August 11, 2008
A Vascular RoadMmap — Organizing Arterial VIR Information for a Successful Coding Trip
By Donna J. Richmond, RCC, CPC, PCS
Vol. 9 No. 16 P. 32
Coding for most vascular interventional radiology (VIR) procedures starts with the catheterization code (or codes), but choosing those codes can be extremely confusing for a novice coder. The interventionalist must document both where he or she started the procedure and where he or she stopped along the way. The coder is left to interpret the documentation and choose the correct code. The first step is to decide whether the catheterization is nonselective or selective.
A common example of nonselective arterial catheterization is an aortogram. From any access point, the catheter is moved into the aorta and then removed the same way, without entering into any other arteries. The catheter can be moved up and down within the aorta, stopping one or more times to take images. It can be moved to the ostium (opening) of one of the visceral arteries. As long as it does not go into the artery, it is considered nonselective.
The most common code for this is 36200, Introduction of catheter, aorta. This code is used if the catheter started in one of the extremity arteries before being moved to the aorta. A less commonly used code is 36160, Introduction of needle or intracatheter, aortic, translumbar. This access was almost extinct but is coming back due to the increasing number of aortic stent grafts being performed. It is used to view the aneurysm sac outside a stent graft.
Other arterial nonselective codes include the following:
• 36100, Introduction of needle or intracatheter, carotid or vertebral artery, is access by a direct stick into a carotid or vertebral artery.
• 36120, Introduction of needle or intracatheter; retrograde brachial artery, is access into the brachial artery. In this case, the brachial, axial, subclavian, and innominate arteries are treated as one vessel. As long as the catheter does not leave one of those, it is considered nonselective.
• 36140, Introduction of needle or intracatheter; extremity artery, is access into any other extremity artery. In the lower extremity, this is usually accomplished by groin puncture. As long as the catheter stays in the common and/or external iliac, it is considered nonselective.
For selective catheterization, the coder must determine how many vascular families were involved. Vascular families are defined by the vessels that arise directly off the aorta or vessel punctured. For instance, the innominate defines one particular vascular family. Within that family, you’ll find the right common carotid, the right subclavian, the right vertebral, and all other arteries that branch off of those, including all the arteries of the right arm.
Once the catheter is moved beyond the accessed vessel without going into the aorta or into the aorta and moved further, the catheterization is considered selective. The catheter must move into a vessel and not just the ostium. Think of it as going into a room—not just standing in the doorway but actually entering the space. Selective arterial catheterization codes include the following:
• 36215, 36216, and 36217 for arteries above the diaphragm;
• 36245, 36246, and 36247 for arteries below the diaphragm; and
• second and additional catheterizations in a given family are coded with 36218 and 36248 because the first, second, and third order codes can only be used once within any one vascular family.
Selective catheterization codes are determined by how far they are from the aorta or the vessel catheterized. First-order catheterization codes 36215 and 36245 are used when the catheter only goes into an artery that comes directly off the aorta or vessel catheterized. Think of it as a road trip—you turn off Main Street (the aorta) onto First Avenue (the first-order vessel) and park. The most common first-order vessels above the diaphragm are the innominate, also called the brachiocephalic, left common carotid, and subclavian arteries. Below the diaphragm, the most common are the left and right renal, celiac, superior and inferior mesenteric arteries, and the left and right common iliac arteries.
Remember that road trip? Say you get back into the car and continue down First Avenue until you turn right onto Second Street, where you park again. Vessels that arise off of first-order vessels are second-order vessels. To get to these vessels, you must go through two others—the aorta, or vessel punctured, and the first-order vessel.
Above the diaphragm, second-order codes 36216 and 36246 are coded most often for catheterization of the right subclavian or right common carotid (from the innominate), left internal carotid (from the left common carotid), and left vertebral arteries (from the left subclavian). In the abdominal area, commonly selected second-order vessels include the splenic, the left gastric, and the common hepatic from the celiac and the external and internal iliac arteries in the lower extremities.
If you didn’t find what you were looking for on Second Street, you’d keep going on up to Third Street, or the third order, a higher catheterization using codes 36217 and 36247. These codes are used when the catheter is moved from the aorta or initial access point, through a first-order vessel, into a second-order vessel, and beyond. Common third-order vessels are the right vertebral (through the aorta, right subclavian) and right internal carotid (aorta, right common carotid). From the celiac, the gastroduodenal, the proper hepatic, and the right and left hepatic arteries are all third order or beyond. The superficial femoral, popliteal, and tibioperoneal arteries are all commonly selected third order or beyond in the lower extremities.
If, for your trip, you went straight from Main Street to First Avenue to Second Street to Third Street. In VIR coding, this would be considered one vascular family, and you would code only the end placement of the catheter, the third order. You can code for imaging done along the way but only for the farthest catheterization.
But say that you turn around on Third Street and head back to Second Street, where you turn onto Broadway. You couldn’t go straight from Third Street to Broadway because you had to backtrack. From a coding standpoint, this stop would be an additional selection in a vascular family—36218 or 36248. The most common use of 36218 is when both the right vertebral and right common carotid arteries are selected. They are both in the innominate vascular family: The right vertebral is third order coded with 36217, and the right common carotid is second order and must be coded with 36218.
On any road trip, the traveler should be cognizant of possible detours or changes. The same applies to VIR coding. Coders should be aware of how vascular anomalies can change coding. For instance, a patient’s left common carotid artery occasionally arises from the innominate artery instead of the aorta. This would make the left common carotid a second-order vessel in the innominate family. The right subclavian and the right common carotid then become third-order vessels rather than second order.
It’s worth noting that the arteries mentioned in this article are the ones most commonly seen in angiograms, but they aren’t the only ones that can be selected and imaged. Fortunately, many companies offer color-coordinated diagrams to help choose the order of a vessel. In addition, many medical dictionaries include charts in the appendices that give artery names, origins, and distributions. These can help when the radiologist selects a vessel that is less commonly used.
— Donna J. Richmond, RCC, CPC, PCS, is the coding services supervisor for CodeRyte, Inc.