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Don't risk losing up to $315 that Medicare allots for PV studies You know you can't report nonselective catheter placement with selective placement from the same access site but which codes should you report if the physician inserts the catheter selectively in multiple vessels from the same access site? To code these selective vascular catheterization studies correctly you should determine whether the radiologist catheterized more than one vascular family during the procedure coding experts say. 1. Don't Bill for Catheter Exchanges Radiologists often perform a diagnostic study with the catheter in a selective location and then exchange the diagnostic catheter for an interventional one before treating the lesion. What to do: When the radiologist performs a catheter placement for a selective left renal artery study from a femoral access site you should report 36245 (Selective catheter placement arterial system; each first-order abdominal pelvic or lower-extremity artery branch within a vascular family) for the selective renal artery study. If the imaging shows a high-grade stenosis in the left renal artery and the physician decides to perform a percutaneous transluminal angioplasty (PTA) he should first remove the diagnostic catheter and completely advance an interventional catheter into the same location. But even though the physician advanced a second catheter into the same selective location you cannot report this access service separately. Instead you would report the angioplasty code (35471 Transluminal balloon angioplasty percutaneous; renal or visceral artery) to include the catheter placement and the transcatheter therapy. You would also report 75966 (Transluminal balloon angioplasty renal or other visceral artery radiological supervision and interpretation) for the imaging. "You would only bill one catheter placement unless there is more than one access site " says Roseanne R. Wholey president of Roseanne R. Wholey and Associates in Oakmont Pa. 2. Separate Families: Code Highest-Order Catheter If the physician selectively positions the catheter in two different vascular families (a network of arterial branches supplied by the same artery with a proximal connection to the aorta) such as the contralateral lower-extremity and the left renal artery you should code the highest-order selective catheterization in each vascular family separately. The Society of Interventional Radiology's 2003 Coding Guide confirms that within each vascular family "the highest-order catheterization is coded." This means that the highest-order catheter placement code includes all lesser-order catheter positions necessary to reach the target destination. And the procedure "will include all of the work involved puncturing the artery negotiating any anomaly or stenosis and advancing the catheter into the lumen of the target " the SIR guide states. Coding example 1: From a femoral puncture site the physician selectively places a catheter in both renal arteries. "These are two different vascular families and the first-order catheter code 36245 can be billed twice " Wholey says. "But since the procedure is bilateral you would use modifier -50 (Bilateral procedure)." Helpful hint: Check with your carrier for modifier guidelines. "Some carriers want 36245 listed once with modifier -50 while others want 36245 listed twice with modifier -59 (Distinct procedural service) or a modifier -50 on one of them " says Jim Collins CHCC CPC president of Compliant MD Inc. "Despite the standardized code set requirements established by HIPAA there is little consistency among payers in many areas." Some insurers prefer that you report 36245-LT (Left side) and 36245-RT (Right side). Coding example 2: The physician may need to puncture both femoral arteries. For instance on one side he places the catheter into the aorta for an aortogram but cannot advance the catheter over the aortic bifurcation. He punctures the other femoral artery and places the catheter in the popliteal artery. In this situation you can code both catheter placements Wholey says. You should report 36246 (Selective catheter placement arterial system; initial second-order abdominal pelvic or lower-extremity artery branch within a vascular family) for the ipsilateral second-order catheter placement in the popliteal and bill 36200 (Introduction of catheter aorta) for the catheter to the aorta she says. "This is one case where you can bill a nonselective cath placement as well as a selective one because there are two puncture sites." Be sure to add modifier -59 to 36200 says Rhonda Burge CPC coding and billing supervisor for Mid-Ohio Vascular Consultants in Columbus. "Otherwise 36200 will be bundled into 36246 " she says. 3. Same Family: Check Multiple Cath Positions The physician may place the catheter in two selective positions within the same vascular family. In some of these cases you can bill for multiple catheter placements depending on the final catheter positions. Coding example 1: From a right femoral access point the radiologist positions the catheter in the right subclavian artery performs imaging and then repositions the catheter in the right common carotid artery. Both of these vessels are branches of the brachiocephalic/innominate artery that arises at the aortic arch and they both represent second-order selective catheter positions. For the initial second-order catheter position above the diaphragm you should report 36216 (Selective catheter placement arterial system; initial second-order thoracic or brachiocephalic branch within a vascular family). Report the second catheter position with +36218 (...; additional second-order third-order and beyond thoracic or brachiocephalic branch within a vascular family [list in addition to code for initial second- or third-order vessel as appropriate]). Here's why: CPT indicates that you should report one of the selective catheter placement services with the regular code that indicates the initial/selective catheter placement (36215 36216 or 36217 for vascular families above the diaphragm; or 36245 36246 or 36247 for vascular families below the diaphragm). You should report 36218 or 36248 for the additional second- or third-order selective catheter placement depending on whether the vascular family arises above or below the diaphragm. Don't miss: The key to billing multiple catheter positions in the same vascular family is that the multiple positions cannot be along the same path Collins says. For such procedures the physician would have to retract the catheter tip proximally through the bifurcation/trifurcation and then advance the catheter down a different pathway so it is distal to the bifurcation/trifurcation he says. Coding example 2: The radiologist positions the catheter tip in the right vertebral and then in the brachiocephalic artery. Here's why: In this case you would report only one code (36217 Selective catheter placement arterial system; initial third-order or more selective thoracic or brachiocephalic branch within a vascular family) assuming a femoral puncture site. You would not need to report the additional vessel code (36218) because the physician navigated the brachiocephalic artery en route to the right vertebral. "
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