual artery is not necessary because there are so many named vessels, and coding can vary for the same vessel depending on the access site, approach to the vessel, and variant anatomy. For example, a superficial femoral artery (SFA) selection is a first order placement for an antegrade approach with an ipsilateral common femoral access but is a third order placement for a contralateral approach (up and over the bifurcation of the aorta).
For a physician to meet the minimum documentation requirement, it’s imperative for the documentation to include all locations used to gain access into the vascular system, all vessels into which the catheter is placed, and the route the catheter took to get to these vessels. Documenting variant anatomy encountered during the procedure also is necessary as this may affect coding.
The following concepts, along with good physician documentation, will allow you to code even the most challenging reports.

Know These Key Terms

To gain a better understanding of arterial system catheter placement coding, familiarize yourself with these key terms.
Vascular access is the location(s) where the patient’s vascular system is entered. The common femoral artery (CFA) and brachial arteries are the most frequently used.
A vascular family is a vessel that arises from the aorta or is off the access vessel, and includes all of that vessel’s branches. For example, the left subclavian artery and its many branches are considered as one vascular family off the aorta.
Non-selective catheter placement refers to a catheter that remains in the accessed vessel or that has made it into the aorta, which is still considered non-selective.
Selective catheter placement is a catheter placed into (not at or near the origin) a branch off the aorta or the access vessel. Each of these vessels arising from the aorta or access vessel represents different vascular families. Code to where the tip of the diagnostic or working catheter is placed, but not the wire. A working catheter could be an angioplasty, atherectomy, or stent catheter.
Vascular order describes the level of a vessel. The initial vessel off the aorta or access vessel is considered a first-order vessel. When this initial vessel starts to branch, it becomes smaller and more difficult to catheterize, with the resulting branches becoming second-order selections. When the second-order vessel starts to bifurcate, the resulting branches become third-order selections, and so on. The highest level of selection in the arterial system is a third-order vessel, so it is not necessary to distinguish higher levels of selection. One main exception is that the popliteal artery becomes the next-higher order beyond the SFA without a bifurcation.

Apply Coding Guidelines

Refer to Table A for code descriptions.

• Select the appropriate non-selective code when an access is made and the catheter does not reach the aorta or a branch off the access vessel. For example, if the right common femoral artery is entered and a sheath is placed for a right lower extremity angiogram, the catheter placement code is 36140.
• Do not report a separate code for the access site (sheath placement) when the aorta is entered or there was a selective catheter placement.
• Report 36200 when the catheter enters the aorta (which is non-selective). Remember not to code where the tip of the wire is placed, but rather where the sheath, diagnostic catheter, or working catheter tip is placed. For example, during an ostial stent placement in a renal artery, the wire may be placed into a second- or third-order vessel for stability, but the correct code is 36245 because the catheter the stent was deployed from is a first-order selection.
• Call upon the appropriate selective code when a vessel off the aorta or access vessel is entered. The documentation must confirm that a particular vessel was selected, or that the catheter tip was placed into the vessel. Placement of a catheter “near” or “at” the origin of a vessel does not document a selective catheter placement.
• The selective code includes the non-selective code from the same access site. For example, if the right renal is selected, report only 36245, not 36200 and 36140 from a transfemoral approach.
• Code once the highest order/level of catheter selection within a vascular family (e.g., 36xx5, 36xx6, or 36xx7). If, in the same vascular family, additional branch vessels are catheterized, use the appropriate additional second-order, third-order, and beyond code (36218 or 36248) for each additional vessel that is selected. These are add-on codes and do not require modifier 59 Distinct procedural service for multiple service units.
• The highest level vessel selected in a vascular family includes the lesser-order selective codes in route. For example, if the celiac, common hepatic, and right hepatic are separately injected, report only 36247 (the less selective procedures 36246 and 36245 are included).
• Repeat the same guidelines above for each separate vascular family that is selected. For example, in a normal aortic arch, if each of the great vessels (e.g., brachiocephalic, left common carotid, and left subclavian) are selected, you will have a minimum of three codes to report (36xx5, 36xx6 or 36xx7). If additional vessels within any of these three vascular families are also selected, additional (36xx8) code(s) are necessary.
• If a second access is performed, the coding starts again following the same guideline above for any and all vessels selected. For example, if the right femoral is entered and a catheter is placed into the bilateral renals and a second access is made into the left femoral with a catheter placed into the aorta, the reported codes would be 36245-50 and 36200-59. Modifier 59 indicates this to be a separate and distinct procedure, while modifier 50 Bilateral procedure describes the bilateral access to the renals.

Real Scenarios Reveal Correct Coding

Case 1 – Right transfemoral approach with the right vertebral, right common carotid artery, left common carotid artery, left vertebral arteries selected with normal arch anatomy.
Catheter codes: 36217, 36218, 36215-59, 36216-59
Case 2 – As case 1, but with bovine arch (variant anatomy with left common carotid originating from the brachiocephalic, resulting in only two vascular families arising from the arch instead of the normal three).
Catheter codes: 36217, 36218, 36218, 36216-59
Notice different codes secondary to the variant anatomy.
Case 3 – Right transbrachial approach with the same vessels selected as in case 1.
Catheter codes: 36215-59, 36215-59, 36215-59, 36216-59
Notice different codes for different approach.
Case 4 – Right transfemoral access with the celiac, splenic, gastroduodenal, and superior mesenteric arteries selected.
Catheter codes: 36247, 36248, 36245-59
Remember: The celiac would be included in the third-order selection in the same vascular family.
Case 5 – Left transfemoral with an up-and-over contralateral approach with the right SFA, popliteal, anterior tibial, posterior tibial, and peroneal arteries selected.
Catheter codes: 36247, 36248, 36248
These codes are for the anterior tibial (AT), posterior tibial (PT), and the peroneal arteries. The SFA and popliteal are “along the route” to the highest level selection and are not reported separately.

Table A

Non-Selective Arterial Codes
36100      Introduction of needle or intracatheter; carotid or vertebral artery
36120      Introduction of needle or intracatheter; retrograde brachial artery
36140      Introduction of needle or intracatheter; extremity artery
*36147     Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); initial access with complete radiological evaluation of dialysis access, including fluoroscopy, image documentation and report (includes access of shunt, injection[s] of contrast, and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava)
*+36148   Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); additional access for therapeutic intervention (List separately in addition to code for primary procedure)
36160      Introduction of needle or intracatheter, aorta, translumbar
36200      Introduction of catheter, aorta
Selective Arterial Codes Above the Diaphragm
36215      Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family
36216      Selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch, within a vascular family
36217      Selective catheter placement, arterial system; initial third order or more selective thoracic or brachiocephalic branch, within a vascular family
+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)
Selective Arterial Codes Below the Diaphragm
36245      Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family
36246      Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family
36347      Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family
+36248    Selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriate)
* New code for 2010

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David Dunn

David Dunn, MD, FACS, CIRCC, COC, CCVTC, CCC, CCS, RCC, vice president of ZHealth Publishing, oversees physician coding. He coauthors the Vascular & Endovascular Surgery Coding Reference and the new Cardiothoracic Surgery Coding Reference from Dr. Z’s Medical Coding Series, and is a contributor to the Interventional Radiology Coding Reference and the Diagnostic & Interventional Cardiovascular Coding Reference. Dunn served as president of the AAPC National Advisory Board from 2013-2015, and is a member of the Nashville, Tenn., local chapter.

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