CPT codes 36245, 36246, 36247, and 36248 are used to report endovascular procedures for the treatment of arterial or venous disease. Here are some coding tips for using these codes:
- Confirm medical necessity: Before assigning a CPT code for endovascular procedures, it is important to confirm that the procedure was medically necessary. This may involve reviewing the patient’s medical history, diagnostic imaging, and any other relevant clinical information.
- Assign the correct code: The appropriate code should be assigned based on the type of endovascular procedure performed. CPT code 36245 is used to report a transluminal balloon angioplasty, 36246 is used to report a transluminal stent placement, 36247 is used to report a transluminal mechanical thrombectomy, and 36248 is used to report a transluminal mechanical atherectomy.
- Use appropriate modifiers: Modifier -LT and -RT may be used to indicate the side on which the procedure was performed if the procedure is bilateral.
- Ensure complete documentation: Accurate and complete documentation is crucial when coding for endovascular procedures. The documentation should include information about the type of procedure performed, the specific vessels treated, the location and size of any access incisions, and any intraoperative findings or complications.
- Assign additional codes: If additional procedures or services are performed in conjunction with the endovascular procedure, additional CPT codes may be necessary to report these services. For example, a separate code may be used to report imaging guidance for the procedure or the use of ultrasound to guide the catheter.
- Follow local guidelines: Be sure to follow any local coding guidelines or payer policies that may impact coding for endovascular procedures. Some payers may have specific requirements for documentation or coding of certain procedures.