Super tips for Interventinal coding Upper extremity catherization 36221-36228

Interventinal coding Upper extremity catherization 36221-36228
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Interventional Coding: +36227 and +36228 Primer Puts You on the Path to Clean Carotid Claims
Ace add-on coding with this guide to 2 new selective catheter codes.
Taking in all of the CPT 2013 changes for cervicocerebral angiography is no easy task, but the two add-on codes have raised questions in particular. Avoid mix-ups with a breakdown of when to use the codes, what’s included, and tactics for proper use.




+36227 Is the Go-To Code for ECA
The code: The first add-on code in the range is +36227 (Selective catheter placement, external carotid artery, unilateral, with angiography of the ipsilateral external carotid circulation and all associated radiological supervision and interpretation [List separately in addition to code for primary procedure]).
When to use +36227: Code +36227 represents catheter placement and diagnostic imaging of external carotid circulation on one side of the body. You should use +36227 only when the service is performed at the same session as one of the following angiography services (bold added):
·         36222, Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral extracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed
·         36223, Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed
·         36224, Selective catheter placement, internal carotid artery, unilateral, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed.
What’s included: Code +36227 represents accessing the external carotid artery (ECA), catheter placements, contrast injections, fluoroscopy, and radiological supervision and interpretation, including imaging in multiple projections. These tips are really important for Certification exams like CPC, you can go through sample CPC questions here which is surely help in clearing CPC exam.

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Symposium takeaways:
The designated primary codes for +36227 are carotid codes 36222-36224, which makes sense if you consider the anatomy. Code +36227 requires selection of the ECA, which "is always selected after the common carotid artery is selected," explained Sean P. Roddy, MD, FACS, of the Society for Vascular Surgery and an AMA CPT Advisory Committee member in the presentation "Vascular Surgery and Interventional Radiology" at the AMA’s CPT and RBRVS 2013 Annual Symposium.
Further catheter selection, meaning higher order catheterizations, are included in +36227, so you should not code them separately, Roddy explained.
+36227 example: The physician images the intracranial carotid from the internal carotid (36224) and then advances the catheter to the external carotid and images that vessel (+36227).
+36228 Is for Additional Intracranial Branches
The code: The next add-on code to review is +36228 (Selective catheter placement, each intracranial branch of the internal carotid or vertebral arteries, unilateral, with angiography of the selected vessel circulation and all associated radiological supervision and interpretation [e.g., middle cerebral artery, posterior inferior cerebellar artery] [List separately in addition to code for primary procedure]).
When to use +36228: Code +36228 represents catheter placement and diagnostic imaging of initial and additional intracranial branches of the internal carotid and vertebral arteries on one side of the body. You should use +36228 only when the service is performed at the same session as one of the following services (bold added):
36224, Selective catheter placement, internal carotid artery, unilateral, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed
36226, Selective catheter placement, vertebral artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed.
What’s included: Code +36228 represents accessing the designated intracranial branches, catheter placements, contrast injections, fluoroscopy, and radiological supervision and interpretation, including imaging in multiple projections. CPT guidelines instruct that additional selective catheter placement is included if it’s in "the same primary branch of the internal carotid, vertebral, or basilar artery."
Symposium takeaways: From the previous paragraph, you know that +36228 includes further selection of the same primary branch. But if the physician selects a separate branch off of the internal carotid or vertebral, you may report +36228 more than once for the same session. In fact, you may report +36228 up to twice per side for a maximum of four times per encounter, Roddy stated.
Example: The physician places the catheter in the right vertebral artery to image the vertebral circulation (36226). He then moves the catheter to the right posterior inferior cerebellar for imaging and to the anterior spinal artery for imaging (+36228 x 2).
Don’t Overlook Additional Guidelines
Although codes +36227 and +36228 relate to imaging of different vessels, there are some rules that apply to both codes.
Work on 2 sides: You may report services performed on opposite sides of the head separately. If the same services are performed on both sides, append modifier 50 (Bilateral procedure). But if separate territories are imaged on each side, then you should append modifier 59 (Distinct procedural service).
No +75774: Don’t report +75774 (Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation [List separately in addition to code for primary procedure]) to indicate additional diagnostic angiography of the extracranial and intracranial cervicocerebral vessels. Further selection is included in the carotid codes.
3D rendering: You may report 3D rendering separately using 76376-76377 (3D rendering with interpretation and reporting …).
US guidance: Ultrasound guidance for vascular access is separately reportable using +76937 (Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting [List separately in addition to code for primary procedure]).
But remember that +76937 is not appropriate for US guidance to mark a vessel for access. The physician must meet the code definition’s requirements to capture this service.
Modifier 51: Both codes are modifier 51 (Multiple procedures) exempt, meaning that you don’t need to append this modifier to the codes.

Reader Question: 36222 Offers Extracranial Option
Question: When I would code for a bilateral carotid angiogram in 2012, I would use 36215-59, 36216, and 75680-26. Now in 2013 I am not sure if am supposed to use 36223 or 36222. The difference is "intracranial" and "extracranial."

SuperCoder.com Member
Answer: Because you mention deleted cervical carotid angiography code 75680 (Angiography, carotid, cervical, bilateral, radiological supervision and interpretation), check your 2013 documentation against extracranial code 36222 (Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral extracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed).
Cervical carotid arteries may be referred to as extracranial, and cerebral carotid arteries may be called intracranial.

Tip: Carefully review the references to both intracranial and extracranial in 36223 (Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed).
Code 36223 applies when documentation shows intracranial carotid angiography alone or shows both intracranial and extracranial carotid angiography. You should not additionally report 36222. Cervicocerebral arch angiography is also included in 36222 and 36223 when performed with the carotid angiography services.
Bilateral: Also be sure to use modifiers to indicate the bilateral nature of the service. CPT says to use modifier 50 (Bilateral procedure) if the same procedure is performed on both sides, and use modifier 59 (Distinct procedural service) if the services on each side are different. Payers may have their own preference, such as LT (Left side) and RT (Right side).
Snag: The original 2013 Medicare Physician Fee Schedule (MPFS) gave unilateral codes 36222-+36228 a bilateral indicator of "0," which meant Medicare would not pay extra for a bilateral service. The April fee schedule update revises the bilateral indicators for these codes, allowing 150 percent payment for bilateral services. The change is retroactive to Jan. 1, 2013, so check that all of your 2013 bilateral claims have been paid correctly. Review the update in CMS Transmittal 2663, CR 8169.
CPT 2013: 36221 to +36228 Shake Up Carotid and Vertebral Angiography in the New Year
Heed the hierarchy, or denials are guaranteed.
One of the biggest coding changes radiology practices will face in 2013 is a new series of codes specific to cervicocerebral angiography.
Anatomically, these codes relate to vessels in the neck and head.

2012 comparison: The new codes each include angiography and radiological supervision and interpretation (RS&I). This is a significant shift from 2012 coding, which required separate codes for catheter placement and RS&I, Fletcher notes.
Because of this change, CPT 2013 will delete angiography codes 75650 and 75660-75685 for the carotid, cerebral, vertebral, and cervical arteries, says Julie Graham, BA, CPC, coder and compliance specialist for Concentra in Texas.
What's included: Codes 36221-36226, which are primary rather than add-on codes, include vessel access, catheter placement, any contrast injections, fluoroscopy, RS&I, and arterial closure by pressure or device. If the physician performs any arterial, capillary, or venous phase imaging, you shouldn't report that separately. That imaging is included in each of the new codes (36221-+36228). Below you'll find details to help you choose among the different possibilities.
36221: Know the Non-Selective Option
The first new code is specific to non-selective catheter placement:
·         36221, Non-selective catheter placement, thoracic aorta, with angiography of the extracranial carotid, vertebral, and/or intracranial vessels, unilateral or bilateral, and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed.
Code 36221 applies only when the catheter goes as far as the thoracic aorta and no farther. Imaging of the aortic arch and origin of the great vessels is also included in this code, CPT guidelines state.
Note that 36221 is the only code that specifies "unilateral or bilateral." All of the others are unilateral. This makes sense because imaging from the thoracic aorta allows visualization of both sides from that single catheter position. In contrast, the other codes require selective placement of the catheter in either a right-side or left-side vessel.
36222-36224: Choose the Most Comprehensive Service
The first three selective codes in the new range are 36222-36224. To select the proper code, you must watch for where the catheter terminates (common carotid, innominate, internal carotid) and which vessels are imaged (extracranial carotid, intracranial carotid). Imaging of the cervicocerebral arch will not change your coding because all of the codes include that service when performed, says Graham.
·         36222, Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral extracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed
·         36223, Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed
·         36224, Selective catheter placement, internal carotid artery, unilateral, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed.
Guidelines instruct that these codes are hierarchical, so you may report only one code from 36222-36224 for each same-side carotid territory. In other words, if the physician places the catheter in the left common carotid and images the extracranial circulation and then places the catheter in the left internal carotid and images the intracranial circulation, you should report only 36224. You should not report 36222, as well. Code 36224 represents the most selective catheter placement and all of the angiography services performed.

36225-36226: Catheter Position Is the Key
The next two new codes are also hierarchical, only varying based on the placement of the catheter:
·         36225, Selective catheter placement, subclavian or innominate artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed
·         36226, Selective catheter placement, vertebral artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed.
As you might expect, you should report only one of these codes per same-side vertebral territory. Vertebral artery placement is more selective than subclavian or innominate. So you should report 36226 if the physician images the vertebral circulation from the subclavian or innominate in addition to from the vertebral artery.
+36227: Limit This Add-On to 3 Primary Codes
The first new add-on code in the series is +36227:
·         +36227, Selective catheter placement, external carotid artery, unilateral, with angiography of the ipsilateral external carotid circulation and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure).
CPT guidelines state that this code includes artery access, catheter placement, contrast injection, fluoro, and RS&I. Add-on codes are designed to be reported in addition to primary procedure codes. In this case, you should report +36227 in addition to 36222, 36223, or 36224.
+36228: Don't Take 'Each Branch' at Face Value
The final new code in the range is also an add-on code:
·         +36228, Selective catheter placement, each intracranial branch of the internal carotid or vertebral arteries, unilateral, with angiography of the selected vessel circulation and all associated radiological supervision and interpretation (e.g., middle cerebral artery, posterior inferior cerebellar artery) (List separately in addition to code for primary procedure).
The primary code options for this add-on code are 36224 and 36226.
Although the definition states "each intracranial branch," you shouldn't get carried away with units. Guidelines clarify that you should not report the code "more than twice per side regardless of the number of additional branches selectively catheterized."
A single unit of the code includes the usual list of vessel access, cath placement, contrast injection, fluoro, and RS&I. But for proper application of the code, you also need to understand that once you've coded cath placement in a primary branch of the internal carotid, vertebral, or basilar artery, then any additional second or third order cath placement in that branch is included in the code, too.

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