Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services and angiography (36140, 36200, 36216, 36221, and 75710) provided on April 28, 2021.
You asked the Plan to pay for codes 36140, 36200, 36216, 36221, and 75710. You say that the medical records support the billing of codes 36140, 36200, 36216, 36221, and 75710. The Plan denied your request. The Plan says the medical records do not support the billing of codes 36140, 36200, 36216, 36221, and 75710.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 36216 is Selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch, within a vascular family. The definition of code 75710 is Angiography, extremity, unilateral, radiological supervision and interpretation. The definition of code 36140 is Introduction of needle or intracatheter, upper or lower extremity artery. The definition of code 36200 is Introduction of catheter, aorta. The definition of code 36221 is Non-selective catheter placement, thoracic aorta, with angiography of the extracranial carotid, vertebral, and/or intracranial vessels, unilateral or bilateral, and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for codes 36140, 36200, 36216, 36221, and 75710. Our reviewer says that the medical records do not support the billing of codes 36140, 36200, 36216, 36221, and 75710. Our reviewer found the enrollee is with an occluded right subclavian artery and stenosis of the right common and external iliac artery. On April 28, 2021 the enrollee underwent an arch angiogram, selective left carotid artery angiogram, selective left subclavian artery angiogram, aortogram and bilateral iliac artery angiogram, angioplasty of the right common iliac artery, and angioplasty of the right external iliac artery, with radiologic interpretation. Procedure code 36216-59 is not supported by the available medical records. The Operative Report does not include documentation of selective catheter placement into the arterial system, for the initial second order thoracic or brachiocephalic branch, within a vascular family. Procedure code 75710 is not supported by the available medical records. The Operative Report did not include documentation of radiological supervision and interpretation of a unilateral extremity angiography, as an independent procedure. Procedure codes 36140-59-51, 36200-51-59, and 36221-59 are denied as they are inclusive to another billed code (36215). We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes 36140, 36200, 36216, 36221, and 75710 have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services and angiography (36140, 36200, 36216, 36221, and 75710) provided on April 28, 2021