The Coding Sleuth 13
by Tara Conklin
Snow was falling softly outside my window laying a fresh layer upon on the week old dirty one which lay beneath. A lone light sat on my desk; its soft glow reflecting on the papers that lay scattered about. As I looked over my notes the disorganized clutter of my desk contrasted sharply with the immaculate order of Dr. Osis. My last meeting with him was in 20 minutes. I looked up from my papers and gazed out the window. Day had come and gone as it does so quickly this time of year. The snow shone under the glow of the street lamps which were joined by various holiday lights that had appeared in shop windows over the past few days. The night was calm and I was getting tired.
I got up and put on my coat and scarf, grabbed my hat and headed out the door.
The warm air of Dr. Osis’s office greeted me from the cold winter air. His staff most courteously took my coat and scarf. My blood was just beginning to warm from the coffee they offered me when Dr. Osis appeared. He wore a green tie covered in red hearts which were adorned with Christmas lights. I grinned.
Several of the claims he corrected since our first visit had been paid recently which he thanked me again for my assistance. The stack of claims on his desk had decreased immensely. Looking at them I noticed these were reports that included interventions he had performed outside the heart and it’s vessels during a cardiac catheterization. Understandably this was the subject we were going to cover today.
Often times a patient requires diagnostic or therapeutic procedures in other vessels and since the catheter is already in place during the heart cath the physician will perform these at the same time. Before I explained how to code these to Dr. Osis there was some basic information he needed to understand first.
Vessels outside the heart are broken down into two subcategories, “non-selective” and “selective”. Non-selective vessels are categorized to the access vessel (site of catheter insertion) regardless of where it might be and the Aorta. All vessels that branch directly off a non-selective vessel are considered ‘selective’. These vessels are like branches of a tree. They come directly off the trunk and the further the branches go up and split the higher the order they become. The point where each vessel (branch) joins with the Aorta (trunk) is considered a first order. When that branch split into two or more smaller limbs, each of these limbs is a second order. After this each additional split is considered a third order. All diagnostic work in the lower orders is included in any work done in the higher orders. Code to the highest order in EACH vessel (branch) off the Aorta. Regardless of how many time the branch splits the orders will never go higher than the third. The whole concept of interventional radiology is rather complex and requires intense study but this was the basic understanding needed to explain the coding to Dr. Osis. Each once of these codes will have a surgical code and a radiology code. The surgical code reports the catheter placement or procedure being done and the radiology code reports the diagnostic information associated with that particular code. The surgical codes for vessels above the heart were 36215-36218 and below the heart were 36245-36248.
We learned in our first meeting that injections of the Aorta during a heart cath were coded based on their diagnostic purpose. If injection of the Aorta was for visualization of the renal or iliac vessels we billed the G codes in lieu of 93544. It is possible to bill both the G codes AND 93544 but there were requirements. 93544 was billed if one injection was done at the aortic root near the heart for visualization of the aorta and great vessels. The G codes were also billable if the catheter was then moved further down the Aorta and a separate injection for visualization of the renals or iliacs was done.
Here’s where the interventional coding rules come into play. If during a cardiac procedure the catheter is moved into the renal vessels themselves these are now “selective catheter placements”. Each separate vessel (branch) off the Aorta is coded separately. For catheter into the 1 st order Rt renal we would have 36245 & 75722. If both the RT & LT renal are catheterized we would have 36245-RT, 36245-LT & 75724. We would drop the G0275 and the 93544. Only if we had the two separate injections at the aortic arch and in the renals would we code 93544 additionally. This is bundled and would need modifier -59. 75722 & 72724 include aortic run-off so separate injections for separate purposes would need to be clearly indicated. Any other vessels stemming directly off the abdominal Aorta are considered “visceral” arteries and are also coded separately when selectively catheterized.
If the catheter is pulled down the bottom of the Aorta and another injection is done after renals and/or initial Aortic injection, the coding rules change here a bit also. We could just pick up our ‘drive-by iliac’ code G0278 if the documentation only reflects to the iliacs or common femorals. However if documentation reflects interpretation from the popliteals and/or further down the leg then instead of only G0278 the physician can pick up 75716 for interpretation of bilateral lower extremities. We can’t code 75630 (aortic run-off) as this is included in the renals; so we break it into its two parts 75625 & 75716 and drop the 75625.
In the head and neck vessels these were pretty cut and dry. Code each one appropriately according to the work done. The only place this gets confusing is during Subclavian injections. During a cardiac cath, sometimes the physician needs to examine the internal mammaries whether native or used for bypass. In order to access these vessels he has to pull the catheter out of the heart and place it up into the Subclavian which stems off the aortic arch. This is one of the Great Vessels. These included the Left Subclavian, Left Common Carotid and Right Innominate vessels. When dictation reflects interpretation of these, 75650 can be coded. Anyway, back to the Subclavian.
When injection of the Subclavian is done, knowing what to code will depend on what is reflected in the operative report. If it’s done for the purpose of examining the internal mammaries the only thing we would code is 93539. However, if the same injection is done for interpretation of the Subclavian or upper extremity then we would code 36215 (1 st order vessel off the Aorta) and 75710 (unilateral extremity S&I). If the same injection reflects both the mammaries and extremity vessels you can code all three codes from this one injection.
These were the most common procedures usually seen during a cardiac catheterization. Whenever performed “interventional” procedures knowing what to code is all about “what was the purpose of the catheter movements and what diagnostic injections were done”. Remember the 75000 codes are only coded when “diagnostic” interpretations are done. Follow-up up to therapeutic procedures is included, so is injection done for clarification of catheter positioning.
I looked at Dr.Osis and the look on his face reminded me of a Christmas light that had not been screwed in all the way, it was plugged in just not lit up. He seemed lost in thought, like a sponge absorbing everything around it. He didn’t speak so I just watched and waited. Then I saw it… the twist of the bulb….. He looked up and sure enough the light came on. His understanding glowed like the star at the top of the tree. I couldn’t help but laugh in spite of myself.
Weeks of notes and claims and education and all the pieces came together in a moment of clarity. We stood and he shook my hand, thanked me earnestly and actually laughed himself a bit…, but just a bit. Was he afraid to wrinkle his face.., I wondered. With this our meetings ended.. at least for now. He walked me to the door and offered me Season Greetings. As I wrapped my scarf around my neck once again, I returned the gesture and left.
The snow continued to fall gently and the crisp air felt good for a change. I looked around took a deep breath and decided to walk for a bit. Tucking my hands into the deep pockets of my coat I took off down the street. The snow crunched under my feet and the lights blinked around me. As I approached a streetlamp entwined with yellow lights I noticed one was not working. I stopped and examined it for a moment. Then reaching out I gave it a little twist.
It sparked to life and shone brightly…. I laughed and continued on my way.
Until next time Coding Sleuths!
--Tara