Abdominal aortography and lower extremity angiographs are one of the most commonly performed procedures by vascular surgeons for diagnosing different vascular diseases. These procedures help physicians evaluate and diagnose conditions such as peripheral arterial disease, aneurysms, thrombosis, claudication and other vascular malformations. These procedures can be done preoperatively to diagnose a patient or intraoperatively to asses blood flow, guide procedures and ensure the success and safety of the surgery. Due to the various situations these procedures can be performed it is important that codes are assigned appropriately and that current bundling guidelines are understood.
Before we jump into coding lets discuss the anatomy and language used to describe these procedures.
An abdominal aortogram is a diagnostic medical imaging procedure that involves injecting contrast dye into the abdominal aorta, followed by X-ray imaging. This technique helps visualize and assess the blood vessels in the abdominal region, including the aorta and its branches, providing information about potential abnormalities such as aneurysms, stenosis, or other vascular conditions.
Lower extremity angiography is a medical imaging procedure that involves injecting contrast dye into the arteries of the lower limbs and using X-ray technology to visualize the blood vessels. This diagnostic technique helps assess the circulation in the lower extremities, identify blockages, narrowing, or other vascular issues, and guide medical interventions such as angioplasty or stent placement to improve blood flow.
Below is a map reflecting the arterial and venous anatomy. In addition to being familiar with the vascular anatomy it is also important to understand the vascular orders, see the second image. In order to understand the CMS CPT descriptions you must have a clear understanding of the vascular orders.
Catheterizations are broken into two categories; selective and non selective catheter placement. Non selective and selective codes are not to be coded together.
Selective Catheter Placement- Think of this as inserting and advancing the catheter to a specific location/vessel. The advancement must go past the aorta and past the iliac and femoral location shown above in yellow.
Non-Selective Catheter Placement-Non-selective catheter placement involves inserting a catheter into a larger vessel without specifically targeting a particular branch or area. If the catheter is inserted and is not advanced any farther it is considered non selective. If the catheter is inserted into the aorta and not moved it is considered non selective.
Supervision & Interpretation coding- S&I codes are used in conjunction with the catheterization codes to describe the physicians work involved in supervising and interpreting the results of the radiological piece of the procedure.
Tips & Tricks
Code to the highest order only for each access site. This means if the catheter is advanced to a vessel in the third order any non selective, 1st or 2nd order catheterizations are going to be bundled to the third order code.
If lower extremity endovascular revascularization is performed at the same time as a diagnostic lower extremity study, the catheter placement in the interventional target vessel is bundled, unless the intervention is performed using a separate site. Ex: diagnostic runoff using right femoral access followed by left popliteal access for stent placement then the diagnostic catheter placement is billable and the popliteal access catheter placement for the sent is bundled to the stent.
If the exact location of catheter placement was not documented or if there was a repositioning no clearly described you must code the lesser territory code.
Diagnostic angiography (S&I) codes should not be used with interventional procedures for the following:
Contrast injections, angiography, road mapping, and/or fluoroscopic guidance for the intervention,
Vessel measurements, and
Post angioplasty/stent/atherectomy angiography, as this work is captured in the radiological supervision and interpretation codes. In those therapeutic codes that include S&I, this work is captured in the therapeutic code.
Diagnostic angiography performed at the time of an interventional procedure is separately reportable if:
No prior catheter-based angiographic study is available and a full diagnostic study is performed, and the decision to intervene is based on the diagnostic study OR
A prior study is available, but as documented in the medical record:
The patient's condition with respect to the clinical indication has changed since the prior study, OR
There is inadequate visualization of the anatomy and/or pathology, OR
There is a clinic change during the procedure that requires new evaluation outside the target area of the intervention.
If diagnostic angiography is necessary, is performed at the same session as the interventional procedure and meets the above criteria, modifier 59 or the appropriate X modifier must be appended to the diagnostic radiological supervision and interpretation code(s) to denote that diagnostic work has been done following the above guidelines.
If you are billing for the physicians work only you must append modifier 26 to the radiological codes to indicate reimbursement is only for the S&I only not the technical part of the code.
If a code requires both the 26 and the 59/X modifier the 26 modifier must be added first in front of the 59/X.
Lets Code It!!!
Antegrade Right Femoral Approach
CPT Code | Vessel Location/Name | Catheterization Type |
|---|---|---|
36140 | Common Iliac, External Iliac, Common Femoral | Non-Selective |
36245 | Internal Iliac, Profunda Femoral, Superficial Femoral | First Order |
36246 | Medial Descending Branch of Profunda Femoral, Popliteal, | Second Order |
36247 | Lateral Circumflex Femoral, Perforating Profunda Branches, Superior Geniculate, Inferior Geniculate, Tibial/Peroneal Trunk, Anterior Tibial, Peroneal, Posterior Tibial, Dorsalis Pedis. | Third Order |
Retrograde Right Femoral Approach
CPT Code | Vessel Location/Name | Catheterization Type |
36245 | Common Iliac | First Order |
36246 | Internal Iliac, External Iliac, Common Femoral | Second Order |
36247 | Profunda Femoral, Lateral Circumflex Femoral, Medial Descending Branch of Profunda Femoral, Perforating Profunda Branches, Superficial Femoral, Superior Geniculate, Popliteal, Inerior Geniculate, Tibial/Peroneal Trunk, Anterior Tibial, Peroneal, Posterior Tibial, Dorsalis Pedis | Third Order |
Supervision & Interpretation
CPT Code | Description |
36200 | Introduction of catheter into aorta |
75625 | Aortography, abdominal, by serialography, radiological supervision and interpretation. |
75630 | Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision and interpretation. |
75710 | Angiography, extremity, unilateral, radiological supervision and interpretation. |
75716 | Angiography, extremity, bilateral, radiological supervision and interpretation. |
75630 is used for aorto-pelvic angiography performed for AAA work-up, despite any catheter movement between the aortic and the pelvic oblique study. This also includes imaging of the abdominal aorta and bilateral oblique views of the pelvis. If the initial imaging is done at the time of the EVAR or FEVAR, even if a diagnostic study has not been done previously, it is bundled and not reported.
Use codes 75625 and 75716 if full and complete aortogram and a separate run-off study are performed from high and low catheter positions in the aorta.
Code 75630 requires imaging o the abdominal aorta, not just the distal most aspect of the aorta.
Use 75630 if complete angiogram and run-off is performed from a single catheter position, if the documentation does not support separate complete studies from two catheter positions, or if only a limited study of the aorta with obliques of the pelvis )aorto-ilio-femoral) is performed regardless of catheter positioning.
Use 36200 & 75630 for aortogram and unilateral or complete bilateral run-off from one catheter position in the aorta.
Do you fear RCM professionals don't understand the vascular language?
Yes, I fear revenue is missed due to misinterpretation.
No, everyone I work with speaks the language.
It doesn't really matter to me
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Citing
Dr. Z's Medical Coding Series Vascular & Endovascular Surgery Coding Reference, ZHealth Publishing, pgs 167-176.
https://musculoskeletallkey.com, Fig 8.6 Schematic diagram of the arterial and venous anatomy of the lower extremity showing important related anatomic landmarks.
AMA CPT professional edition 2023. pgs 489-491 & 263-266