Procedure performed for Renal Artery Catheterization

The physician first takes the access into the skin through an underlying artery of lower extremity and introduce a guidewire through the needle. The wire is threaded into the main renal artery or any branch of renal artery. A catheter is introduced through the guidewire and then the contrast material in injected for arteriography. Images are obtained once the contrast is injected.  CPT code 36251, 36252, 36253 and 36254 are used for coding selective catheter placement in renal artery and its branches.

In this scenario, the catheter first enters into the aorta and then moves toward renal arteries and perform renal arteriograms. You can check out the vascular family rules and the difference between the selective and Non-selective catheterization to learn more about these code. This technique will really help to improve your skills in medical coding.

Read also: Coding tips for Central Venous Catheter placement

Description of CPT code 36251, 36252, 36253 and 36254

These procedure codes have been revised recently. There is no major change in the description except the removal of the moderate conscious services. Yes, from 2017 we have new CPT codes for moderate conscious sedation, which need to code separately for all the procedures performing sedation. Below is the detail description of these procedure codes.

36251         Selective catheter placement (first-order), main renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, contrast injection(s), image post processing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; unilateral

36252        bilateral

A superselective catheterization is performed on one or more of the second order (branch) or higher of the renal artery branches. Superselective catheterization is needed for extremely small vessels or vessels that have sharp angles when branching to another order. The physician inserts a needle through the skin and into an underlying artery, usually a lower extremity artery, and threads a guidewire through the needle and into the artery. The needle is removed. The wire is threaded into the targeted artery and any accessory renal arteries of the second order or higher.

A super fine and small catheter follows the wire into the arteries. The wire is removed. Contrast material for arteriography is injected into the catheter. Images are taken, the catheter is removed, and pressure is applied to stop bleeding at the injection site. These codes include image postprocessing, permanent recording of images, and radiological supervision and interpretation (e.g., pressure gradient measurements and flush aortogram). CPT code 36253 is reported for a unilateral procedure and CPT code 36254 for a bilateral procedure.

36253     Superselective catheter placement (one or more second order or higher renal artery branches) renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture, catheterization, fluoroscopy, contrast injection(s), image post processing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; unilateral

36254        bilateral

Read also: Coding tips for Carotid and Innominate artery Stent placement procedures

Indications for renal angiography

Renal angiography is considered medically reasonable and necessary for any of the following:

• renovascular occlusive disease* (e.g., renal artery stenosis (RAS), severe or difficult to control renal hypertension, resistant hypertension, or progressive renal insufficiency)
• renal aneurysm
• renovascular trauma
• primary vascular abnormalities, including aneurysms, vascular malformations, and vasculitis
• renal neoplasm
• hematuria of unknown cause
• pre- and postoperative evaluations for renal transplantation
• other intrinsic defects prior to interventional procedures on the renal arteries
• abnormal kidney imaging involving radioisotopes
• prior to interventional procedures on the renal arteries

Read also : Coding Guide for Renal Ultrasound CPT codes

Do and Don’t with CPT code 36251, 36252, 36253 and 36254

CPT code 36251 and 36252 are used only for coding first order selective catheter placement in the main renal artery. And 36253 and 36254 are used for coding super selective catheter placement for second and third order branch of main renal artery. Use code 36251 and 36253 for unilateral procedure and code 36252 and 36254 for bilateral procedure.

Do not report CPT code 36253 along with 36251

Do not report CPT code 36254 along with 36252

Placement of close device (HCPCS code G0269) at the vascular access in included in these procedure codes. Hence, do not report Code G0269 along with these procedure codes.

Do not report abdominal aortography (CPT code 75625) in along with these procedures, aortogram is included in these CPT codes.

Do not report Renal angiography of all ipsilateral vessels, they are included in the procedure codes.

Code Moderate conscious sedation separately for CPT codes 36251, 36252, 36253 and 36254

Do not report radiological supervision and interpretation

Report ultrasound guidance (CPT code 76937) separately for these procedure codes.

Read also: Difference between Aftercare and Follow-up CPT codes

Coverage Indications, Limitations, and/or Medical Necessity

According to the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) High Blood Pressure Clinical Practice Guideline, a blood pressure is considered normal for adults with a systolic blood pressure of less than 120 mm Hg and a diastolic blood pressure of less than 80 mm Hg. Hypertension Stage 2, also known as severe hypertension, is noted to be a systolic blood pressure of greater than or equal to 140 mm Hg or a diastolic blood pressure of greater than or equal to 90 mm Hg. Resistant hypertension is uncontrolled high blood pressure despite the use of at least three different antihypertensive medication classes. 

Diagnostic arteriography is an invasive procedure for the purpose of evaluating vascular disease. The process involves passing a needle or catheter through the skin under fluoroscopic guidance into an artery followed by injection of contrast material and imaging of the vascular area in question using digital imaging or serial film imaging. The procedures for abdominal aortography or renal arteriography are most commonly done under conscious sedation.

Angiography or arteriography is a medical imaging technique used to visualize the inside, or lumen, or blood vessels and organs of the body, particularly in arteries, veins, and chambers of the heart. This LCD applies the term angiography when referring to abdominal angiography or renal arteriography. 

Covered Indications

1. Medical Necessity for Abdominal Aortography/Angiography
   • Acute traumatic abdominal injury
   • Aneurysm and other primary vascular abnormalities
   • Occlusive disease, including evaluation for acute or chronic intestinal ischemia
   • Acute GI hemorrhage
   • Congenital anomaly
   • Prior to arterial interventional procedures or open surgical procedures
2. Medical Necessity for Stand-Alone Renal Angiography
   • Severe or difficult to control renal hypertension
     • for severe or difficult to control renal hypertension, OR
     • progressive renal insufficiency, OR
     • resistant hypertension
   • Renal neoplasm
   • Hematuria of unknown cause
   • Abnormal kidney imaging involving radioisotopes
   • Renal artery stenosis, aneurysm, trauma, or other intrinsic defects prior to renal arterial intervention
3. Medical Necessity for Lower Extremity or Renal Angiography done at the same time as a different interventional procedure (for example, cardiac catheterization with coronary angiography)Diagnostic renal angiography or lower extremity angiography performed at the time of an interventional procedure is separately reportable if at least one indication for medical necessity for a stand-alone lower extremity or renal angiography is met AND one of the following are also met:
   • 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 or pathology; OR
     • There is a clinical change during the interventional procedure that requires new evaluation outside the target area of intervention.
4. Medical necessity for a Stand-Alone Lower Extremity Angiography must be documented by pre-procedure clinical assessment. This assessment should include the following:
   • Documentation that an invasive intervention is planned, AND
   • Documentation that a prior non-invasive study was completed and indicates further study is needed by angiography for the planned intervention, AND
   • Documentation of one of the following conditions: arterial embolism, acute or chronic ischemia, peripheral vascular disease (includes claudication), or aneurysm.

Limitations

LIMITATIONS FOR ABDOMINAL OR RENAL AORTOGRAPHY/ANGIOGRAPHY OR LOWER EXTREMITY ANGIOGRAPHY:

1. There are no absolute contraindications to diagnostic aortography/angiography. Relative contraindications include but are not limited to:
   • Severe hypertension
   • Uncorrectable coagulopathy or thrombocytopenia
   • Clinically significant sensitivity to iodinated contrast material
   • Renal insufficiency based on the estimated glomerular filtration rate (eGFR)
   • Congestive heart failure
   • Certain connective tissue disorders which may indicate increased risk for complications at the puncture site
2. Diagnostic angiography performed at a separate session from an interventional procedure may be separately reportable. If a diagnostic angiogram was performed prior to an interventional procedure, a second diagnostic angiogram performed at the time of an interventional procedure is separately reportable when documentation supports it is medically reasonable and necessary to repeat the study to further define the anatomy and pathology. If the prior diagnostic angiogram was performed, a second angiogram (e.g. for the dye injections necessary to perform the interventional procedure) is not separately reportable.
3. The localization or guidance is integral to an interventional procedure and is not separately reportable unless CPT instructions specify otherwise.
4. In addition to the initial procedure, an appropriate frequency of repeat procedures can be allowed as long as medical necessity is clearly established and documented. It is expected that important diagnostic information will be obtained from the angiography, which will assist in patient management and treatment. Repeat angiography may be medically reasonable and necessary if there is documentation of new and incapacitating symptoms.
5. CMS issued HCPCS code G0278 for femoral or iliac angiography when done at the time of coronary angiography. Medicare would not expect to see a high percentage of femoral or iliac angiography done at the same time of coronary studies and such billing could be subject to review.
6. Renal angiography performed at the time of cardiac catheterization in the absence of accepted clinical indication that support medical necessity will be denied as such services are generally not indicated, as mentioned in this LCD.
7. Appropriate non-invasive tests should be performed prior to a repeat angiography. A trial of or a change in medical management would be expected prior to repeat angiography unless the patient is deemed unstable and in need of some type of surgical intervention.

Place of Service (POS)

Angiography services described in this LCD are considered reasonable and necessary when performed in any POS listed below:

• Office (POS 11)
• Off Campus-Outpatient Hospital (POS 19)
• Inpatient Hospital (POS 21)
• On Campus-Outpatient Hospital (POS 22)
• Emergency Room-Hospital (POS 23)
• Ambulatory Surgical Center (POS 24)

Mobile units and all other locations are non-covered.

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.