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Procedure
Practice 11/15/98 - Coding
Recommendations
Feature
Article 11/15/98:
Coding
Interventional Radiology Procedures
Nonvascular
Interventional Procedures - Vascular
Interventional Procedures
Arterial System
- Venous System
- Pulmonary
System - Portal
System
Background
Education and skill-building are lifelong
pursuits for dedicated coders. As medicine and technology
advance, so must our coding skills. This month, we provide
an overview of the complexities of CPT coding for a rapidly
growing medical specialty, interventional radiology services.
In 1992, the American Medical Association
(AMA) and the Health Care Financing Administration (HCFA)
of the US Department of Health and Human Services officially
recognized interventional radiology as a separate medical
specialty. Today, with more than 4,000 interventional radiologists
in the United States, many coders regularly review operative
reports in conjunction with radiology reports to correctly
assign CPT codes for all components of the procedures performed.
Interventional radiology has been called
"the surgery of the 21st century." Under the guidance
of radiologic images, interventional radiologists insert catheters
and other tiny instruments through blood vessels and other
channels within the body to diagnose and treat a wide variety
of conditions percutaneously. Interventional procedures are
generally less costly and less traumatic to the patient, requiring
only tiny incisions and shorter hospital stays.
Prior to 1992, "complete codes" were used to capture
both the surgical and radiological components of interventional
procedures. In 1992, the AMA eliminated complete codes and
instituted a new system of "component coding." Component
coding enables identification of all interventional services
regardless of whether the provider is a surgeon or a radiologist.
The procedural portion of the service is assigned a code from
either the medical or surgical codes section, and the radiological
supervision and interpretation is assigned a code from the
70000 series. Accurate component coding demands that coders
expand their knowledge of surgical procedures to include the
techniques of interventional radiology.
Component coding also requires a detailed source document.
While a single report may contain all the procedural details,
often both an operative report and radiology report are needed
for a complete picture of the surgery and the radiology services
provided. Regardless of how the information is recorded in
the patient’s chart, coders must address each component
separately in order to code accurately. First decide what
codes are needed to correctly identify the surgery performed.
Then go on to select the correct codes for the radiology service.
It is important to remember that there may not be a one-to-one
relationship between the surgery and radiology codes. Thinking
about each component individually keeps the coding process
on track.
Biopsies
Tissue sampling for biopsy may be performed on many areas
of the body either percutaneously or endoscopically. Various
imaging techniques are used for guidance. To accurately code
these procedures, the coder selects the appropriate CPT code
to identify the anatomic site biopsied and then selects the
radiology code that identifies the imaging method (fluoroscopic,
ultrasound, or CT) used for guidance.
Example:
A surgeon performs a percutaneous liver biopsy under
CT guidance. The two codes assigned are 47000, Biopsy
of liver, needle; percutaneous, and 76360, Computerized
tomography guidance for needle biopsy, radiological supervision
and interpretation.
Abscess Drainage
An abscess can often be drained by inserting a catheter through
a small nick in the skin and guiding it to the abscess site.
Again, fluoroscopy, ultrasound, or CT may be used to guide
the catheter to the drainage site.
Example:
A patient presents with a left renal pelvis abscess.
The surgeon drains the site by first inserting a needle
percutaneously via translumbar approach and then advancing
the needle under fluoroscopic guidance into the abscess
to drain it. The codes assigned are 50021, Drainage
of renal abscess, percutaneous, and 75989, Radiological
guidance for percutaneous drainage of abscess ...
fluoroscopy, ultrasound, or CT …
Gastrostomy (Feeding) Tubes
Gastrostomy tubes are often placed percutaneously directly
into the stomach or small intestine if a patient is unable
to take sufficient food by mouth. In the procedure, a needle
with a suture attached is passed through the abdominal wall
into the stomach. The needle is snared and brought up and
out through the mouth. The gastrostomy tube it attached to
the suture and passed through the mouth into the stomach and
anchored to the abdominal wall with sutures. Imaging guidance
is sometimes used to verify correct tube placement.
Example:
The surgeon places a percutaneous gastrostomy tube under
fluoroscopic guidance. Placement of the gastrostomy tube
is coded 43750, Percutaneous placement of gastrostomy
tube, and the fluoroscopic guidance is coded 74350,
Percutaneous placement of gastrostomy tube ...
Hysterosonography
This test is a recently developed ultrasound procedure to
assess uterine pathology and tubal patency. Hysterosonography
is most commonly indicated in female infertility patients
and for dysfunctional uterine bleeding in postmenopausal women.
When a hysterosonogram is done, a catheter is advanced through
the cervical canal and into the endometrial cavity. A transvaginal
probe is then inserted and saline solution (or other contrast
agents) is slowly injected through the catheter under direct
ultrasound visualization. Multiple images of the endometrial
cavity and/or the fallopian tubes are obtained. Color Doppler
may be performed to evaluate fluid flow through the fallopian
tubes. If blockage of the fallopian tubes is present, another
catheter is threaded into the tubes to remove the blockage
and restore patency.
Example:
A patient with dysfunctional uterine bleeding undergoes
a hysterosonogram. The physician introduces saline into
the uterine cavity via a catheter and multiple images
of the uterine cavity are obtained. Fallopian tube study
is not done. The injection of saline into the uterine
cavity is coded 58340, Catheterization and introduction
of saline or contrast material for hysterosonography or
hysterosalpingography, and the radiological supervision
and interpretation of the images is coded 76831, Hysterosonography,
with or without color flow Doppler.
Arthrography
Arthrograms are performed to evaluate suspected joint pathology.
A small amount of contrast material is injected into the joint
to highlight its internal structures. This procedure offers
a minimally invasive approach to determine if internal joint
derangement is present. Arthrography is coded quite simply.
Procedure codes and radiology codes have a 1:1 relationship
if a single joint injection was done. For multiple injections
into the same joint, modifier -51 is appended to the injection
code, but because the radiology interpretation portion of
the procedure remains identical regardless of the number of
injections, only one 70000 series code is assigned.
Example:
A 25-gauge needle is inserted into the radionavicular
joint of the right wrist and several cc's of contrast
agent are injected into the joint. The wrist injection
is coded 25246, Injection procedure for wrist arthrography,
and the radiology portion of the exam is coded 73115,
Radiologic examination, wrist, arthrography ...
Biliary Duct Dilation and
Stent Insertion
The biliary duct system is similar to a tree with intrahepatic
bile ducts branching out of the liver to ultimately merge
with the cystic duct of the gallbladder to form the common
bile duct. Interventional management frequently requires nonsurgical
drainage of blocked ducts either via endoscopy or percutaneously.
Example:
In order to treat a stenotic common bile duct, the physician
performs a percutaneous biliary endoscopy and inserts
a stent into the common bile duct to dilate it. Fluoroscopic
guidance is used throughout the procedure. The endoscopy
with stent insertion is coded 47556, Biliary endoscopy,
intraoperative ... choledochoscopy; with dilation
of biliary duct stricture with stent. The radiology
supervision and interpretation portion of the procedure
is coded 74363, Percutaneous transhepatic dilatation
of biliary duct stricture with or without placement of
stent ...
Getting Started
Coding vascular interventional procedures is a complex process.
Coders need to be familiar with blood flow through all the
body's circulatory systems: arterial, venous, pulmonary, and
portal. Good reference materials are essential as the coder
"maps" his/her way through these vascular networks.
An illustrated vascular anatomy atlas is an invaluable reference
book for interventional coders. In addition, the following
guide, Interventional Radiology Coding Users' Guide,
published in 1994 by SCVIR, ACR, RBMA, and AHRA, 10201 Lee
Highway, Suite 160, Fairfax, VA 22030, is an excellent teaching
tool and reference for all types of interventional procedures.
All vascular procedures begin with the introduction of a
needle or catheter into a blood vessel followed by injection
of contrast dye. Diagnostic vascular procedures are important
tools for detection of thrombosis, hemorrhage, arteriovenous
malformations, aneurysms, tumors, and plaque formation. Therapeutic
vascular procedures used to treat vessel disease include embolization,
intraluminal stent placement, balloon angioplasty, thrombolytic
therapy, and vena cava filter placement. To understand the
basic process for coding vascular procedures, we need to look
at each of the four circulatory systems separately.
Arterial
System Coding Conventions
If we compare the arterial system to a tree with the aorta
as the trunk, we can see that primary branches extend off
the main trunk. They give rise to secondary branches, and
the secondary branches give rise to tertiary branches. In
the arterial system, catheterization of a primary branch is
called a first order catheterization; catheterization of a
secondary arterial branch is a second order catheterization;
and catheterization of a tertiary branch is a third order
catheterization. A vascular family is a group of arteries
that is fed by the same primary branch of the aorta or a primary
branch of the vessel punctured.
All vascular catheterizations are either nonselective or
selective. Nonselective placement means the needle or catheter
is placed directly into the vessel under study. The catheter
is not moved or manipulated to any other vessel. The only
exception to this rule is catheterization of the aorta. Aorta
catheterization is always considered nonselective regardless
of the puncture site. Selective placement means that the catheter
must be moved or guided into an artery other than the aorta
or the vessel punctured. In other words, the punctured vessel
is merely being used as a route to gain access to a selected
vessel. Selective procedures involve more work and effort
than nonselective procedures. Usually selective procedures
are done under fluoroscopic guidance.
To correctly code vascular interventional procedures, the
coder must know the puncture site and the final position of
the catheter. Within each vascular family, only the highest
order catheterization is coded. This code includes all the
work involved to access that artery. Lesser order branches
of the same vascular family are not coded separately. Always
use the code that describes the most selective catheter placement
performed via a single puncture site. All lower order placements
are considered incidental to the catheter’s final destination.
Careful identification of vessels catheterized during any
given study is important to ensure appropriate coding.
Examples:
The target for this examination is the left external
carotid artery. In our first example, the artery is accessed
via a femoral approach. The catheter is advanced into
the aorta and then guided into the left common carotid
artery and finally into the left external carotid artery.
Based upon the definitions just discussed, the catheterization
of the aorta is nonselective; however, catheterization
of the left common carotid is a first order selective
procedure, and catheterization of the left external carotid
is a second order selective procedure. Therefore, this
example is correctly coded as 36216, Selective catheter
placement, arterial system; initial second order thoracic
or brachiocephalic branch, within a vascular family;
and 75660, Angiography, external carotid, unilateral,
selective, radiological supervision and interpretation.
In our second example, the left external carotid artery
is accessed via direct puncture of the left common carotid
artery. Again referring back to the definitions in the
first two paragraphs above, the external carotid artery
is a primary branch of the punctured vessel. Therefore,
the code must reflect a first order catheterization. The
correct codes for this scenario are 36215, Selective
catheter placement, arterial system; each first order
thoracic or brachiocephalic branch, within a vascular
family, and 75660, Angiography, external carotid,
unilateral, selective, radiological supervision and interpretation.
If two different punctures were performed, i.e., two separate
vascular access sites were used, then each puncture is coded
separately.
Example:
The radiologist performs an abdominal aortogram via a
left femoral puncture. During the same procedure, a right
colic arteriogram is performed via a right femoral puncture.
The abdominal aortogram is a nonselective procedure and
is coded 36200, Introduction of catheter, aorta,
and 75625, Aortography, abdominal, by serialography,
radiological supervision and interpretation. The
right colic arteriogram is a second order selective catheterization
because the catheter must travel from the aorta to the
superior mesenteric and then to the right colic artery.
The codes for this procedure are 36246, Selective
catheter placement, arterial system; initial second order
abdominal, pelvic, or lower extremity artery branch, within
a vascular family, and 75726, Angiography, visceral,
selective or supraselective, with or without flush aortogram,
radiological supervision and interpretation.
If additional second and third order selective catheterizations
within the same vascular family were done from the same puncture
site during a single study, the additional branch catheterization
is described by one of the following codes:
- 36218, Selective catheter placement, arterial system,
additional second, third order, and beyond, thoracic or
brachiocephalic branch, within a vascular family (use
in addition to 36216 or 36217 as appropriate), and
- 36248, Selective catheter placement, arterial system,
additional second order, third order and beyond, abdominal,
pelvic, or lower extremity artery branch, within a vascular
family (use in addition to 36246 or 36247 as appropriate).
Example:
Via a femoral puncture, both the left external and left
internal carotid arteries are catheterized for study.
Following the course of the catheter, we see that from
the aorta the catheter is guided into the left common
carotid artery. Both the left external and left internal
carotid arteries branch off the left common carotid, so
they are in the same vascular family. Catheterization
of each of these arteries via a femoral approach is a
second order selective procedure. Assign 36216 for the
initial second order catheter placement and 36218 for
the additional second order catheterization.
Let’s return to the tree analogy and apply it to the
venous system. The trunk of the venous tree is the vena cava
(superior and inferior), with primary venous branches arising
from it, and secondary and tertiary venous branches arising
from them in turn. As in the arterial system, catheterization
of a primary branch of the vena cava is called a first order
catheterization; selective catheterization of a secondary
venous branch is a second order catheterization; and selective
catheterization of a tertiary branch is a third order catheterization.
A venous vascular family is a first order vein and all of
its secondary and tertiary branches.
Just as with arterial procedures, venous catheterizations
are either nonselective or selective. Direct puncture of peripheral
veins or of the vena cava is considered nonselective catheterization.
Placement of a catheter into either the inferior or superior
vena cava from any access route is also considered a nonselective
procedure. Selective placement means that the catheter must
be moved or guided into a vein other than the vena cava or
the vessel punctured. Codes for selective procedures include
all the work involved in guiding the catheter to the target
vessel.
Again, as with arterial procedures, determination of the
order of catheterization depends upon what vein was punctured
for access. Always use the code that describes the most selective
catheter placement performed via a single puncture site. Lower
order placements are considered incidental to the catheter’s
final destination.
Examples:
The targeted vessel for this study is the left internal
jugular vein. In our first procedure, the vein is accessed
via a femoral vein puncture. The catheter travels up the
vena cava (nonselective) to the left subclavian vein (first
order selective) and then into the internal jugular vein
(second order selective). Based upon our definitions,
this procedure is a second order selective venous catheterization
and is coded 36012, Selective catheter placement, venous
system; second order, or more selective branch ...,
and 75860, Venography, sinus or jugular, catheter,
radiological supervision and interpretation.
In our second example, the left internal jugular vein
is accessed via puncture of the subclavian vein. In this
case, the internal jugular is a primary branch of the
punctured vessel, so the code must reflect a first order
selective venous catheterization. The correct codes are
36011, Selective catheter placement, venous system;
first order branch, and 75860, Venography, sinus
or jugular, catheter, radiological supervision and interpretation.
When coding two or more second or third order venous catheterization
via the same puncture site, modifier -51 is needed to indicate
that multiple vessels were studied.
Example:
Via a left femoral approach, contrast venograms are performed
on the left adrenal and left ovarian veins. Both the adrenal
and ovarian veins are second order vessels that branch
off the left renal vein. The correct codes for this procedure
are 36012 and 36012-51, Selective catheter placement,
venous system; second order or more selective branch ...,
multiple second order vessels, and 75840, Venography,
adrenal, unilateral, selective, radiological supervision
and interpretation.
As with all other vascular catheterizations, the highest
order vessel catheterized is coded. The pulmonary circulation
system is comprised of only two vascular families, the right
and left pulmonary arteries.
Example:
Both right and left pulmonary arteries are catheterized
under fluoroscopic guidance via a femoral puncture. Code
36014-50, Selective catheter placement, left or right
pulmonary artery; bilateral, is assigned for the catheterization
of both arteries. Code 75743, Angiography, pulmonary,
bilateral, selective, radiological supervision and interpretation,
is assigned for the imaging portion of the procedure.
Segmental pulmonary artery catheterization is coded 36015,
Selective catheter placement, segmental or subsegmental pulmonary
artery, and 75741, Angiography, pulmonary, unilateral
selective, radiological supervision and interpretation.
Segmental catheterizations are higher order procedures than
either a right or left pulmonary artery catheterization; therefore,
lesser order catheterizations are not coded.
If separately definable services were performed within the
central venous system and the pulmonary system in the same
operative setting, each procedure is coded separately.
Example:
Via femoral puncture and under fluoroscopic guidance,
the physician performs an inferior vena cavagram and a
left pulmonary angiogram. Procedure codes assigned are
36010, Introduction of catheter, superior or inferior
vena cava, and 36014, Selective catheter placement,
left or right pulmonary artery. Radiology supervision
and interpretation codes are 75825, Venography, caval,
inferior, with serialography ..., and 75741, Angiography,
pulmonary, unilateral selective ...
Portal vein catheterization is the exception to the "code
only the highest order catheterization" rule. A single
code, 36481, Percutaneous portal vein catheterization
by any method, exists for nonselective portal vein catheterization.
This code describes placement in the portal vein from any
access site. Selective placement within the portal system
is coded in addition to the nonselective access code.
Example:
Under fluoroscopic guidance, the physician performs a
percutaneous portal vein catheterization and a pancreatic
vein hormonal sampling during the same operative session.
The portal vein catheterization is coded 36481, Percutaneous
portal vein catheterization by any method, and 75887,
Percutaneous transhepatic portography without hemodynamic
evaluation … The pancreatic vein sampling is
coded 36500, Venous catheterization for selective organ
blood sampling, and 75893, Venous sampling through
catheter, with or without angiography ...
Practice Makes Perfect!
Are you ready for some hands-on practice?
Read the patient report(s) on our procedure
practice page. Assign the appropriate codes and
then compare your answers with our coding
recommendations. Good luck!
Back to:
Top - Nonvascular
Interventional Procedures - Vascular
Interventional Procedures
Arterial System
- Venous System
- Pulmonary
System - Portal
System
If you have comments or suggestions about our code selections
or about any topic on our Coding Edge® pages, please e-mail
us at codingedge@lagunamedsys.com.
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