Cardiology Coding Alert

Question: When a peripheral angiogram of the legs is completed, should both 36245 and 36246 be billed?

A Texas cardiology practice

Answer: Usually 36245 (selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch within a vascular family) should not be coded together with 36246 (initial second order abdominal, pelvic, or lower extremity artery branch).
To code arterial procedures correctly, lets first review the difference between selective and nonselective catheter placements.

Selective catheter placements, which are indicated by codes 36245 to 36248, must be moved, manipulated, or guided into a part of the arterial system other than the aorta. Generally this procedure is done under fluoroscopic guidance. The procedure becomes more complicated as the cath goes through the increasingly smaller vessels of the first, second, and third orders. (Order is coding jargon for the clinical term branch: an offshoot or division of main portion of structure, especially that of a nerve, blood vessel or lymphatic. The third order is usually the finest in size and highest paid one.) Because selective catheter placement involves more work, the cardiologist is reimbursed at a higher rate than with a nonselective cath.

In contrast, nonselective catheter placement, which is indicated by 36100, 36120, 36140, 36160, 36200, means a cath or needle is placed directly into an artery and not moved or manipulated further.

A catheterization is also considered nonselective if the cath is negotiated only into the thoracic or abdominal aorta from any approach. This means that if the cardiologist manipulated the cath from the femoral into the aortic arch because the aortic arch is the final placement, the procedure would be billed as nonselective.

So, in order to code arterial procedures correctly, you have to know the puncture site and the final position of the catheter. For example, suppose the left femoral artery was punctured, then the catheter was threaded around the horn to the contralateral common iliac. If the cardiologist stopped there, you would code it as 36245, because it is a first order.

However, if the final catheter placement was the contralateral external iliac, or the second order, you would use the code 36246. You would not code for both 36245 and 36246 because, within each vascular family, only the highest order is coded.

Heres the exception. The only time the codes 36245 and 36246 should be billed together is if there are two different puncture sites or an additional vascular family is catheterized.