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CodeMap® 11/07/2008: Interventional Radiology Coding 3 CodeMap®-11/07/2008: Interventional Radiology Coding 3 Archive

CodeMap® Radiology Briefing: 11/07/2008


Editor's Welcome:

This CodeMap Radiology Briefing is the third installment in a four part series devoted to the procedure coding rules associated with interventional radiology. This week, we discuss the basic coding rules of angiography. The next CodeMap Radiology Briefing, scheduled for November 21, will conclude our series with the presentation of several case studies that apply all the coding rules and conventions previously discussed. We look forward to the final installment, and as always thank our radiology coding expert, Ms. Stacie Buck, for her contributions. If you have any questions, comments, or suggestions, please feel free to email either Stacie Buck or me.

Sincerely,

Gregory Root, Esq.


Diagnostic Angiography Coding Rules

by:  Stacie L. Buck, RHIA, CCS-P, LHRM, RCC, CIC
Vice President, Southeast Radiology Management
stacie@southeastrad.com

Introduction

As described by the editor, this CodeMap Radiology Briefing will focus on the basic coding rules for angiography. First, let's review the definitions of non-selective and selective catheterization as these definitions are still crucial in selecting the correct imaging codes for interventional procedures.

Nonselective catheter placement means the catheter is placed directly into an artery (or vein) and is not advanced further into a branch or is advanced only into the aorta (or vena cava) from any approach.

Selective catheter placement means that the catheter is advanced beyond the vessel punctured or beyond the aorta (or vena cava) into a vascular family. Selective catheterization involves first, second, and third order or higher degree vessels.

Radiological Supervision & Interpretation (RS&I) Coding

There are several radiological supervision and interpretation codes that describe imaging services performed via vessel catheterization. These codes are assigned when contrast is injected into a vessel and the radiologist provides an interpretation for the vessel imaged.

There are four main points to remember when assigning RS&I codes for diagnostic angiography:

  1. Several RS&I codes specify "unilateral" or "bilateral".
  2. Several RS&I codes have the term "selective" in the code descriptor. This means that the catheter must be placed in the vessel that is imaged and for which there is an interpretation.
  3. Some non-selective RS&I codes are "bundled" into some of the selective RS&I codes.
  4. There is not a 1:1 ratio of the imaging codes to the surgical codes assigned for a particular case. It is possible to have more than one imaging code assigned to a case and only one surgical code.

Let's take a look at some examples:


Example 1: Access is gained at the right common femoral artery. The physician advances the catheter to the aorta, injects contrast and provides an interpretation for an abdominal aortogram.

The following codes are reported:

  • 36200 Catheterization of the aorta.
  • 75625 Imaging and interpretation of the aorta.

The catheter was advanced to the aorta and was not manipulated any further (non-selective). Injection and imaging of the aorta was performed and an interpretation was provided by the radiologist.


Example 2: Access is gained at the right common femoral artery. The physician injects contrast at the distal end of the common femoral and provides an interpretation for an extremity angiogram.

The following codes are reported:

  • 36140 Catheterization of the femoral artery.
  • 75710 Imaging and interpretation of the right lower extremity.

The catheter remained in the common femoral after access was gained into the vessel (non-selective). Injection and imaging of the extremity was performed and an interpretation was provided by the radiologist.


Example 3: Access is gained at the right common femoral artery. The physician advances the catheter to the left common carotid for injection.  Imaging and interpretation of the left common carotid, left internal carotid, and left external carotid are performed via the LCC injection. Next he advances the catheter into the right common carotid for injection and imaging. Imaging and interpretation of the right common carotid, right internal carotid, and right external carotid are performed via the RCC injection.

The following codes are reported:

  • 36216 Catheterization of the right common carotid.
  • 36215-59 Catheterization of the left common carotid
  • 75671 Bilateral imaging of the cerebral (internal) carotids
  • 75680 Bilateral imaging of the common (cervical) carotids

Although the catheter was not placed in the internal carotids, we may assign code 75671 because the code descriptor does not specify "selective". We cannot assign code 75662 for imaging of the external carotids because the code descriptor states "selective". To assign code 75662 the catheter must be placed in the external carotids. If the physician had further manipulated the catheter into the external carotids and injected contrast for imaging of the external carotids, code 75662 would be appropriate.


Example 4: Access is gained at the right common femoral artery. The physician advances the catheter to the right internal iliac and injects contrast and provides an interpretation of images. Next, the catheter is advanced to the left internal iliac where contrast is injected and an interpretation of images is provided by the physician.

The following codes are reported:

  • 36245-59 Catheterization of the right internal iliac
  • 36246 Catheterization of the left internal iliac
  • 75736-RT Imaging of the left internal iliac (pelvis)
  • 75736-LT Imaging of the right internal iliac (pelvis)

Note that because the code for pelvic angiography, 75736, does not specify unilateral or bilateral, it may be assigned two times-one time for the left and one time for the right.


Example 5: Access is gained at the right common femoral artery. The physician advances the catheter to the left common carotid for injection and imaging. Next he advances the catheter into the left vertebral for injection and imaging, then to the right common carotid for injection and imaging, and finally the right vertebral for injection and imaging. An interpretation is provided for all vessels catheterized.

The following codes are reported:

  • 36218 Catheterization of the right common carotid
  • 36217 Catheterization of the right vertebral
  • 36216-59 Catheterization of the left vertebral
  • 36215-59 Catheterization of the left common carotid
  • 75680 Bilateral imaging of the common (cervical) carotids
  • 75685-RT Right vertebral  
  • 75685-LT Left vertebral  

Note there is not a 1:1 ratio of surgical codes to imaging codes. Also note that because the code for vertebral angiography, 75685, does not specify unilateral or bilateral, therefore it may be assigned two times-one time for the left and one time for the right.


Example 6: Access is gained at the right common femoral artery. The physician advances the catheter to the aorta, injects contrast and provides an interpretation for an abdominal aortogram. Next the physician advances the catheter to the superior mesenteric artery where he injects contrast for imaging and provides an interpretation.

The following codes are reported:

  • 36245 Catheterization of the superior mesenteric artery
  • 75726 Imaging of the superior mesenteric artery (visceral)

The catheterization of the aorta, 36200, (non-selective) is not coded because, the physician selectively catheterized the SMA. Remember that selective catheterization is always coded over non-selective from the same access. Code 75726 has "with or without flush aortogram", in the code descriptor, therefore we do not assign code 75625 for the abdominal aortogram. It is considered integral to code 75726.

In our next issue, we will put together all of our coding rules and apply them to some cases for diagnostic interventions for the head and neck.


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CodeMap Compliance Briefing: 10/14/05: Providing Regulatory Information to Customers
CodeMap Compliance Briefing: 10/07/05: Employee Screening
CodeMap Compliance Briefing: 9/29/05: Waived Testing
CodeMap Compliance Briefing: 09/23/05: Drafting Compliance Policies
09/16/2005 2006 Lab Codes and Proposed Payments
09/09/2005: LIS and Medical Necessity
08/19/2005: Lab Tests on the 2006 Physician Fee Schedule
08/05/2005 Coding Bone Marrow and Bone Biopsies
CodeMap Compliance Briefing 07/22/05: Coding Antibody and Antigen Assays II
07/08/2005 Coding Antibody and Antigen Assays: I
06/24/2005 Resubmitting Denied Medicare Claims
06/17/2005 Diagnosis Coding Rules-Part 2
05/20/05 Diagnosis Coding Rules Part 1
05/13/2005 Reflex Manual WBC Differentials
05/06/2005 Incident To Services
04/29/2005 CMS Manuals
04/22/2005 Reflex Testing
04/15/2005 Custom Panels
04/08/2005 Medicare Administrative Contractors (MACs)
04/01/2005 Place of Service (POS) Codes
03/18/2005 Subscriber Questions
03/11/2005 Medically Unbelieveable Edits
03/04/2005: Final Hospital Compliance Guidance 4
02/25/2005: Final Hospital Compliance Guidance 3
02/18/2005 Final Hospital Compliance Guidance 2
02/11/2005 Final Hospital Compliance Guidance
02/04/2005 Final Diabetes Screening Rules
01/28/2005 Medicare Appeals II
01/21/2005: Medicare Appeals I
01/14/2005 Providing Services to SNFs
01/07/2005 Medicare Errors
12/17/2004 Year End Subscriber Questions
12/10/2004 Coding Flow Cytometry Services
12/08/2004 Alert: 2005 CodeMap Manual Production Schedule
12/03/2004 Diabetes Screening Tests
11/22/2004 Announcing CodeMap Data Files
11/19/2004 Flow Cytometry Coding and Reimbursement
11/12/2004 New Venipuncture Rules
11/05/2004 Medicare Cardiovascular Screening Benefits
10/29/2004 Subscriber Questions
10/22/2004 Genetic Testing Modifiers
10/15/2004 Coding Glucose Tests
10/08/2004 Shared Laboratories
10/01/2004 Stark II and POLs
09/24/2004 New CPT Codes for Pathology Services
09/17/2004 New CPT Codes for Lab Services
08/27/2004 SNF Consolidated Billing Exceptions
08/20/2004 The OIG Exclusion Program
08/13/2004 Medicare Initial Preventive Physical Exam
08/06/2004 New Medicare Coverage for Screening Tests
07/30/2004 Discounts to Financially Needy Patients
07/23/2004 Date of Service for Lab Tests
07/16/2004 New CPT Codes for 2005
06/25/2004 Updates to NCDs and LMRPs
06/18/2004 New Compliance Program Guidance for Hospitals II
06/11/2004 New Compliance Program Guidance for Hospitals II
06/04/2004 Annual Physician Notices
05/21/2004 Screening Pap Smear Coverge
05/14/2004 Transfusion Medicine Codes II
05/07/2004 Transfusion Medicine Codes I
04/23/2004 Anti-Mark-Up Controversy
04/16/2004 Subscriber Questions
04/09/2004 Genetic Testing Codes II
04/02/2004 Genetic Testing Codes I
03/26/2004 Laboratory Marketing Practices III
03/19/2004 Laboratory Marketing Practices II
03/12/2004 Laboratory Marketing Practices I
03/05/2004 Medicare Payment for CLIA Waived Tests
02/27/2004 Medicare Payment for ReferredTests
02/20/2004 Grace Period for CPT Codes Eliminated
02/14/2004 CCI Edits Associated with New Lab and Pathology Codes
02/06/2004 CCI Edits Associated with New Radiology Codes
01/30/2004 Venipunctures
01/23/2004 The Medicare Prescription Drug, Improvement, and Modernization Act of 2003
01/16/2004 Travel Allowances
12/19/2003 Medicare Modernization Act
12/12/2003 Medicare Reform Bill Part 2
12/05/2003 Medicare Reform Bill Part 1
11/21/2003 New HCPCS Codes for CBCs without Platelets
11/07/2003 GA, GY and GZ Modifiers
10/31/2003 Specimen Collection
10/24/2003 Coding Qualitative Drugs-of-Abuse Tests
10/17/2003 The OIG's Work Plan, Medicare CDs, Recent Enforcement Actions.
10/10/2003 ESRD Composite Rate Lab Tests
10/03/2003 End Stage Renal Disease (ESRD) Reimbursement for Automated Tests
09/26/2003 Proposed Rules from the OIG
09/12/2003 Category III (Tracking) CPT Codes
09/05/2003 New Proposed Rules for Flow Cytometry
08/15/2003 Thyroid Testing
08/01/2003 CMS Lab Reimbursement Meeting
07/25/2003 NCD Misconceptions
07/18/2003 The -GZ Modifier
07/11/2003 Screening Mammogram Codes
06/27/2003 Correct Coding Edits II
06/20/2003 Correct Coding Edits I
06/13/2003 Diagnosis Coding Rules II
06/06/2003 Diagnosis Coding Rules I
05/23/2003 Revised Medicare Appeals Provisions II
05/16/2003 Revised Medicare Appeals Provisions I
05/09/2003 Business Associates Agreements
05/02/2003 Pathologist Interpretation of Clinical Lab Tests
04/25/2003 TC Billing of Pathology Services
04/18/2003 Medicare Reimbursement for Pathology Services
04/11/2003 How to Respond to a Search Warrant
03/28/2003 How to Respond to Subpoenas
03/21/2003 How to Respond to Investigators
03/14/2003 Mandatory Claim Submission
03/07/2003: Who Can Order Diagnostic Tests?
02/28/2003 Changes in 2003 Physician Fee Schedule
02/21/2003 Medical Necessity Requirements for Chemistry Panels, Part II
02/14/2003 Medical Necessity Requirements for Chemistry Panels I
02/07/2003: ABNs and Client Cooperation
01/31/2003: Patient Ordered and/or Performed Testing
01/24/2003: The Beneficiary Anti-Kickback Statute
01/17/2003: Significant Changes in 2003 Medicare Reimbursement
01/10/2003: 2003 Medicare Lab and Physician Fee Schedules
12/13/2002: More National Coverage Policies
12/06/2002: How Medicare Sets Fees for New CPT Codes
11/22/2002: Critical Year End Dates
11/15/2002: 2003 Medicare Laboratory Fee Schedule
11/08/2002: Stark Self-Referral Prohibitions
11/01/2002: Using Modifiers -59 and -91
10/25/2002: Introduction to Privacy Regulations
10/18/2002: New Codes for Obstetrical Ultrasound
10/11/2002: National Coverage Determinations (NCDs)
10/04/2002: Implementing a Radiology Compliance Program
09/27/2002: New 2003 Lab CPT Codes
09/20/2002: Automated Order Entry
09/13/2002: National Coverage Policy for Lipids
09/06/2002: The Anti-Kickback Statute
08/23/2002: Using the New ABN Forms
08/16/2002: Advance Beneficiary Notices
08/09/2002: Medicare Coverage for PET Scans
08/02/2002: Reflex Testing
07/26/2002: 2003 Hematology CPT Code Changes II
07/19/2002: 2003 Hematology CPT Code Changes I
07/12/2002: Direct Billing Rules II
06/28/2002: Direct Billing Rules I
06/21/2002: Medicare Reimbursement for Lipid Panels
06/14/2002: Bone Density Studies
06/07/2002: CLIA Waived Testing Rules
05/31/2002: Blood Draws and the Anti-kickback Statute
National Coverage Determination (NCD) Updates
05/01/2002 - CodeMap® Quarterly Reports, Volume I, No. 2
01/15/2002 - CodeMap® Quarterly Reports, Volume I, No. 1