Interventional Radiology

Vascular IR Fundamentals – Building a Foundation for a New Year

As you know, coding for vascular angiography and interventions is complicated. Adding to the challenge, it is open to interpretation (hello often unclear documentation!) and tends to change frequently making for a problematic mix that places even the most experienced coders under pressure. Coders must be fully up to speed regarding current code choices and consistently watching for changes, not only to the codes themselves but also to additional guidelines released throughout the year.

The start of a new year is the best time to re-set and refresh foundational knowledge with a review of vascular IR coding fundamentals.

Angiography – A generic term for imaging of vessels after the introduction of contrast material.

Diagnostic angiography may be performed as a stand-alone procedure, or it may precede an intervention performed during the same session. In some cases, diagnostic angiography performed at the same session as an intervention is included in the code for the intervention and will not be separately reported. When diagnostic angiography is not included, the diagnostic angiogram may be separately reportable if:

  1. There is no prior catheter-based diagnostic study available, a full diagnostic study is performed and the decision to perform the intervention is based on the diagnostic study, OR
  2. There is a prior study available, but documentation in the patient’s medical record:

    a. Illustrates that the patient’s condition relating to the clinical indication has changed since the prior study, OR

    b. The visualization of the anatomy and/or pathology is inadequate, OR

    c. A clinical change during the procedure requires a new evaluation outside the target area of the intervention

Clear documentation is critical in determining what is reportable and what is not. Physicians, not coders, have the right to say what is diagnostic and what is not. However, it is the responsibility of coders to determine if the documentation provided supports a diagnostic exam based on established guidelines.

Unfortunately, documentation isn’t always as clear as we would like. Therefore, it is imperative that coders are familiar with terminology frequently seen in reports and guidelines. Understanding the terminology helps with coding, even when the documentation is less than ideal, and can also assist with communication back to providers to ensure they understand what is required in the documentation in order to bill for procedures.

Terminology Review

As many of you certainly know, some of the terms most commonly used in reports and guidelines include:

AntegradeWith the normal flow of blood
RetrogradeAgainst the normal flow of blood
IpsilateralArteries or veins on the same side of the body as the access point
ContralateralArteries or veins on the opposite side of the body as the access point

For example, documentation states, “antegrade access of the common femoral with catheterization of the ipsilateral popliteal artery.” In other words, since blood flows away from the heart in the arteries, this means that the catheter was placed into the groin ‘pointing down’ the same leg and then maneuvered down into the popliteal artery.

Selectivity and Vascular Family Review

The following terms are also critical for proper code assignment:

Non-Selective CatheterizationThe catheter stays in the artery or vein accessed or is maneuvered into the aorta or vena cava from any access and is not further maneuvered beyond that location.
Selective CatheterizationThe catheter is maneuvered from the access site into another artery or vein other than the aorta or vena cava. There are degrees of selectivity depending on how far beyond the access, aorta or vena cava the catheter is moved.
First-Order SelectionThe catheter is maneuvered into a vessel that arises directly from the aorta or vena cava; or, the catheter is maneuvered into a vessel beyond the access site if the aorta or vena cava is not catheterized.
Second-Order SelectionThe catheter is maneuvered into a vessel that branches from a first-order selection.
Third-Order SelectionThe catheter is maneuvered into a vessel that branches from a second-order selection.
Vascular FamilyA vessel that branches off the aorta or vena cava along with all secondary (and additional) vessels that branch from that vessel

Vascular families and the order of selectivity are often described using a tree. For arterial vascular families, picture a tree – trunk, roots, limbs, and branches. The aorta would be the trunk. Coming directly off the trunk are the roots (i.e., external iliac, common iliac) and main limbs (i.e., brachiocephalic, left common carotid, left subclavian) – each of these roots and limbs would be first- order selections and the beginning of separate vascular families.

The smaller branches that come off the main limbs would be the second and third-order selections of that vascular family. For example, the brachiocephalic limb divides into the right subclavian and right common carotid branches, which divide into smaller branches – these three vessels, and the smaller branches, are a vascular family. Wherever there is a branching and the physician must decide which way to go, that is where the next order of selectivity starts.

Simple, right? Absolutely not, and that’s why it’s important to diligently maintain foundational knowledge while continuing to build – because, if there’s one thing we can be sure of with IR coding it’s that, at some point, it’s going to change. A stable foundation allows us to absorb those changes with a little more ease and confidence.

Master the Fundamentals of IR Coding

Join us Wednesday, January 8 for the first installment of our 11-part interventional radiology coding series, featuring prominent interventional radiology coding expert Jeff Majchrzak, BA, RCC, CIRCC. This session provides a foundation for interventional radiology coding with an opportunity to reset and get grounded in a broad range of coding basics – covering terminology, vascular anatomy, modifiers, CCI fundamentals, and bundled and component coding rules for diagnostic and therapeutic IR services.