How To Use CPT Code 36216

CPT 36216 describes the selective catheter placement within a vascular family, specifically in the second order thoracic or brachiocephalic branch. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 36216?

CPT 36216 can be used to describe the selective catheter placement within a vascular family, specifically in the second order thoracic or brachiocephalic branch. This code is used when a provider advances a catheter into these branches to perform angiography, a diagnostic study of the blood vessels.

2. Official Description

The official description of CPT code 36216 is: ‘Selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch, within a vascular family.’

3. Procedure

1. The provider gains access to the blood vessels, typically through the femoral artery, by making a small incision in the skin and inserting a catheter.
2. The catheter is guided through the arteries to the area of focus, such as the second order thoracic or brachiocephalic branch.
3. Contrast material is injected through the catheter, and X-ray or fluoroscopic images are taken to visualize the blood vessels.

4. Qualifying circumstances

CPT 36216 is used when the provider performs selective catheter placement within a vascular family, specifically in the second order thoracic or brachiocephalic branch. This procedure is typically done to perform angiography and diagnose or treat medical conditions. It is important to note that this code supersedes codes for nonselective catheter placement, and both should not be reported for the same access and in the same vascular family.

5. When to use CPT code 36216

CPT code 36216 should be used when the provider performs selective catheter placement within a vascular family, specifically in the second order thoracic or brachiocephalic branch. It is important to ensure that the procedure meets the specific criteria outlined in the code description.

6. Documentation requirements

To support a claim for CPT 36216, the provider must document the following information:

• Point(s) of access where the sheath has been placed
• Approach used (ipsilateral or contralateral)
• Point(s) of the highest level where the catheter was manipulated
• Imaging studies performed
• Each vascular family and access separately coded
• Additional second or third order catheterizations within a family
• Additional imaging studies within a family above the basic examination

7. Billing guidelines

When billing for CPT 36216, ensure that the procedure meets the specific criteria outlined in the code description. It is important to code all imaging studies performed and to report each vascular family and access separately. Additionally, do not report both selective and nonselective catheter placement for the same access and in the same vascular family.

8. Historical information

CPT 36216 was added to the Current Procedural Terminology system on January 1, 1992. There have been no updates to the code since its addition.

9. Examples

1. A provider performs selective catheter placement in the second order thoracic branch to perform angiography on a patient with suspected coronary artery disease.
2. A provider advances a catheter into the brachiocephalic branch to visualize the blood vessels in a patient with suspected cerebrovascular disease.
3. A provider performs selective catheter placement in the second order thoracic branch to diagnose and treat a patient with aortic aneurysm.
4. A provider guides a catheter into the brachiocephalic branch to perform angiography on a patient with suspected subclavian artery stenosis.
5. A provider performs selective catheter placement in the second order thoracic branch to evaluate a patient with suspected pulmonary embolism.
6. A provider advances a catheter into the brachiocephalic branch to visualize the blood vessels in a patient with suspected aortic dissection.
7. A provider performs selective catheter placement in the second order thoracic branch to diagnose and treat a patient with arteriovenous malformation.
8. A provider guides a catheter into the brachiocephalic branch to perform angiography on a patient with suspected carotid artery disease.
9. A provider performs selective catheter placement in the second order thoracic branch to evaluate a patient with suspected pulmonary hypertension.
10. A provider advances a catheter into the brachiocephalic branch to visualize the blood vessels in a patient with suspected thoracic outlet syndrome.