The bundled renal angiography codes 36521- 36524 (which bundle the work of selective catheterization with the diagnostic imaging and interpretation) have created questions regarding how to report them in conjunction with interventional codes that do not include catheterization of the vessels. As a general coding guideline, the selective catheterizations performed for the intervention should be reported with a diagnostic renal angiography code if diagnostic renal angiography is performed in conjunction with a renal arterial intervention. Angiography is reported using the highest degree of selectivity required for the procedure (ie, angiography and intervention). Even when diagnostic angiography is performed using first-order selectivity and the intervention requires a higher degree of selectivity, the superselective renal angiography code(s) would be reported to account for the additional work of higher-level selective catheterization(s).
Additional selective catheterization codes should not be reported for selective catheterization(s) related to the intervention if diagnostic renal angiography of that kidney is also being reported. If a renal intervention is performed without diagnostic renal angiography in the same setting, the intervention is reported using standard rules for selective catheterization of the vessel(s).
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SCENARIO 1
A patient presents with uncontrolled hypertension and is on multiple antihypertensive medications. Magnetic resonance angiography (MRA) has been performed, suggesting moderate stenosis of the right renal artery, but with suboptimal visualization due to motion and artifact. Renal angiography is performed from a femoral approach, consisting of flush aortography followed by first-order selective catheterizations and injections in single renal arteries bilaterally. Pullback pressures are measured across each renal artery origin. The angiogram shows fibromuscular disease in the main renal arteries bilaterally, which are estimated to cause 80% maximum stenosis, resulting in 30-mm Hg systolic gradients. It is elected to proceed with balloon angioplasty of each renal artery.
Coding
- 36252: Bilateral diagnostic renal angiography with first-order selective catheterizations of the renal arteries (includes the flush aortography and the pullback pressure measurements)
- 35471-50, 75966, 75968: Balloon angioplasty, bilateral renal arteries
SCENARIO 2
This is the same patient as in scenario 1, but in addition, the fibromuscular dysplasia is seen to extend into a branch of the main right renal artery. This branch is also subselected and treated with balloon angioplasty.
Coding
- 36253: Diagnostic angiography of right renal artery with superselective catheterization (because a secondorder branch was selected for the branch angioplasty)
- 36251: Diagnostic angiography of the left renal artery with first-order selective catheterization
- 35471-50, 35471, 75966, 75968×2: Balloon angioplasty of three renal arteries/branches
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In this case, if it were necessary to protect an adjacent renal branch with a safety wire during angioplasty of the diseased renal branch in the right kidney, a safety wire might be introduced from a new femoral puncture in the contralateral groin. An additional selective catheterization code (36246-59) would therefore also be reported because the puncture of the opposite groin and selective catheterization from that entry site is not included in the work reported by 36253. The -59 modifier is needed to designate that this catheterization is separate work that is not included in 36253 because it is performed from a separate puncture.
SCENARIO 3
A patient is seen for uncontrolled hypertension with multiple medications. MRA of the renal arteries shows a high-grade stenosis at the origin of the right renal artery and an atrophic left kidney with an atrophic left renal artery. The patient is scheduled for right renal artery stenting, which is performed from a femoral puncture. Angiography at the time of the procedure is performed, confirming the findings of the MRA, and a renal stent is successfully placed to treat the right renal artery stenosis.
Coding
- 36245: First-order selective catheterization of right renal artery
- 37205, 75960: Stent placement, right renal artery
In this case, the MRA performed before stent placement diagnosed the anatomy and pathology, and a decision to treat was made based on the findings of the MRA. A diagnostic study would not be reported in this case because the imaging was done to confirm the MRA findings and to road map and guide stenting (services reported by 75960). Because a bundled renal angiography code is not reported, the selective catheter placement for the stent is reported using 36245.
SCENARIO 3
A patient presents to the emergency department with hypotension, back and abdominal pain, and bright red blood in his urine following an outpatient kidney biopsy performed for proteinuria 2 days ago. The patient is taken directly to the interventional suite. Diagnostic angiography is performed, showing an arteriovenous fistula (AVF) in the lower pole of the left kidney at the site of the recent biopsy, with active extravasation identified. Additional subselective catheterization of multiple branches is performed, with superselective angiography identifying the feeding branch, which is then subselected and directly embolized. Follow-up completion angiography shows closure of the AVF.
Coding
- 36253: Superselective left renal arteriogram (diagnostic)
- 37204, 75894, 75898: Embolization of the AVF
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No prior diagnostic imaging was performed in this case because the most likely diagnosis is bleeding from the site of recent biopsy. The superselective diagnostic angiography code (36253) includes all selective catheterizations of any branches performed for the diagnostic and interventional procedures for that kidney.
SCENARIO 4
A patient with tuberous sclerosis presents with hematuria. The CT findings are consistent with a left angiomyolipoma. The interventionist decides to perform embolization of the tumor. Selective angiography of the left renal artery confirms findings compatible with angiomyolipoma. The feeding vessels are identified, and the tumor is embolized using selective catheterization of the main feeding branch, which is a second-order branch, and selective catheterization of the two smaller feeding branches, which are third-order vessels off of a separate renal artery branch. Completion angiography shows successful closure of the flow to the tumor.
Coding
Option 1: If one performs diagnostic angiography in this case, the codes reported would be:
- 36253: Unilateral superselective diagnostic renal angiogram
- 37204, 75896, 75898: Embolization of renal arteries for a tumor
Option 2: If it is determined that the imaging performed for the case is not diagnostic (confirming a previously diagnosed tumor and road mapping/guidance for the intervention), the codes reported would be:
- 36247: Third-order selective catheterization for smaller feeder branch
- 36248X2: Each additional second-/third-order selective catheterization off of the main aortic branch for the main feeder vessel and the additional smaller feeder),
- 37204, 75894, 75898
If one determines that a diagnostic angiogram is required for this procedure, the coding would be different than if one determines that the angiography performed for the procedure is road mapping and guidance for the embolization. This likely depends on one’s comfort with the CT findings, including whether diagnostic angiography is needed to determine if any smaller tumors are present.
Katharine Krol, MD, FSIR, FACR, is an interventional radiologist and has recently retired from active clinical practice. She has disclosed that she has no financial interests that pertain to this topic. Dr. Krol may be reached at (317) 595-9413.
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