Selective versus Non Selective Catheter Placement

There are two types of vascular catheter placements:

• Non-selective and
• Selective

Non-selective catheter placement is any of the following:

• Placement of a catheter or intra-catheter into the access vessel and leaving it in that vessel,
• Advancement of the catheter more centrally in the same access vessel,
• or advancement of the catheter from the access vessel into the aorta.

Even if the catheter is advanced more centrally or into the aorta it is still designated as a non-selective catheter placement as the catheter never diverts off its main pathway.

The term “selective” is also used in the context of advancing the catheter distally (past a vascular
bifurcation) to a more distal branch vessel.

This only applies when the catheter is manipulated distally or into a smaller vessel.

In diagnostic catheterization, codes are given simply at the final position of the catheter. This can be simply understood if we know the anatomy of Aorta. As we know, most of the major arteries arise from Aorta for example, Inominate artery, Left common carotid artery, Left subclavian artery, celiac trunk, superior mesenteric artery, inferior mesenteric artery and Common Iliac artery.

The arteries arising directly from the aorta form an individual vascular family. Now, the catheter moves in the aorta either in retrograde or antegrade direction. Now, suppose for an access the catheter is inserted on left femoral artery and the catheter moves in the opposite direction to right femoral artery, this movement is called retrograde movement.

On the contrary, if the catheter moves from left femoral artery into the left side only, is considered an antegrade movement of catheter. Now, if you can understand retrograde and antegrade movement of catheter, you can understand what is Selective and Non Selective Catheter Placement? Also in interventional radiology coding, we sometimes use ipsilateral(antegrade) or contralateral(retrograde) direction to document the movement of catheter. Now, suppose the physician want to study the right femoral artery. The physician takes an access in the left femoral artery and moves the catheter to aorta.

Now, here if you know the anatomy of aorta, to move a catheter from one vascular family to another it has to pass through aorta. Now, when we are taking access on left side and moving towards right, we have to pass through aorta. Therefore, when the catheter reaches Aorta it is always considered as Non Selective Catheter Placement area (CPT code 36200). Now, when the catheter cross the aorta and enters into another family, Selective catheterization starts.  Always remember one rule:

“Code Selective catheterization over Non-selective Catheterization”

Now, when we are passing the catheter in the retrograde direction, form left femoral artery to aorta to right femoral artery, we are entering from Non Selective Catheter Placement to Selective catheter placement Zone. So, whenever we are coding do not code Non-Selective Catheterization code 36200 along with Selective catheterization (36245-36247) unless both have Separate access (will learn in next Para)

There are terms in the descriptions of the arterial catheter placement codes that are important:

Branch – a branch is a vessel arising off the access vessel or off the aorta

Vascular family – a branch artery and all subsequent branches

Order – the level of advancement of the catheter in a branch

• The initial branch is a first order vessel
• A branch of the initial vessel selected or, in cases when the vessel changes names, is a second order vessel
• A branch of a second order vessel is a third order vessel, and so on

Read also: Coding tips for Mechanical Thrombectomy in AV fistula

Coding of Lower Extremity Vascular Family

The CPT codes are divided based on branches. The first branch Common iliac artery arising directly from aorta is considered as first order artery (36245). The secondary branches like internal iliac, external iliac and common femoral artery are considered as secondary order artery (36246). The arteries arising from the second order arteries are called as Third order arteries (36247). In addition, we have an Add-on code 36248 if an additional artery is catheterized from same vascular family. So, whenever the CPT codes are coded for lower extremity the code for highest order is coded. The highest order will include the lower order procedure codes hence the highest order catheterization is coded.

36247>36246>36245
Add-on 36248

36245- Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family

36246- Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family

36247- Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family

36248 – Selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriate)

So, if we are selecting Common iliac artery first (36245), followed by Common Femoral artery (delete 36245, code 36246) and the again the catheter is moved ahead and placed at superficial femoral artery (delete 36246, code 36247) and selecting additional artery Profunda femoris artery as well to study (code 36248). Therefore, the final code will be 36247, 36248.

Read also: How to code Intravascular Vena Cava filter

Coding of Lower extremity vascular family with different access

Sometimes the physician takes different access to study the same vascular family. In such case, each vascular access is coded separately. For example, first access is taken in left femoral artery to study right common femoral artery (36246) and he took one more access from left common iliac artery to study right common iliac artery (36245-59). Now, hope you would have understood that the time and work taken for both access was same hence, we have to code both the access separately. Take a note of use of 59 modifier as well, since we are cannot code 36246 and 36245 together. Because 36245 is included in 36246, we are using 59 modifier with 36245 just to tell the payer that the 36245(second access) procedure is different from the 36246 (first access).

Coding rules for Selective Catheterization 

1.Each vascular family is coded independently.

2.There can be only one initial first, second, or third order catheter placement reported in a vascular family.

3.Any section of a vessel that the catheter went through to get to the most remote placement is included in the final placement.

• If you had to go through another artery, it is included in the final catheter placement code.

4.Catheter placements in the access vessel and in the aorta are included in selective catheter placement.

5. When more than one access site is used, the catheter placements from each access site are coded separately.

If more than one branch in the same vascular family is catheterized but each one is separate from the other (the catheter didn’t traverse one to get to the other), then the additional catheter placements are reported with code 36248.

• This code is described as “additional” arterial selections and is designated as an add-on code.
• It is added on to the initial catheter placement code in a vascular family when additional work is performed to catheterize an additional branch of a vascular family.
• It is never the only code reported for catheter placement in a vascular family