Outpatient Facility Coding Alert

Published on Mon Jan 16, 2017 PDF

Question: The provider performed selective catheterization of the right internal carotid, with digital subtraction angiography of the right carotid system. Conscious sedation was administered by anesthesiology. How would you code for this scenario?

Mississippi Subscriber

Answer: For this procedure, you may report CPT^® 36224 (Selective catheter placement, internal carotid artery, unilateral, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed). Append modifier RT (Right side) to indicate the procedure was performed on the right side of the brain.

In 2017, you will need to report moderate sedation separately, using 99152 (Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes intra-service time, patient age 5 years or older) and add-on code +99153 (…each additional 15 minutes of intra-service time [List separately in addition to code for the primary service]) depending on the duration of the service.

Related Articles

Reader Question: Choose 43760 for Gastrostomy Tube Change

Patient Status: 3 Steps Show You When Facility's Overnight Patient Qualifies for Outpatient Coding

Reader Question: Sum the Surface Area of Those Wounds for Multiple Wounds