Do you have trouble with IR coding?  It can be difficult to determine code selection but understanding the rules can go a long way to understanding how CPT code assignment works.  It’s all about the position of the catheter and the hierarchy of the codes.

In a non-selective catheter placement, the catheter stays in the original vessel that was punctured or advances only to the aorta or vena cava, a larger diameter vessel.  But as soon as that catheter is maneuvered into a branch vessel – a smaller diameter vessel – the level of difficulty increases, and the catheter placement code becomes selective.  An interventional radiologist may perform an angiography using a non-selective catheter placement in order to image a larger or more generalized area; the image taken will capture everywhere the contrast flowed and can help identify diseased anatomy.  Selective catheter placement gets more specific with the targeted contrast area and can offer more detailed images of the anatomy.

Now that you know how to identify a non-selective versus a selective catheter placement, the challenge becomes which order?  Some vessels have their very own codes (e.g., the carotids, the renals) but most of the time you will have to follow the road map of vessels to determine the order of selectivity for the final catheter position.  Speaking of road maps, anatomy charts or diagrams are a must!  These will be your guide to determine how many branches (or forks in the road, if you will) the interventional radiologist had to take and will thus drive your code assignment.  Let’s say Dr. Smith gained access via the right common femoral artery.  The catheter was then maneuvered through the iliacs, around the corner of the aorta and into the left common iliac.  If the catheter stopped there for angiography, we would assign the first-order catheter selection code 36245 (the catheter moved from a larger diameter vessel, the aorta, into a smaller diameter vessel, the common iliac).  But Dr. Smith cruises that catheter on into the left common femoral, and as soon as it went past the fork in the road that was the internal iliac/external iliac intersection, the catheter selection then became second-order, 36246, because the catheter moved into an even smaller diameter vessel.  If Dr. Smith decides to go even further, say into the femoral, the catheter selection becomes third-order, 36247 (you guessed it, because it passed another intersection at the femoral/profunda femoral).  Most vascular families don’t stop branching at the third-order; however, CPT stops counting and the code descriptors state “third-order or more selective” when catheter’s road trip to it’s destination is a long one.  In this scenario the final code would only be 36247 since we only code to the highest order catheter placement within a vascular family.  “What is a vascular family,” you say?  Keep an eye out for RMC’s basics of interventional radiology coding webinar, coming soon!  In it you will learn about and apply the guidelines for catheter selection, walk through several coding examples, learn about diagnostic verses therapeutic procedures, and so much more.

Written by Raylene Spicer, RHIT, CCS, CIRCC