Unlock Expert Pro Tips for Understanding Head and Neck-Related Angiography Codes

Arch, carotid, and vertebral angiography are integral services included in head and neck interventional radiology coding. The reality is that codes encompassing head and neck IR coding are challenging enough to be targeted by our subject matter experts as an area needing review and expert guidance. Note that complete codes that include catheterization and imaging are assigned for diagnostic cervicocerebrain angiography. There are several intricacies and nuances that make code selection challenging. We will explore some of the nuances for accurate understanding. In this month’s IR edition, codes 36221–36224 are illuminated, shining a light for success in 2024.

Deciphering Coding Services

First, understand that code 36221 describes the arch study. Unless otherwise instructed by a payer, if the same procedure is performed on both sides, assign the appropriate code once with modifier 50. If different procedures are performed, assign the individual codes with modifiers RT and LT.

How do you choose the appropriate code? The key is to identify the final catheter placement as well as the vessels that were imaged. However, do not assign separate codes for imaging of the vessels included within the code’s descriptor.

It is important to note that codes 36215, 36216, 36217, or 36218  cannot be used for head or neck catheterization when a diagnostic angiogram is also performed. Codes 36222–36228 describe unilateral procedures. These codes are also unchanged regardless of the initial vascular access point. Coders may be wondering about when anomalies impact coding selection. Vascular anomalies such as a bovine arch do not change the coding for these diagnostic exams.

CPT® code 36221 is assigned for what is commonly called an arch study. What is involved in this study? The study is an examination of the carotid and vertebral arteries from a non-selective catheterization of the thoracic aorta. In the carotid and vertebral diagrams on the following pages, the dot(s) indicate possible catheter locations while the arteries colored gray indicate the possible imaging for each code.

If the descending thoracic aorta is imaged other than during a carotid/vertebral diagnostic exam, such as during an extremity angiogram, code 75600 or 75605 (even if arch is included). Assign code 36221 if no further selective catheterization and imaging is performed for carotid and/or vertebral diagnostic imaging.

Codes 36222–36224 are assigned for diagnostic carotid angiography. Choose only one code per side.  It is important to know that these codes are built on a hierarchy; that is, each code is built on and includes the imaging designated in the lesser codes, including arch exam 36221. So, therefore, code 36224 includes all the work of 36221, 36222, and 36223. Code 36223 includes all the work of 36221 and 36222. Code 36222 includes all the work of 36221.

Demystifying Code Descriptions

Understanding the nuances of code descriptions is critical to selecting codes  with confidence.

First, note in the code descriptions, “extracranial carotid circulation” includes imaging of the common carotid, the proximal internal carotid, and non-selective imaging of the external carotid and branches—imaging of neck, and head outside of the skull.  Add-on code 36227 would be assigned in addition to one of these codes if the external carotid artery is selectively catheterized and imaged.

“Intracranial carotid circulation” encompasses the distal internal carotid artery and cerebral arteries. The internal carotid artery begins outside of the skull as a cervical (neck) artery and then goes through a hole (foramen) in the skull to become an intracranial/cerebral artery.

Dictation is often a problem area that can unravel accurate coding if not translated and understood correctly. If dictation is unclear whether cervical and/or cerebral imaging was performed, clarify with the physician. Coders may recognize that both codes 36222 and 36223 involve selective catheterization to either the innominate or commoncarotid artery and may have confusion over the differences of the codes and when to report each. The inherent difference in these two codes is the extent of the imaging.

Assignment Specific Details

• Assign code 36222 if the catheter is maneuvered into either the innominate artery or the common carotid artery with imaging of the extracranial carotid arteries. If the arch is evaluated, it is included; do not code 36221 in addition to 36222. If bilateral common carotid arteries are selected with extracranial carotid imaging bilaterally, code 36222-50.
• Report code 36223 when the intracranial carotid arteries are imaged from the innominate artery or the common carotid artery. Any arch or extracranial carotid imaging is included if performed. Do not code 36221 and/or 36222 in addition to 36223. If bilateral common carotid arteries are selected with intracranial imaging bilaterally, code 36223-50.
• Apply code 36224 when the internal carotid artery is selectively catheterized, and imaging of the intracranial carotid circulation is performed. This code includes imaging of the arch and extracranialcarotid imaging if performed. Do not assign 36221, 36222, or 36223 with 36224. If bilateral internal carotid arteries are selected with intracranial imaging bilaterally, code 36224-50.

These are not all the tips and tricks necessary to tackle head and neck interventional radiology coding.

As service volumes rebound and every dollar of reimbursement counts more than ever in the face of payment cuts, it’s imperative to make sure your CPT® coding is correct and compliant. Master more IR coding topics and break down the complexity with our expert-infused 2024 Head and Neck Interventional Radiology Coding live on July 17, 2024, at 11:00 am CT, or on demand past this date. This webcast is an essential training tool for both audio and visual learners.