Basics of CPT code 36245, 36246, 36247 & 36248

Procedure or CPT codes 36245, 36246, 36247 & 36248 are used in coding vascular family. These codes are used for selective catheter placement in an abdominal, pelvic, or lower extremity branch of a single vascular family of the arterial system.

A catheter is introduced first into an extremity artery, with the preferred introduction site being a femoral artery, although an upper extremity artery may also be used. A small skin incision is made over the planned insertion site. An introducer sheath is placed in the artery and a guidewire inserted. If the right femoral artery is used, the guidewire is manipulated through the femoral and iliac arteries and into the aorta. A catheter is advanced over the guidewire into the aorta. The guidewire is advanced as needed and the physician then manipulates the catheter over the guidewire into a first order abdominal, pelvic, or lower extremity branch off the aorta.

The physician continues to selectively advance the guidewire and catheter through higher order branches (second, third, and beyond) until the catheter is situated in the highest order branch requiring evaluation. The guidewire is removed. Injection of medication and/or radiopaque contrast media is performed as needed.

Report CPT code 36245 if a first order branch is the highest order branch catheterized within the vascular family, and report CPT code 36246 if a second order branch if the highest order branch catheterized, report CPT code 36247 if a third or higher order branch is the highest order branch catheterized.

Code description of CPT code 36245, 36246, 36247 & 36248

Use CPT code 36248 for catheterization of each additional second, third, or higher order abdominal or pelvic, or lower extremity branch within the same vascular family.

Coding rules for CPT code 36245, 36246, 36247 & 36248

There are four basic and important rules should be followed for selective and Non-selective catheterization.

• Code Selective over Non-selective catheterization
• Code each vascular family separately
• Code the highest order of each vascular family
• Code each access separately

Catheterization coding the clear documentation fo the arterial entry site and final resting point for the end of the catheter at the time of imaging. It is very importatnt to know about the selective and nonselective catheterization coding with regard to a vascular family.

Nonselective implies that the puncture vessel itself is cannulated for imaging or a catheter is advanced along the artery retrograde from the puncture into the aorta. It does not matter whether the access site is the brachial artery or the femoral artery. If a catheter is advanced from either extremity vessel into the aorta, a nonselective aortic catheterization has occurred. This is described by CPT code 36200.

Selective catheterization occurs when cannulation of a vessel is performed at a branch point.  A vascular family is a network of vessels that originate from an arterial branch point off a nonselective vessel. This initial vessel is termed first order. The branches of first order are termed as second order and their branches as third order arteries.

Branch point negotiation beyond third order is not recognized in component coding. When selective catheterizations occur below the diaphragm, CPT codes 36245, 36246, and 36247 describe first-, second-, and third-order catheterizations, respectively.

When selective catheters are placed within vascular families above the diaphragm, CPT codes 36215, 36216, and 36217 again describe first-, second-, and third-order catheterizations, respectively. Every vascular family that is selected during an angiogram for imaging and/or intervention purposes will generate a separate and distinct catheter CPT code. Also, the same vessel can be different based on the puncture site or anatomic variation (e.g., the left common carotid artery [CCA] is a first-order catheterization in standard arch anatomy but is a second-order vessel in bovine aortic arch anatomy as a branch off the innominate artery). Therefore when describing catheter manipulations in an operative report, it is important to note all branch entry points in a given examination for billing purposes. This was set up to describe the quantity of physician work dedicated to placing a catheter into a given artery. Advancing a catheter farther into a vessel has a different amount of work associated with it compared with pulling that catheter back from a branch into the aorta and placing the catheter in a separate and distinct vessel.

If the catheter is brought back into a nonselective position and a separate vascular family is catheterized, this will necessitate an additional catheter code. For example, if the right common femoral artery (CFA) is punctured, this would generate the nonselective CPT catheterization code 36140. This describes retrograde femoral artery access. If the catheter is advanced into the aorta, the nonselective catheterization code, 36200, would be recorded, and this would nullify the 36140 code. The 36200 code contains the work described within the 36140 code, as well as the additional work required to advance the catheter into the aorta. Similarly, if the left renal artery is cannulated as a first-order catheterization, the code 36245 would take the place of the 36200 code; 36245 contains the relative value associated with the work required not only to get the catheter into the aorta but also to select the left renal artery. If the catheter is pulled back into the aorta and then placed in the right renal artery, which is an entirely different vascular family, a separate and distinct 36245 code would be appropriate. Bilateral renal artery selective catheterization would allow for billing the CPT code 36245 twice. If a catheter is further advanced within a given vascular family, branch points will need to be negotiated. A selective catheterization of the celiac artery would be termed “first order” similar to the renal artery cannulation described above and billed at 36245. However, if the catheter is advanced into the common hepatic artery past the left gastric and splenic artery branch points, the catheter is now in a “second-order” vessel. Second-order catheterization below the diaphragm is CPT code 36246 and includes the work of 36245 plus the work to enter the second-order vessel. Further advancement of the catheter into the proper hepatic artery past the gastroduodenal artery branch point is a “third-order” catheterization. Third-order catheterization is billed as a 36247 and, following the previous examples, voids and replaces the prior 36246 code.

If one enters a vascular family and proceeds to second- or third-order catheterization, there are times when the catheter is pulled back within that family (but not back into the aorta) and a separate second- or third-order branch is selected for further angiography. An example is selective catheterization through the innominate artery into the right CCA for carotid imaging. This is a second-order catheterization above the diaphragm (36216). The catheter is pulled back into the innominate artery and then into the right subclavian artery for further imaging. Placement of the catheter into the right subclavian artery is a “subsequent second- or third-order” catheterization and is billed with the add-on CPT code 36218. Similarly, if this occurred below the diaphragm, 36248 would be used.

References: 

https://www.sciencedirect.com/topics/medicine-and-dentistry/catheterization