IINTERVENTIONAL RADIOLOGY – Vascular Procedures

 Interventional Radiology – Vascular Procedures

                Vascular procedure consist of two major parts Surgical and Radiological S&I

First part: Surgical codes

      1.       Vascular access

      2.       Catheter placement

      3.       Interventions Š

Second part: Radiological supervision and interpretation

     1.       Imaging (guidance and images taken)

     2.       Interpretation of films

     3.       Physician must supervise and interpret to assign S&I codes.


In case physician performs only the S&I part alone - Append Modifier -52


In Medical Coding - Five vascular systems for interventional procedures:

         1.       Arterial

         2.       Venous

         3.       Pulmonary

         4.       Portal

         5.       Lymphatic


Components of IVR

         1.       Catheter insertion point Š

         2.       Catheter end point Š

         3.       Vessels catheterized Š

         4.       Vessels visualized Š

         5.       Abnormal anatomy findings

Access Site       

      1     Where physician enters the vascular system by puncturing a vessel Š

      2     Multiple access sites and their catheterizations are reported separately

Vascular Family

     Network of vessels that arise from a single branch from the aorta or vena cava

        Š  First Order - Vessel that is a primary branch off the aorta or vena cava Š

          Second Order - Vessel branching from a first order vessel Š

          Third Order - Vessel branching from a second order vessel

Non-Selective Catheterization - The catheter or needle is placed directly into an artery or vein (and not moved or manipulated further) or is placed only into the aorta (thoracic and/or abdominal) from any approach.

Selective Catheterization - Movement of the catheter into the arterial or venous system beyond the aorta or vena cava

Catheterization Coding Rules Š

                Code each vascular family to the highest order selected. Š

                Each vascular access is coded separately. Š

                Additional vascular families catheterized are coded separately.

                Each family is coded separately when two or more vascular families are catheterized.


Additional Branches in Same Family

                Only 1 initial catheter placement code can be reported per vascular family. Š

                Catheter may be pulled back and advanced into a different branch within the same family. Š

                Code (36218 or 36248) (36012) for the lower of the two placements in addition to the highest catheter placement code in the family  36218 and 36248 may be assigned multiple times.


Supervision & Interpretation Coding Š

               Contrast is injected for imaging of vessels Both unilateral and bilateral codes Š

                Some codes specify selective imaging Š

               S&I codes are assigned for each vessel studied Š


Modifiers usage Š

               Do not use modifier 50 or RT/LT with Vascular catheterization codes.

               Use modifier 59 to indicate separate vascular families. Š

               For S&I codes – RT/LT or 59 when applicable

Catheter Placement - Aorta

      1.       When catheter placement in aorta and contrast flows into lower extremities – runoff

               Assign CPT = 36200 and 75630 Š

      2.       When catheter placement in abdominal aorta and catheter repositioned in lower aorta for a lower extremity study

               Assign CPT = 36200, 75625, 75716

Example: Š


       Access: Femoral Artery then catheter advanced to aorta, contrast injected with imaging. Catheter advanced to the right common iliac, contrast injected with imaging of the right lower extremity and right internal iliac.

   36245 (R C Iliac)

   75625 (Aortogram)

   75710 (RLE) Š

    Access: Femoral Artery then catheter selectively advanced to the bilateral internal iliacs and bilateral uterine arteries with contrast injection and imaging.

     36247 (RUA)

     36247-59 (LUA)

     75736-RT (R Iliac)

     75774 (RUA)

     75774 (LUA)

     75736-LT (L Iliac)

    Access: Right Common Femoral then catheter advanced to the aorta, injection performed for aortogram. Catheter advanced to the left renal with injection an imaging, then advanced to the right renal with injection and imaging. SMA is selectively catheterized with injection and imaging.

       36245 (L Renal)

       36245-59 (R Renal)

       36245-59 (SMA)

       75724 (bilateral renal)

       75726 (SMA)


     Access: Right Common Femoral then catheter advanced to the aorta, injection performed for aortogram. Catheter advanced to the celiac with injection and imaging, then advanced to the right hepatic with injection and imaging, then advanced to the left hepatic with injection and imaging.

       36247 (R hepatic)

       36248 (L hepatic)

       75726 (Celiac)

       75774 (R hepatic)

       75774 (L hepatic)


Therapeutic Interventions:

     1.       Angioplasty

     2.       Stents Š

     3.       Atherectomy Š

     4.       Embolization Š

     5.       Thrombolysis Š

     6.       Thrombectomy Š

     7.       Dialysis Graft Declotting


NOTE:

Diagnostic angiography codes should not be used with interventional procedures for:

  Contrast injections, angiography, road mapping, and/or fluoroscopic guidance for the intervention,    Vessel measurement, and post-angioplasty/stent angiography as this work is captured in the interventional radiologic supervision and interpretation code(s).


Stent Placement

          Angioplasty performed solely to deploy a stent is not separately coded.


Atherectomy

           Report one Atherectomy per vessel

           Do not report an angioplasty when a positioning balloon is utilized for Atherectomy.


Embolization

           Embolization code is assigned once per operative field.

INTERVENTIONAL RADIOLOGY - INTRODUCTION

INTERVENTIONAL  RADIOLOGY

INTRODUCTION:

1.  INTERVENTIONAL RADIOLOGY is a medical sub specialty of Radiology that uses minimally invasive image-guided procedures to diagnosis and treat diseases in nearly every organ system.

    Classified into Vascular procedures and non vascular procedures.   

CPT’s: TWO COMPONENTS

1  SURGICAL CODES – Describe the work of actually performing the intervention such as inserting catheters or needles, inflating balloons, deploying stents, etc.

2  RADIOLOGICAL S&I CODES - Describe the work of taking x rays, performing image guidance, and the processing and interpreting of the images. 

VASCULAR PROCEDURES –TYPES

1  NON SELECTIVE PROCEDURES

       When the catheter stays in the vessel entered or only advances to the aorta. 

2  SELECTIVE PROCEDURES

      When the catheter advances from the vessel entered or from the aorta into a branch vessel.

INCLUSIVE:

1  Regardless of the approach (arm/leg) once the aorta is entered and a branch is selected – a selective catheter placement code must be used and the non-selective catheter position is included.

2  If you had to go through a section of a vessel to get to a more selective vessel the catheter placement in the initial vessel is included in the higher order selection as well as non selective placement.

EG:  3^rd order includes 2^nd and 1^st order as well as non selective placement.

SAMPLE CHART

A catheter is placed in the right femoral artery, it is advanced to the abdominal aorta(36200) contrast is injected, and imaging of the abdominal aorta is performed(75625) the catheter is advanced into the left common iliac artery(36245) and images taken of the entire left lower extremity of the foot (75710). The catheter is then advanced into the left superficial femoral artery (36247) and additional images are obtained to further evaluate the Tibial vessels (75774)

  36247- (Left superficial femoral artery) (Final placement includes lesser first order selection 36245 and non-selective 36200)

  75625-(Abdominal aorta), 75710 (Unilateral extremity) 75774 (for the additional selective imaging of the Tibial vessels)   

2 access site:

A sheath and guidewire are placed in the right femoral artery (36140). The guidewire will not advance to the aorta. An injection of the right femoral artery through the sheath is performed showing occlusion of the right common iliac. Right leg runoff angio is then completed. The right side is abandoned and access is gained through the left femoral artery. The catheter is advanced into the abdominal aorta at the L2 level (36200). Contrast is injected, and imaging of the abdominal aorta is performed (75625). The catheter is pulled down to L4 and left leg runoff done (75716).

  36140-59(right sided access), 36200(left sided access)

  75625 (abdominal aorta), 75716(Bilateral runoff)

ADD ON CODES:

There are 2 codes that describe the coding of each additional second order, third order, and beyond selective catheter placement in the same vascular family. 36218 and 36248.

As vessels are get more selective each lower level is passed through is included in the final destination.

Some vessels can only be selected by pulling the catheter back and going a different route in the same vascular family.  This is where additional second or higher selective catheter position codes 36218 & 36248 apply. 

SAMPLE CHART:

A catheter is placed in the right femoral artery. It is advanced to the high abdominal aorta, and an aortogram is performed (36200, 75625). The catheter is advanced into the common hepatic artery for additional selective imaging (add 36246, 75774) the catheter is withdrawn from the common hepatic artery and placed in the splenic artery for additional selective imaging (36248, 75774).

  36246 (Common hepatic), 36248 (splenic)

  75726 (Celiac), 75774 (Common hepatic), 75774(splenic) 

                 

DO AND DON’T

  Do code to where the tip of the catheter is.

  Do code each individual vascular family separately with the same rules using- 59 modifiers as necessary.

  Do code each approach from a different access site separately.

  Do code the aorta placement (36200) instead of other non-selective codes if the aorta has been entered.   

  Do use code 36251-36254 for unilateral or bilateral selective or superselective renal angiography. These codes include catheter placements, renal S&I, accessory renal catheter placements and S&I, non-selective abdominal aortography, 3D reconstructions and pressure gradient if obtained.

  Do use codes 36222- 36228 for selective or superselective cervicocerebral angiography. These codes include catheter placements, cervical carotid, cerebral carotid, vertebral, intracranial and external carotid supervision and interpretation, as well as non-selective arch aortography.

  Do not code imaging codes for injecting small amounts of contrast to localize a vessel for subsequent selection.

  Do not code the access site separately once a catheter through the sheath has reached the aorta or selected another vessel.

2015 CPT Codes Change for Arthrocentesis, Aspiration and/or Injections

Arthrocentesis, Aspiration and/or Injections

Starting from Jan. 1, 2015, there are three new CPT codes to report Arthrocentesis, Aspiration and/or injection procedures when ultrasound guidance is used.

The new codes are (20604, 20606 & 20611):

1.      20604—Arthrocentesis, aspiration and/or injection, small joint or bursa (e.g., fingers, toes); with ultrasound guidance, with permanent recording and reporting.

                (Do not report 20600–20604 in conjunction with 76942)

2.      20606—Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting; and

                (Do not report 20605–20606 in conjunction with 76942)

3.      20611—Arthrocentesis, aspiration and/or injection, large joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting.     

               (Do not report 20610–20611 in conjunction with 76942) 

CPT code series 20600, 20605 & 20610 have not been deleted and are still applicable codes to use when an injection/aspiration has been performed.

CPT 20604 Procedure

The physician inserts a needle through the skin of a patient and into a small joint or bursa, E.g. the fingers or toes, and then uses the syringe attachment to the needle to remove fluid or he may inject a drug into the joint for therapeutic purpose.

The physician also uses ultrasound guidance with permanent recording and reporting to perform this service.

·         When the physician performs Arthrocentesis, aspiration and or injection of a small joint or bursa, without ultrasound guidance, use code 20600

CPT 20606 Procedure

The physician inserts a needle through the skin of a patient and into an intermediate joint or bursa, E.g. The wrist, elbow, ankle, temporomandibular & acromioclavicular Joints and then uses the syringe attachment to the needle to remove fluid or he may inject a drug into the joint for therapeutic purposes.  

The physician also uses ultrasound guidance with permanent recording and reporting to perform this service.

·         

      When the physician performs Arthrocentesis, aspiration and or injection of an intermediate joint or bursa, without ultrasound guidance, use cpt 20605

CPT 20611 Procedure

The physician inserts a needle through the skin of a patient and into a Large joint or bursa, E.g. The shoulder, Hip & Knee joints and then uses the syringe attachment to the needle to remove fluid or he may inject a drug into the joint for therapeutic purposes.  

The physician also uses ultrasound guidance with permanent recording and reporting to perform this service.

When the physician performs Arthrocentesis, aspiration and or injection of a large joint or bursa, without ultrasound guidance, use cpt 20610.