Radiology Coding Alert

Interventional radiology cases are among the most difficult to code for three reasons:

multiple areas of anatomy are often involved,

lengthy dictation is typical to describe the numerous steps and techniques involved, and

multiple combinations of radiological supervision and interpretation (S & I) codes as well as surgical procedural codes are required.

So interventional coding trainer Gary Burns, MBA, RRA, has come up with a five-step approach that seems to cut through the confusion of coding these complex cases. This approach can be applied to almost any interventional radiology case, adds Burns, principal of Medical Asset Management, Inc., a national training and contract coding auditing firm in Atlanta. Here is Burns five-step method:

1. Catheter Access Points. Identify and note documentation of all the catheter access points.

Tip: If multiple access points are used, a code for each access point is appropriate.

2. Catheter End Points. Review documentation and identify all catheter end points. Remember you are looking for a description of the most selective vessel catheterized within each vascular family accessed. For example, if a catheter is placed in a first order vessel for angiography and then the second order vessel is selected, the second order (more selective) vessel is coded and not the first order vessel, even though an angiogram was performed at the first order site. Then appropriate supervision and interpretation codes may be used for each service performed.

3. Radiographic Exams. Next, code for all separately defined radiographic examinations (not views) with appropriate supervision and interpretation codes.

4. Supervision and Interpretation. Then, for each separate exam, code all appropriate instances of supervision and interpretation based on vessels visualized and interpreted.

5. Vascular Abnormalities. Finally, identify and code any vascular abnormalities (i.e., with ICD-9 Codes ).

With these five steps in mind, read the following note which describes a case of head and neck arterial angiography:

Case Description

The right groin was draped and prepped in the usual sterile fashion. Using a pigtail catheter, an initial digital arch injection was performed. The catheter was then exchanged for a Headhunter catheter followed by selective injection of the right common carotid, left common carotid, left vertebral artery, and right subclavian artery for visualization of the right vertebral.

The right common carotid injection demonstrates minimal plaque at the level of the carotid bulb extending into the internal carotid with an estimated cross-sectional stenosis of approximately 30 percent. There is antegrade flow filling the right external and internal carotid vessels. There is visualization of the right ophthalmic artery.

Left carotid injection demonstrates an area of mildly ulcerated atherosclerotic plaque along the posterior aspect of the bulb extending into the internal carotid with an estimated stenosis of 40 percent. There is normal antegrade flow filling the left external and internal carotid vessels.

The left vertebral artery was injected. There is an area of fairly short segment 99 percent stenosis of the high left vertebral approximately 1.5 cm before the origin of the left PICA. There is extremely sluggish antegrade flow within the distal left vertebral with extremely sluggish flow filling what appears to be the basilar artery with poor visualization of the basilar tip and posterior cerebral bifurcation.

The right subclavian artery was injected at the origin of the right vertebral demonstrating perhaps a 50 percent stenosis of the origin of the right vertebral. There is antegrade flow within the right vertebral vessel. I was unable to successfully catheterize the right vertebral artery, but right subclavian artery injection with an inflated blood pressure cuff was performed with intracranial filming. AP and lateral views demonstrate antegrade flow within the right vertebral to the level of the right PICA. There is no significant flow distal to the right PICA and no significant filling of the basilar artery from this injection. Reflux of the right common carotid is noted.

Case Conclusion: There is minimal bilateral atherosclerotic change involving the common carotid vessels greater on the left than right. There is an area of critical stenosis involving the distal left vertebral just proximal to the left PICA. There is extremely sluggish antegrade flow within the basilar with poor visualization of the basilar tip. The right vertebral artery was identified with no significant antegrade flow past the right PICA. Poor visualization of the basilar artery and basilar tip suggest the possibility of the basilar tip syndrome with clot within the basilar tip.

Coding Solutions

A. Surgical Coding. First, the coder should identify the catheter access position. The first sentence reveals the access point as the right groin (or right common femoral) puncture. This is important because once the catheter is moved selectively into vessels that branch off of the aorta, the head and neck vascular orders are determined (Step 1 of Burns five-step coding approach) as first, second, and third orders vessels.

Editors note: Steps 2 and 3 of Burns coding approach apply to the following section.

The catheter is then manipulated into the aortic arch with an injection procedure to visualize the head and neck vessel origins. The positioning of the catheter in the aortic arch is not surgically coded due to the fact the interventionalist next moves the catheter selectively into the head and neck vascular families. Catheter selectivity into the head and neck vessels reveals more than the nonselective catheter movement to the aorta.

Movement of the catheter into the aorta from the access site (right groin) is considered nonselective catheter placement. This case reveals catheter selectivity (movement of the catheter into a vascular family arising off of the aorta). Selective coding takes precedence over nonselective coding from the same access site. In this case we have selective catheter placement into the head and neck vessels. Thus, the nonselective catheter movement through the aortic arch is not coded separately.

The catheter is then selectively placed into the right common carotid artery (36216, second order vessel branching from the brachiocephalic) with an injection procedure. The catheter is then positioned within the left common carotid artery (36215, first order vessel that branches directly off of the aorta) with an injection procedure. The common carotid arteries are each surgically coded since they are classified as separate vascular families. Each vascular family selected is coded separately from the same access point. A vascular family in this case is defined as a grouping of vessels that arise from the aorta with a single branch that gives rise to secondary and tertiary branches. From the diagram you can identify three main vascular families that arise from the aorta.

Next, the catheter is placed within the left vertebral artery (36216, first order vessel that branches off of the left subclavian artery) with an injection procedure. And finally, the catheter is manipulated into the brachiocephalic artery with movement into the right subclavian artery (36218, additional second order vessel branching from the brachiocephalic) with an injection procedure to visualize the right vertebral artery.

Note: The right subclavian artery and the right common carotid artery are both second order vessels that arise off of the brachiocephalic artery. Applying the specific coding rules for additional second or third order vessel catheterizations within the same vascular family reveals a code of 36218 rather than an additional 36216 for the right subclavian artery.

In the brachiocephalic family the right common carotid and the right subclavian artery are coded to each catheter end position. However, as stated in Burns Step 3 we also code for each vessel selectively catheterized within a vascular family. Thus, the right common carotid was coded to 36216 and the right subclavian was coded with 36218 as an additional second order vessel catheterized.

The left common carotid, although only a first order vessel, is coded because it is a separate vascular family and it is the highest order vessel catheterized (36215) in the family. The left vertebral is coded to 36216 because it is a second order vessel and the highest order vessel catheterized within the left subclavian artery family.

Remember, the highest order vessels catheterized within a vascular family include the lesser order vessels catheterized, the movement of the catheter through the aorta, as well as the catheter access point. This is the reason in this case that we do not code the first order vessels of the right brachiocephalic artery and the left subclavian artery. The reimbursement amounts for the higher ordered vessels include payment and the work component for the lower order vessel catheterizations, the movement of the catheter through the aorta, and the vascular access. Thus, separate coding for these would be considered inaccurate and inappropriate.

B. Utilizing Modifiers. The modifiers for right (-RT), left (-LT), and -59 (separate and distinct service) should be used in this case. The common carotids are labeled -RT for the right common carotid and -LT for the left common carotid. This notifies the payer that separate vascular families were selectively catheterized and payment for each separate family is appropriate. The -59 is placed on the left vertebral artery so that payment will not be rejected as a duplicate to the right common carotid second order vessel. The additional selective second order right subclavian (36218) does not usually need a modifier since it is considered an add-on code in CPT.

Tip: Many payers establish their own modifiers. Contact your payers for guidance on modifier application to interventional radiology cases.

C. Supervision and Interpretation. Burns Step 4 codes supervision and interpretation (S&I) for all vessels visualized (from the 70000 section of the CPT manual). Visualization must include an interpretation in the report. The code narrative states Supervision of the procedure and Interpretation of the results visualized.

The first interpretation was performed at the aortic arch (75650). Note the injection performed in the first paragraph of the dictated report and the interpretation of the vessel origins in the second paragraph of the report. This documentation reflects an arch aortography visualization S&I procedure (75650). The aortic arch is specified as an angiography, cervicocerebral catheter with vessel origin study in the CPT manual.

Next, the physician documents the interpretation of the right common carotid artery as stenosis. Filming of the vessels intracranially to the right middle and anterior cerebral vessels is also documented. The interpretation of the right common carotid artery and right internal carotid are well documented. Thus, at this point we have S&I of the unilateral right common carotid (Carotid Cervical labeled in the CPT manual) and the unilateral right internal carotid (Carotid Cerebral labeled in the CPT manual). Coding should be avoided until it is determined if there is appropriate documentation for the left common carotid and left internal carotid visualization to determine if bilateral coding is appropriate.

There is documentation of vessel filling of the right external carotid. Aside from the fact that there is not adequate interpretation of the vessel documented in the report, the CPT manual narrative for unilateral and bilateral external carotid states selective. As we revealed the definition of surgical code selective above, the term selective in the narrative of the S&I codes establishes a rule that the external carotids can not be coded unless the catheter is selectively placed in the vessels with injection and interpretation.

It is also important to know if the vessel filling was intentional and medically necessary. If contrast happens to fill vessels that are not germane to the clinical question at hand, coding is neither ethical nor legal and becomes an issue of fraud and abuse. Furthermore, the S&I code for cervical angiography includes the interpretation of the vessels filled by injecting the common carotid arteries through the carotid syphons. Only if there is a full and complete intracranial carotid study (as in this case) is one entitled to additionally apply the intracranial S&I code(s). There is no such convention regarding the external carotid. Therefore, one is not entitled to code the S&I external carotid in this case even if it did happen to fill and even if the radiologist had provided an interpretation.

The internal carotid arteries are coded for two reasons. The first is adequate interpretation of the internal carotid vessels with the documentation on intracranial filling of middle cerebral and anterior cerebral arteries and subsequent venous phases. The second reason is that the CPT manual for the codes of the Internal Carotids (Carotid Cerebral, unilateral or bilateral) does not specify the terminology of selective. Thus, interpretation of the vessels intracranially is acceptable for accurate coding even with the catheter only being placed in the lower order vessel right and left common carotid provided that there is a full and complete description of the entire intracranial vascular system including the venous drainage. The reason that coding this examination is all right in this case is that intracranial disease is often seen or confused with atherosclerotic disease of the carotid bifurcations and the exam is therefore clinically indicated.

Remember Step 4 of Burns five-step coding approach: Coding all vessels visualizedthis rule applies unless the code narrative states selective as in this case.

The interpretation of the left common carotid with visualization of the intracranial vessels off of the left internal carotid artery is identified. Thus, we now have a bilateral common carotid angiography S&I (75680). And also, adequate interpretation for bilateral internal carotid angiography S&I (76671).

We then identify interpretation of the left vertebral artery documenting stenosis. The S&I is coded to 75685. The vertebral interpretation is assumed unilateral since there is not a specific code for unilateral and/or bilateral interpretations designated in the CPT manual. The interpretation of the visualization of the right vertebral artery from the catheter selectivity of the right subclavian is next. This is coded to another 75685. Interpretation of the right subclavian isnt coded because we do not have interpretation of the vessel anatomy nor has medical necessity or intent been reported.

D. Abnormal Vascular Anatomy. Finally, this case does not specify any abnormal vascular anatomy within the visualized or selectively catheterized vessels. Thus, Burns Step 5 does not have any influence on the final coding of this case.

The most commonly documented head and neck vascular anatomy is specified as a bovine arch where the left common carotid artery arises off of the brachiocephalic artery on the right. This is important since the vascular order of the left common carotid is a second order vessel when designated as a bovine arch.

Tip: Most payers request the -59 modifier on the second 75685 code submitted. No modifier is generally required on the first 75685 submitted on the claim form. Again, check with your payer.

E. Diagnoses. The final impressions are coded as critical stenosis at distal left vertebral and stenosis of the right vertebral artery (bilateral vertebral stenosis, 433.30, without mention of infarction). Although basilar tip syndrome (435.0) is noted, since it is labeled as possible it is not coded.

Note: The Interventional Radiology Coding Users Guide, 5th Edition, 1999 is now available from the Society for Cardiovascular and Interventional Radiology (SCVIR). For information call (888) 695-9733.

 

Coding Your Claim

   Item # CPT Code  Description

 1 36216-RT Selective cath placement second order,        right common carotid
 2 36215-LT Selective cath placement first order, 
     left common carotid
 3 36216-59 Selective cath placement second order, 
     left vertebral artery
 4 36218  Selective cath placement additional 
     second order, right subclavian
 5 75650  Angiography, cervicocerebral
 6 75680  Angiography, carotid, cervical, bilateral
 7 75671  Angiography, carotid, cerebral, bilateral
 8 75685-LT Angiography, vertebral, cervical, and/or 
     intracranial, left vertebral
 9 75685-RT Angiography, vertebral, cervical, and/or 
     intracranial, right vertebral