The left vertebral artery was selectively catheterized. Left vertebral angiogram demonstrates a small hypoplastic vessel on developmental basis, with relatively low flow into the basilar circulation. The right vertebral artery is the dominant vertebral artery. Right vertebral angiogram demonstrates a normal appearance of the right cervical vertebral artery. There is no stenosis or dissection. There is patent flow to the basilar artery. There is no aneurysm or vascular malformation. Basilar artery branches are all widely patent. There is no evidence of aneurysm, fistula, or vascular malformation.
- 36217 Right Internal Carotid
- 36218 Right External Carotid
- 36218 Right Vertebral
- 36215-59 Left Common Carotid
- 36216-59 Left Vertebral
- 75660 Right External Carotid (selective)
- 75671 Bilateral Internal Carotid Artery
- 75680 Bilateral Common Carotids
- 75685 RT Right Vertebral
- 75585 LT Left Vertebral
Explanation: Access was gained at the right common femoral artery (36140). The catheter was advanced through the aorta (36200) and into the brachiocephalic family where selective catheterization of the right external carotid, right internal carotid and right vertebral were catheterized.
Once the catheter is manipulated beyond the vessel punctured or beyond the aorta, the non selective codes will not be assigned (36140 and 36200) since selective catheterization has taken place. Remember, selective catheterization is always coded over non selective when both are performed from the same site of access. Once we achieve selective catheterization we drop codes 36140 and 36200.
In the brachiocephalic family, after the physician catheterized the right common carotid (2nd order vessel off the aorta) he advanced the catheter into the right internal carotid (3rd order vessel off the aorta) and then pulled the catheter back to select the right external carotid (3rd order vessel off the aorta), a separate branch of the brachiocephalic family. The physician pulled the catheter back again and then accessed the right vertebral (3rd order branch off the aorta) in another branch of the brachiocephalic family. Three branches of the brachiocepahlic family were catheterized resulting in three codes being assigned for this family.
Remember our coding rules which state to code each vascular family to the highest order of selectivity, therefore we do not assign codes 36215 and 36216 for vessels catheterized along the way to a third order vessel on the same pathway. The highest order of selectivity in the brachiocephalic family is third order, 36217. Note that three 3rd order vessels in separate branches were catheterized, therefore we assign 36217 for the first third order vessel in the family and code 36218 for both additional third order vessels in the same family.
The physician also catheterized a second vascular family, the left common carotid family, advancing the catheter into the left common carotid (1st order branch off the aorta). Code 36215 is assigned for the highest level of selectivity within this family. No other branches were catheterized.
The physician pulled the catheter back and advanced it into a third vascular family, the left subclavian family, advancing the catheter through the subclavian (1st order branch off the aorta) and then into the left vertebral artery (2nd order branch off the aorta). Code 36216 is assigned for the highest level of selectivity within this family. No other branches were catheterized.
Because we have assigned catheterization codes for multiple vascular families, we must append the 59 modifier to the lower order catheterizations indicating the codes are being reported for separate vessels. Catheterization codes: 36217, 36218, 36218, 36215-59, 36216-59.
RS&I Codes: Remember to assign the RS&I codes, the report must reflect documentation of contrast injection with imaging and interpretation. Also note that the codes for the external carotid note “selective” in the descriptor, therefore to assign the codes the documentation must state that the catheter was placed in the external carotid(s).
In the body of the report an interpretation is provided for both internal carotids (75671), both common carotids (75680), both vertebral arteries (75685-RT and 75685-LT) and right external carotid (75660).
Although an interpretation of both external carotids was provided, only the right external carotid was selectively catheterized, therefore we can code only for imaging of the right external carotid since the code descriptor specifies “selective”.
Also note that code 75685 does not specify unilateral or bilateral so the code may be assigned two times once with the RT modifier and once with the LT modifier.