Endovascular coding

[BEVERLYL_66037]

Hello

Can I have this case explained to me why the codes would change from 36223/50 and 36227/50 to 36217 X2 units after I account of the bilateral middle meningeal artery embolization 62624. I need help explaining this to the providers. Thanks in advance.

Provider:
36223/50
36227/50
62624
75898*4
76937
75894

Me:
76937/26
36217*2
61624
75894/26
75898*4

Preoperative Diagnosis Bilateral chronic subdural hematoma Postoperative Diagnosis Same Operation 1. Use of the ultrasound for assistance with intravascular access 2. Diagnostic cerebral angiogram of the bilateral common carotid arteries and bilateral external carotid arteries 3. Transcatheter permanent embolization of the bilateral intracranial middle meningeal artery with n-BCA glue for the treatment of subdural hematoma 4. Follow-up angiography x 4 Indication for Surgery This is a 75-year-old male who presented with bilateral chronic symptomatic subdural hematoma. It was felt that he would benefit from bilateral MMA embolization. The risks, benefits, alternatives, and indications of the procedure were explained to the patient and/or any available family in great detail. Risks include but are not limited to bleeding, infection, stroke, coma, paralysis, and death. All questions were answered to the best of my ability and they elect to proceed with the procedure. Findings 1. Ultrasound image of the right radial artery demonstrates patent artery appropriately sized for catheterization 2. Left common carotid artery AP and lateral views centered over the intracranial circulation demonstrates no evidence of aneurysm AVM or fistula. No evidence of hemodynamically significant stenosis. Normal external carotid artery anatomy over the head and face. No evidence of external to internal collateralization. No evidence of middle meningeal artery contribution to ophthalmic artery. 3. Left external carotid artery AP and lateral views centered over the intracranial circulation demonstrates normal external carotid anatomy over the head and face. No evidence of middle meningeal artery contribution to the ophthalmic artery. 4. Left external carotid artery AP and lateral views centered over the intracranial circulation follow-up angiogram after embolization demonstrates no filling of the distal meningeal artery. No evidence of iatrogenic injury to the external carotid artery after ember embolization. 5. Left common carotid artery AP and lateral views centered over the intracranial circulation follow-up angiogram after embolization demonstrates no evidence of large vessel occlusion or vessel dropout. Normal filling of left retinal blush. 6. Right common carotid artery AP and lateral views centered over the intracranial circulation demonstrates no evidence of aneurysm AVM or fistula. No evidence of hemodynamically significant stenosis. Normal external carotid artery anatomy over the head and face without evidence of external to internal carotid collateralization. No evidence of middle meningeal artery contribution to the ophthalmic artery. 7. Right external carotid artery AP and lateral views centered over the intracranial circulation demonstrates normal external carotid artery anatomy over the head and face. No evidence of middle meningeal artery contribution to the ophthalmic artery. 8. Right external carotid artery AP and lateral views centered over the intracranial circulation follow-up angiogram after embolization demonstrates occlusion of the distal middle meningeal artery without evidence of iatrogenic injury. 9. Right common carotid artery AP and lateral views centered over the intracranial circulation follow-up angiogram after embolization demonstrates no evidence of large vessel occlusion or vessel dropout. Normal filling of right retinal blush. 10. Right common femoral artery oblique angiography centered over the groin demonstrates puncture site above the level of bifurcation without evidence of iatrogenic injury to the vessel 11. Ultrasound image of the right common femoral artery demonstrates patent artery appropriate size for catheterization Complications None Procedure Details The patient was brought to the angiography suite and laid supine on the angio table. The patient was intubated without complication. After all lines were placed the right wrist was prepped and draped in the usual sterile fashion. A surgical pause was performed confirming the correct patient, the correct procedure, and the correct site. The ultrasound probe was used to identify the right radial artery. The vessel was found to be patent and an image was saved to PACS. Under direct visualization with the ultrasound probe a micropuncture kit was used to gain access to the right radial artery. Using a modified Seldinger technique a 6 French radial sheath was placed into the right radial artery. After administration of radial cocktail we advanced a benchmark guide catheter over a Sim 2 select 5 French catheter over a Glidewire up the arm and into the aortic arch. We selectively catheterized the right common carotid artery and obtained AP and lateral angiographic views centered over the intracranial circulation. We then selectively catheterized the right external carotid artery and obtained AP and lateral angiographic views centered over the intracranial circulation. Under roadmap guidance we advanced Prowler select 14 microcatheter over Synchro 2 standard microwire into the right middle meningeal artery. The wire was carefully removed and we performed a microcatheter run centered over the head. This demonstrated that the microcatheter was in appropriate position for embolization. The microcatheter was prepped with D5W and then we proceeded with embolization of the right middle meningeal artery with n-BCA glue. The microcatheter was carefully removed. We performed a follow-up angiogram through the right external carotid artery with AP and lateral views centered over the intracranial circulation. The catheter was pulled back into the common carotid artery and we obtained follow-up AP and lateral angiographic views centered over the intracranial circulation. We attempted to gain access into the left common carotid artery from a transradial approach unsuccessfully. We decided to approach from a right transfemoral approach. The ultrasound was used to identify the right common femoral artery. Using a micropuncture kit and the ultrasound for direct visualization we gained access into the right common femoral artery. Using a modified Seldinger technique a 6 French short sheath was placed into the right common femoral artery. We performed oblique angiography through the sheath centered over the groin. We then advanced the benchmark guide catheter over a diagnostic catheter over a Glidewire up the aorta and into aortic arch. We selectively catheterized the left common carotid artery and obtained AP and lateral angiographic views centered over the intracranial circulation. We then selectively catheterized the left external carotid artery and obtained AP and lateral angiographic views centered over the intracranial circulation. Under roadmap guidance we then advanced a Prowler select 14 microcatheter over a Synchro 2 microwire into the left middle meningeal artery. The wire was carefully removed and we performed a microcatheter run centered over the head. This demonstrated that the microcatheter was in appropriate position for embolization. We prepped the catheter with D5W and then proceeded with n-BCA embolization of the left middle meningeal artery. Once we are satisfied with embolization the microcatheter was carefully removed. We obtained a follow-up angiogram through the left external carotid artery with AP and lateral views centered over the intracranial circulation. We then pulled the catheter back and performed a follow-up angiogram in the left common carotid artery with AP and lateral views centered over the intracranial circulation. The guide catheter was carefully removed. The 6 French short sheath was pulled and a TR band was used to achieve hemostasis on the right wrist. A 6 French Angio-Seal was used to achieve hemostasis in the right groin. The patient tolerated the procedure well and there were no complications. All sponge needle counts were correct at the end the case. I was present to help complete the critical portions of the procedure and was immediately available for all other portions of the procedure. The patient was extubated and transferred to recovery room in stable condition. Summary: Successful embolization of bilateral middle meningeal artery for the treatment of subdural hematoma

 

[Laureen Jandroep]

1. Bilateral Procedure Coding​

• 36217 is for "Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, with angiography of the external carotid circulation, unilateral."
• Since the procedure was performed bilaterally (both left and right external carotid/middle meningeal arteries), 36217 is billed for each side (x2 units), not with a bilateral modifier (not 36217/50, but 36217 x2).

2. Correct Coding for Embolization Workup​

• 36223 and 36227 are more comprehensive codes that include diagnostic angiography of the carotid and external carotid arteries, typically used when a full diagnostic angiogram is performed separate from an intervention.
• However, when a diagnostic angiogram is performed as part of a planned embolization (as in this case), only the catheterization code (36217) is reported, not the full diagnostic angiography codes (36223/36227), unless there is a separate, distinct diagnostic study performed that leads to the decision to do the intervention, and this was not the case here (the embolization was planned preoperatively).

3. NCCI and CPT Coding Guidelines​

• Per CPT and NCCI (National Correct Coding Initiative) guidelines, when diagnostic angiography is performed solely to guide an already planned intervention, only the catheter placement code (36217) is billed, not the full diagnostic angiography codes.
• The full diagnostic angiography codes (36223, 36227) are only appropriate if the diagnostic study is performed and the decision to intervene is made based on those findings, not if the intervention was already planned.

4. Documentation Review​

• The operative note indicates the embolization was planned preoperatively, and the angiograms were performed as part of the embolization procedure, not as a separate diagnostic study.
• Therefore, per coding guidelines, 36217 x2 (one for each side) is correct for the selective catheterizations with angiography of the external carotid arteries, rather than 36223/50 and 36227/50.

 

[BEVERLYL_66037]

You are amazing! Thank you so much for the detailed breakdown I have joined every coding group and every endovascular group but it would not stick