By Leslie Jones, CPC, CPC-H, RCC, CIRCC
In the imaging world, it comes as no big surprise that the bundling continues. There have specifically been major changes in neuroradiology, such as the deletion of all supervision and interpretation (S&I) codes, and creation of new comprehensive codes to include vessel access; catheter placement; arterial contrast injections; fluoroscopy; arterial contrast injection that includes arterial, capillary, and venous phase imaging; radiology S&I; and closure of the site. In addition, these codes have a circled bullet indicating conscious sedation is included. Two additional codes not included are ultrasound guidance for vascular access 76937 and 3D rendering on independent workstation 76377.
The creation of these codes is the second time the American Medical Association has bundled catheter placement and imaging with renal angiography, the first time being in 2012.
Coders and Guidelines
The coding is a new concept and does not follow the same conventions as last year. These codes are built on a hierarchy system with only one primary code reported per side. Codes 36222-36224 and 36225-36226 are built on a progressive hierarchy, with the less intensive services included in the more intensive services. For example, if you place the catheter into the right common carotid arteries and only take an image of the neck (cervical-cerebral), then you would only report code 36222. However, if you happen to move the catheter into the right internal carotid and take images of the head and neck, the code changes to 36223.
It is important for coders to understand how these codes are designed and the differences among each of the codes for proper assignment. After all, one missed code could leave plenty of reimbursement money on the table. Once the concept of these codes has been grasped, coding should become easy as the codes have fewer components and are easier to understand.
There are also plenty of guidelines associated with these codes, especially with the add-on codes for external carotid and additional intracranial vessels. For the primary codes, only one code can be assigned per side depending on the catheter position and imaging. The external carotid code is an add-on and can be used only with a primary injection and imaging of common or internal carotid (whatever is higher). The external carotid code also can be used only once per side, even if more selective vessels are catheterized and an imaging performed (ie, epistaxis embolization).
Physician Education
It is important to document laterality and the furthest catheter position for correct coding. Unfortunately, for those difficult cases where the patient may have abnormal anatomy, the coding does not change; it is reported the same no matter where the vessels branch off. It is also imperative for physicians to remember to follow CPT guidelines for diagnostic angiography performed at the same time as an intervention, which is often not documented. This will ensure credit for the imaging and catheter placement, instead of just the catheter placement (36215-36218) with the intervention. Diagnostic angiography with an intervention cannot be coded if the contrast injections, angiography, road mapping, or fluoroscopy guidance is for the intervention. Diagnostic angiography can be reported separately at the time of the intervention under the following conditions:
- If there is no catheter-based angiography study available and a full diagnostic study is performed and the decision to intervene is based on the diagnostic; OR
- A prior study that indicates the patient’s condition has:
- changed since the prior study or;
- there is an inadequate visualization or;
- there is a clinical change during the procedure that requires new evaluation outside the target area.
Physicians should remember to document laterality, furthest catheter position, diagnostic imaging findings, ultrasound guidance for vascular access components, and 3D imaging on an independent workstation, and follow the guidelines for diagnostic angiography at the time of an intervention. Following these steps will ensure the maximum reimbursement possible for 2013.
Reimbursement
The primary codes are subject to multiple surgery reductions in payment for Medicare. The add-on codes, external and additional cerebral vessels are already reduced in payment. The calculation of the loss in reimbursement is difficult to calculate, as there is not a one-to-one correlation from 2012 to 2013. You can get more information on calculating the impact to reimbursement by contacting your local Medicare carrier.
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Leslie Jones, CPC, CPC-H, RCC, CIRCC, is director of coding and physician education for Zotec Partners, a leader in specialized medical billing and practice management services for the hospital-based specialty market.
