Cardiology Coding Alert

The next time your report reveals an aortogram on a patient with a bovine arch, you've got important decisions to make: Should you choose a second- or third-order catheter code? How will you determine which imaging code to use? When should you report a bovine arch ICD-9 code?

Our experts reveal the answers to all these questions and more in these three steps.

Scenario: Your cardiologist gains access from the right femoral artery and performs an ascending aortogram on a patient with a bovine arch. He places a catheter in the right common carotid with selective angiogram of the right common carotid and obtains intracerebral angiogram on the right side. Step 1: Report a Third-Order Code One school of thought defends coding a third-order catheter placement for this scenario.

Reason: In a patient with a bovine arch, the left common carotid rises from the innominate artery, so the left carotid is a second-order branch and the right carotid becomes a third-order branch, says Dawn Hopkins, senior manager for reimbursement with the Society of Interventional Radiologists (SIR).

How to code: Report 36217 (Selective catheter placement, arterial system; initial third-order or more selective thoracic or brachiocephalic branch, within a vascular family).

You should always choose your code based on accuracy, not payment. If your payer agrees that 36216 (... initial second-order thoracic or brachiocephalic branch, within a vascular family) and 36217 are equally accurate for this procedure, however, you should choose 36217. Why: The higher the vessel order, the higher the relative value units (RVUs), and consequently the higher the payment.

Remember: Your payer will have the final word on whether you may code this as second- or third-order catheter placement, says Deepa Malhotra, MS, CPC, president of Healthcare Education Resource (HERS Inc.) in Chicago.

Caution: Whenever you report a third-order code for a vessel that's normally second-order (including the left internal and left external arteries), be sure the cardiologist specifically documents the bovine arch or states that the left common carotid originates from the innominate.
 
This documentation proves to the payer why the physician could not take the normal route to the vessel, Malhotra says. Step 2: Develop Your Imaging Coding Although you may code only the highest level of catheterization, you may report any diagnostic imaging your cardiologist documents along the way, as long as the cardiologist does not perform it exclusively for guiding purposes. 

Example: You should report an ascending aorta study with 75650-26 (Angiography, cervicocerebral, catheter, including vessel origin, radiological supervision and interpretation; professional component) if it was diagnostic (in other words, you have a documented indication and the report reflects the findings of the diagnostic study).

But if the study was for guiding purposes (in other words, your cardiologist did this procedure to [...]