Top Tips to Tackle Upper Extremity Interventional Radiology Coding

Upper extremity interventional radiology coding is an important area to take to task when it comes to accurate coding. With the pandemic still taking its toll on the financial health of many facilities, coding correctly has never been more important with both reimbursement and compliance on the table. Several tips and advice will help safeguard coding when faced with upper extremity services.

Upper Extremity Coding Knowledge and Definitions Worth Detailing

First know that when performing interventional procedures in addition to diagnostic angiography, it may be appropriate to charge separately for each portion of the study. Reference the CPT Manual for guidelines associated with each code to determine when diagnostic angiography may be separately coded.

Several definitions are key to unlocking successful coding including dialysis circuit components like peripheral dialysis segment and central dialysis segment.

CPT defines the segments of the dialysis circuit as follows:

Peripheral dialysis segment: The peripheral dialysis segment is the portion of the dialysis circuit that begins at the arterial anastomosis and extends to the central dialysis segment. In the upper extremity, the peripheral dialysis segment extends through the axillary vein (or entire cephalic vein in the case of cephalic venous outflow). In the lower extremity, the peripheral dialysis segment extends through the common femoral vein. The peripheral dialysis segment includes the historic “peri-anastomotic region.”

Central dialysis segment: The central dialysis segment includes all draining veins central to the peripheral dialysis segment. In the upper extremity, the central dialysis segment includes the veins central to the axillary and cephalic veins, including the subclavian and innominate veins through the superior vena cava. In the lower extremity, the central dialysis segment includes the veins central to the common femoral vein, including the external iliac and common iliac veins through the inferior vena cava.

Note that the most current information pertaining to CCI instructions relative to this topic can be found in the most recent NCCI Policy Manual for Medicare Services at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.

Selected Top Tips

1. When permitted, you should code to the highest order in each vascular family for final catheter placement. Understand that access into AVF/AVG for diagnostic imaging only is defined by CPT 36901. However, when an intervention is performed in the peripheral segment of the dialysis circuit, diagnostic imaging is included and not reported separately.
   
   
2. Assign one procedure code regardless of the number of studies per operative field or site. However, note that multiple fields qualify as multiple sites.
   
   
3. Intravascular stent codes 37236 (first artery) and 37237 (each additional artery), as well as angioplasty codes 37246 (first artery) and 37247 (each additional artery) include imaging guidance necessary to perform and document completion of the procedure. However, do not report a separate S & I code. Understand that angioplasty, whether performed in the same vessel as part of the intravascular stent placement, is considered inclusive in this service and is not charged separately. Both intravascular stent placement and angioplasty are charged only once per vessel regardless of the number of lesions treated in the same vessel. What about the circumstances regarding multiple intravascular stent placement and angioplasty charges? Multiple intravascular stent placement and angioplasty charges may be submitted when separate and distinct lesions are treated in separate vessels outside of the dialysis circuit.
   
   
4. Therapeutic interventions within the peripheral segment of the dialysis circuit are founded upon a hierarchy of increasing service. Angioplasty, if the only therapeutic intervention, is reported with 36902. Stent placement in the peripheral segment is reported with code 36903 and includes angioplasty if performed. Mechanical thrombectomy and/or infusion for thrombolysis within any portion of the dialysis circuit is reported by 36904. Note that if angioplasty is performed in addition to mechanical thrombectomy/thrombolysis, report 36905 instead of 36904.
   
   • Should stent placement in the peripheral segment is performed in addition to mechanical thrombectomy/thrombolysis, code 36906 must be reported as opposed to 36904 or 36905. Code 36906 includes angioplasty if performed. Know that all codes include diagnostic and completion angiography, so do not additionally assign code 36901.
     
     
5. A no selective or non-selective catheterization code is necessary when submitting code 75898. For intracranial or spinal cord procedures, use this code per follow-up angiogram performed with embolization services. Do not assign code 75898 when performing completion angiography post angioplasty, intravascular stenting, thrombolytic therapy, thrombectomy, non-intracranial/non-CNS/non-head or neck embolization or atherectomy. Know that this code (75898) is submitted only once when extracranial embolization is performed, regardless of the number of separate vessels treated and subsequently injected.
   
   
6. Mechanical thrombectomy by any method and/or thrombolytic infusion within the dialysis circuit is reported with code 36904 unless angioplasty or stent placement is also performed in the peripheral segment of the circuit. In those cases, report 36905 (angioplasty), or 36906 (stent placement including angioplasty if performed). Understand that the removal of the arterial plug using a balloon catheter is considered to be a type of mechanical thrombectomy and not an angioplasty.

These are not all the necessary coding tips and rationale essential for correct upper extremity coding and compliance. As service volumes rebound, now more than ever it is imperative to make sure your CPT® coding is correct and compliant. Master more interventional radiology topics and break down the complexity with expert-infused insight. Our Upper Extremity Interventional Radiology Coding webcast is an essential training tool for both audio and visual learners.