Cardiology Coding Alert

How do you handle a case with a common carotid placement but both common and internal carotid imaging?

That's what one coder wanted to know when she sent in the following scenario: Using femoral access and common carotid placement, the physician images the right common carotid and right internal carotid. The physician documents normal anatomy and states there are no abnormalities in the common carotid, but she finds stenosis in the internal carotid.

Determine your answer, and then see if your solution matches the experts'.

The scenario indicates catheter placement terminated in the common carotid, but the cardiologist imaged both  the common and internal carotid arteries. Assuming your documentation supports it, you will be able to report imaging for both the common and internal carotid arteries.

This imaging of both vessels is possible because the contrast flows upward, says Michele Midkiff, CPC-I, PCS, RCC, executive director of Coding Affiliates Inc., an interventional coding service based in Mountain View, Calif. As a result, physicians can inject contrast at the common carotid artery and "render the interpretation of not only the common carotid bifurcation, specifying what is seen ([for example,] the common carotid bifurcation was clean and free of disease)," but also intracranial segments of the internal carotid artery, Midkiff explains.

The codes: For the unilateral common (cervical) carotid artery angiography, you should report 75676 (Angiography, carotid, cervical, unilateral, radiological supervision and interpretation), says Midkiff. You should apply 75665 (Angiography, carotid, cerebral, unilateral, radiological supervision and interpretation) for unilateral intracranial (cerebral) carotid artery angiography, she says.

Remember to verify that the physician's documentation for the scenario above supports reporting the cerebral code (based on what she performed and the recorded findings) in addition to the cervical code, says Jeff Fulkerson, BA, CPC, CIRCC, senior certified coder with Emory Healthcare in Atlanta.

In addition to imaging, you need to choose the proper catheter placement code. One important factor is whether the cardiologist worked in the left or right carotid arteries. In the scenario above, the cardiologist placed the catheter in the patient's right common carotid.

Impact: The right common carotid originates from the innominate artery which branches from the aorta. Therefore, from a femoral approach, the innominate is the first-order catheterization, and the right common carotid is a second-order catheterization. On the other hand, the patient's left common carotid originates from the aorta in a typical patient and is therefore a first-order catheterization. (See Figure 1.)

Because of these anatomical differences, the appropriate code for a right common carotid cath placement, as described in the above scenario, is second order code 36216 (Selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch, within a vascular family), says Midkiff.

On the other hand, for a left common carotid cath placement, you would report first-order code 36215 (...each first order thoracic or brachiocephalic branch, within a vascular family) for a patient with a normal anatomy,Midkiff says.

Payoff: If you correctly identify the need to code right carotid placement rather than left, you're in for somegood news. Medicare's national nonfacility rate for 36216 ($1,212) is $105 more than the rate for 36215 ($1,107), using a conversion factor of 36.0846. Or if you're coding a service performed in a facility, 36216 will earn you $32 more than 36215.

Depending on the documentation, the appropriate ICD-9 code for stenosis in the internal carotid alone is 433.1x (Occlusion and stenosis of precerebral arteries; carotid artery), says Fulkerson. You must add a fifth digit to the code, basing that digit on whether the physician documents cerebral infarction.

You'll choose from the following options:

• 0 --ithout mention of cerebral infarction
• 1 --  with cerebral infarction.

If the physician's dictation doesn't specifically state cerebral infarction is present, you should report 433.10, says Fulkerson. Inform your clinicians that being "as specific as possible in identifying the location of a stenosis, embolism, thrombosis, or occlusion" will aid you in selecting the proper code, such as choosing between 433.1x and 434.xx (Occlusion of cerebral arteries ...), Fulkerson adds.