Arch, Carotid and Vertebral Angiography: A Quick Review

The concept behind bundled codes is not new to anyone familiar with coding for interventional radiology procedures, and it’s no surprise that complete codes (including catheterization and imaging) exist for arch, carotid and vertebral angiography–CPT® codes 36221-36228. Like other code sets, these codes are built on a hierarchy, meaning the lower-numbered codes are valued into the higher-numbered codes.

The common mistake specific to this code set comes from thinking within the hierarchical logic we are accustomed to: the lower-numbered code(s) in the series are all valued into the higher-numbered code(s) in the series and submitting two codes from the same series would be incorrect. This is true with this series of codes…to a point.

So, what’s different with this code set? It depends on what’s being imaged. Let’s look at our hierarchy in a different way – even though the primary codes are in the same series, we can view this as two hierarchies based on what’s being imaged.

Carotid Angiography

For the codes concerning carotid imaging, the work of the lower-numbered codes is included in the higher-numbered codes. That is, 36222 includes 36221, 36223 includes 36222 and 36224 includes 36223. The difference, and how the appropriate code is determined, is based on:

• Where the catheter is placed (common carotid/innominate or internal carotid), and;
• What is being imaged

Extra-cranial refers to vessels outside of the skull. This may be referred to in the report as imaging of the neck, common carotid, cervical or internal carotid. Intra-cranial refers to vessels inside of the skull. This may be referred to as imaging of the intracranial, head, cavernous portion, MCA, M1 or M2.

For the codes concerning vertebral imaging, the work of the lower-numbered codes is included in the higher-numbered codes. That is, 36225 includes 36221 and 36226 includes 36225.

The codes for carotid and vertebral angiography all include the arch study (36221) and both series (carotid and vertebral) are built on a hierarchy. The difference here is that the vertebral angiography codes, though higher numbered within the same series, do NOT include carotid angiography.

Diagnostic carotid angiography and diagnostic vertebral angiography are considered to be separate services and MAY be coded together if both are performed. Assuming, of course, that the documentation supports coding for both services.