Cardiology Coding Alert

Banish Brachiocephalic Service Confusion With This Step-By-Step Approach

Your second- vs. third-order coding savvy protects your practice's bottom line.

Understanding catheter placement coding guidelines is an absolute must if you want your claims to be accurate and recoup all your deserved pay for these services.

Medicare's national facility price for CPT 36217 (third order) is roughly $55 more than for 36216 (second order). The non-facility prices have an even more impressive $762 difference.

But bringing in those hard-earned dollars means applying the rules to real cases, which is easier said than done.

Opportunity: Bone up on the rules in "Smart Start: Review These Brachiocephalic Coding Essentials" on page 75. Then hone your coding skills by analyzing the angiography report excerpt below, shared by Brenda Cole, CPC, of Dexios Corp. in Greenwood, S.C. Assume that you are reporting only the cardiologist's services.

Put on Your PV Hat to Code This Sample Case

Procedure: The right femoral artery is utilized for vascular access and a 5 French H1 catheter was introduced into the right vertebral, right internal carotid, and right external carotid arteries, and multiple injection runs performed. Images show no vascular abnormality associated with vertebral circulation or the external carotid artery circulation. On internal carotid artery injection there is a small dilated venous structure that corresponds to the abnormality seen on CT angiography performed on [date omitted]. This is in the medial cranial fossa on the right just medial to the tip of the temporal lobe. This fills in the normal mid venous phase and has the appearance of a small venous angioma. No other vascular anomalies are identified.

1: Identify the Access Point

Properly identifying the vascular access site is a common documentation trouble spot, notes interventional coding expert Sheldrian Leflore, BA, CPC, director of revenue management for Integrated Revenue Management of Carlsbad, Calif. The sample report aces this challenge by identifying the right femoral artery as the access site.

Three other areas that the physician needs to document carefully are the following, Leflore says:

1. Where the catheter terminated in each vessel

2. The catheter's location for injection procedures

3. The vessels targeted for angiography.

Benefit: If you know this information, you'll be able to distinguish reportable imaging from roadmapping, guiding shots, and other nonbillable services, Leflore says. We'll follow the example catheter's path and mark reportable services with "(--)." An "(X)" indicates you should not report a code for that spot.

2: Bypass Tempting 'On the Way' Cath Placement

In the sample report, after femoral access the next site where the cardiologist documents selective catheter placement is in the right vertebral artery.

(X) Brachiocephalic: Following the anatomy, that means he advanced the catheter from the femoral artery into the iliac artery, and then into the aorta and arch. From there he moves the catheter into the brachiocephalic (aka innominate) artery.

If the cardiologist had terminated the procedure in the brachiocephalic, you would report 36215 (Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family). He did not stop, however, so you should not report a code here.

(X) Subclavian: The cardiologist documented advancing the catheter from the brachiocephalic into the right subclavian.

If he had terminated the procedure here, you would report 36216 (... initial second order thoracic or brachiocephalic branch, within a vascular family).

(--) Right vertebral: Instead, though, the cardiologist documents moving into the right vertebral artery, performing an injection, and finding no vertebral circulation abnormalities in the imaging.

With the right vertebral, you have your first reportable codes. You should report the vertebral catheter placement with initial third-order code 36217 (... initial third order or more selective thoracic or brachiocephalic branch, within a vascular family), says Leflore.

(--) RS&I: The appropriate code for the vertebra imaging is 75685 (Angiography, vertebral, cervical, and/or intracranial, radiological supervision and interpretation), Leflore adds. Note that you should append modifier 26 (Professional component) to the imaging code to indicate that the cardiologist performed only the professional component of 75685.

3: Report Right Common Carotid? Wrong

The cardiologist next documents injection and imaging in the right internal carotid. To reach this artery, he must move the catheter back into the subclavian and then into the brachiocephalic.

(X) Right common carotid: From the brachiocephalic, he moves the catheter into the right common carotid. If he terminated the procedure here, you would report +36218 (... 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]) because the right common carotid is an additional second-order code in the same vascular family (brachiocephalic) as the right subclavian and vertebral arteries. The cardiologist did not stop in the common carotid, though.

(--) Internal carotid: He moved the catheter into the internal carotid and for the placement, you should report +36218, says Leflore. Here's why: You reported the right vertebral with an initial code (36217), so you need to report an "additional" code for the internal carotid. And +36218 is appropriate whether you're in an additional second- or third-order artery.

(--) RS&I: The appropriate imaging code for intracranial vascular imaging is 75665-26 (Angiography, carotid, cerebral, unilateral, RS&I).

4: End With Another +36218, But Check RS&I

Finally, the cardiologist discusses the right external carotid, describing a small venous structure. To reach the right external carotid artery, the cardiologist would pull the catheter from the right internal carotid, into the right common carotid, and then would advance into the right external carotid artery.

(--) Right external carotid: For the right external carotid catheter placement, you should again report +36218, Leflore says.

Follow your payer's preference for reporting the code twice on the same claim.

(--) RS&I: You have a specific code for external carotid circulation imaging: 75660-26 (Angiography, external carotid, unilateral, selective, RS&I).

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