In vascular surgery, the question of how to code an abdominal aortogram is the topic of many emails I have received over my career and a question I see posted on forums online pretty regularly. So I wanted to dedicate today’s article to answering the question of whether to code CPT 75630 or 75625 when coding a report describing an abdominal aortogram. Distinguishing these codes becomes particularly challenging when imaging of some or all of the arteries of the legs (a lower extremity angiogram) is performed in conjunction with the aortogram. Before we dive into some guidelines and examples, here are a few terms you need to be familiar with to help you understand reports for this procedure:
- Aorta: The aorta is largest artery in the body. This artery extends from the heart to the iliac arteries in the pelvis. The aorta is divided into four segments in anatomy. I have explained the definition and location of all four segments below, but today, we will be focused on the abdominal aorta.
- Abdominal aorta: The segment of the aorta which begins at the level of the diaphragm (the muscle that separates your chest cavity from your abdomen) and continues to what is known as the aortic bifurcation where the abdominal aorta branches into the right and left common iliac arteries which supply blood flow to your legs. This is the segment of the aorta we will be discussing today.
- Descending thoracic aorta: The segment of the aorta which begins at the lower end of the aortic arch (explained below) and proceeds down to the level of the diaphragm.
- Aortic arch: The segment of the aorta which is located between the ascending aorta and the descending thoracic aorta and is the portion of the aorta where the “head vessels” (the subclavian, the carotid, and the brachiocephalic trunk arteries which supply blood flow to the head, neck, and arms) branch off.
- Ascending Aorta: The segment of the aorta that begins at the upper end of the aortic arch and continues through the aortic root and down to the aortic valve. The aortic root is where the coronary arteries which supply blood flow to your heart connect to the aorta. The aorta ends at this point (the heart is located on the other side of the aortic valve).
- Aortogram: A set of images obtained in one segment of the aorta after introducing dye into the aorta through a catheter. An aortogram is sometimes referred to as aortography. These two terms mean the same thing.
- Arteriogram: A more general term used to refer a set of images obtained in any artery in the body after introducing dye into that artery through a catheter. When the term “arteriogram” is used to refer to dye introduced into the aorta, arteriorgram is a synonym for aortogram and would mean the same thing in a report.
- Angiogram: An even broader term than arteriogram, an angiogram refers to a set of images obtained in any blood vessel in the body (artery or vein) after introducing dye into that blood vessel through a catheter. When the term “angiogram” is used to refer to dye introduced into the aorta, it is a synonym for aortogram and would mean the same thing in a report.
- Abdominal aortogram: A set of images of most or all of the abdominal aorta specifically taken after introducing dye into that part of the aorta through a catheter.
- Renal Artery Orifices: The place where the renal arteries connect to the abdominal aorta.
- Aortic Bifurcation: The place where the abdominal aorta ends and branches off into the right and left common iliac arteries.
- Infrarenal Aorta: Term used to describe the portion of the abdominal aorta below the renal artery orifices and above the aortic bifurcation.
- Distal Abdominal Aorta: Term generally used to describe the last few centimeters of the abdominal aorta right above the aortic bifurcation.
- Iliofemoral: A term used to refer to the iliac arteries and femoral arteries together. The iliac arteries are located just below the aortic bifurcation and help to supply blood flow to the legs and the pelvis while the femoral arteries are major arteries in the thigh that help supply blood flow to the legs.
- Lower Extremity Angiogram: A term used to refer to an angiogram obtained of the arteries of the legs. Lower extremity angiograms can be either unilateral (images of the arteries of one leg only) or bilateral (images of the arteries of both legs).
- Serialography: A technique that involves taking multiple images during an angiogram rather than a single image.
Now that we have some of the key terms outlined, let’s look at the description of the two codes we are discussing today:
- CPT 75625: Aortography, abdominal, by serialography, including radiological supervision and interpretation
- CPT 75630: Aortography, abdominal plus bilateral iliofemoral lower extremity, by serialography, including radiological supervision and interpretation
As you can see, CPT 75625 states “aortography abdominal” (referring to an aortogram of the abdominal segment of the aorta) by serialography. So CPT 75625 reports multiple pictures of the abdominal aorta by itself. This code can also be paired with codes for lower extremity arteriograms which we will see in a moment. CPT 75630 is for aortography again in the abdominal segment of the aorta, but it also includes imaging of the iliofemoral arteries bilaterally (both the left and the right sides are imaged).
Where much of the confusion comes in with these two codes lies in whether to code 75625 with a lower extremity arteriogram for imaging of the arteries of the legs (75710 or 75716) or whether to code 75630 alone. There are two keys to look for when trying to decipher these two codes:
- How much of the arteries of the legs were imaged? To determine this, focus on the physician’s interpretation of the images. Is he/she talking only about findings in the upper legs (e.g., do they see the iliac arteries and femoral arteries alone), or are they talking about findings of arteries all the way down the legs (e.g., can you see findings of the below the knee popliteal and the tibial/peroneal arteries which lie in the calf)?
- Where is the catheter at the time dye is introduced, and does that catheter “move” after obtaining the images of the abdominal aorta and before obtaining images of the arteries of the legs? With CPT 75630, the catheter is usually placed in one position towards the top of the abdominal aorta near the renal arteries, dye is introduced once from this one catheter position, and multiple images of the abdominal aorta, iliac, and femoral arteries are obtained. When coding CPT 75625 alone, the catheter is again placed near the top of the abdominal aorta near the renal arteries, dye is introduced from this one catheter position, and multiple images of the abdominal aorta alone are taken. From there the physician may move the catheter down to just above the aortic bifurcation or into the arteries of one or both legs and introduce more dye and then take more images/pictures of the arteries of the legs from this new catheter position(s). It is this movement of the catheter and introduction of more dye from that second catheter position followed by additional imaging that allows us to code 75625 and code 75710 or 75716 together, which tells the payer that the aortogram and the lower extremity artery angiograms were separate studies.
There are a couple of additional tips we need to keep in mind when coding for aortograms:
- CPT codes from the radiology section of the manual like CPT 75625 and 75630 include “radiology supervision and interpretation.” That means that it is not enough for the physician to just tell us where the catheter is located and the fact that he is introducing dye and taking images/pictures (the supervision part). He also has to tell us what he sees on those images/pictures (the interpretation part) to be able to give credit for these CPT codes.
- Per the CPT guidelines, all codes that have the language “radiology supervision and interpretation” in their CPT code description require images to be stored in the patient’s medical record. This means that if the physician introduces dye to visualize the arteries but doesn’t take any images that are stored (e.g., in a system like PACS), you cannot bill one of these codes with the term “radiology supervision and interpretation” in its CPT code description. During aortograms, physicians/hospitals do typically store their images (it would be very rare that they do not store images), but if you work for a coding/billing company where you are coding for clients and cannot see the images on file in the patient’s chart (e.g., you are coding from an electronic medical record and the images are stored in a separate PACS system that you cannot access), it is important to talk to your clients directly or to your management team internally and ensure they understand this rule and have confirmed that the clients are permanently storing all of their images before you proceed with coding and billing.
- When you code an aortogram (either CPT 75625 or 75630), you are indicating that the physician is imaging most or all of the abdominal aorta (based on the definition of an aortogram). If the physician were to image just the last few centimeters of the abdominal aorta (the distal aorta only), he/she would not be meeting the definition of an aortogram. Incidental imaging of just those last few centimeters of the abdominal aorta wouldn’t be billed separately as an aortogram because the physician is not imaging enough of the aorta to confirm or rule out presence of disease in the abdominal aorta. Incidental imaging of those last few centimeters of the aorta just above the aortic bifurcation would be considered part of the lower extremity angiogram and not reported with an aortogram code.
- These codes we are discussing today are for the radiology supervision and interpretation only (obtaining and interpreting the images). They do not include the placement of catheter(s) into the arteries or ultrasound guidance to gain access into the arteries. These procedures are reported with their own CPT codes. We are focusing today on the radiology codes for aortograms, but you can check your CPT manual for guidelines regarding coding your catheter placements and ultrasound guidance separately or head over to our “contact” portion of the Coding Mastery page and reach out if you have questions regarding coding this part of the procedure.
Okay let’s put this in context with a couple of examples and see if we can determine whether 75630 or 75625 is appropriate:
Example #1: The right femoral artery was accessed using Seldinger technique. A 6 French sheath was then inserted and advanced to the proximal abdominal aorta where contrast was introduced. An aortogram was obtained. The catheter was then withdrawn to the distal aorta where additional contrast was introduced. We then obtained images in a step-wise fashion in the bilateral lower extremities. Findings of angiographic imaging are noted below:
Aorta: The abdominal aorta is patent without significant plaque/lesions. The renal artery orifices are patent without significant stenosis.
Right Lower Extremity: The right common iliac artery has minimal plaque that is non-obstructing. The arteries are patent down through the right superficial femoral artery, but in the region of the above the knee popliteal artery, there is a high-grade stenosis (~70%). This artery reconstitutes below the knee. The tibio-peroneal trunk, anterior tibial, and posterior tibial arteries are patent, but the peroneal artery has stenosis on the order of 90%.
Left Lower Extremity: The left common iliac artery is severely stenotic with a near total occlusion just above the origin of the external iliac artery. The remaining arteries including the external iliac, femorals, popliteal, and tibial/peroneal arteries are patent with minimal plaque but no obstructing lesions.
The patient will be referred to vascular surgery to discuss revascularization options based on the left iliac, right SFA, and right peroneal findings.
Answer Coding Example #1: The bolded portions of the note are keys to selecting our CPT code. We first see the physician entering the femoral artery through Seldinger technique (which is a percutaneous approach). He then threads the catheter up into the “proximal” abdominal aorta (so he is up at the top of the abdominal aorta with his catheter). He then tells us that he obtains an aortogram (so the aortogram was obtained with the catheter in the upper part of the abdominal aorta). He then moves the catheter down to just above the aortic bifurcation and introduces more dye where he obtains the lower extremity angiograms. From there, we need to make sure we have an interpretation of findings in both the aorta and the lower extremity arteries. When we go to the findings, we first see findings of the aorta. The aorta is patent (or wide open/normal) and the renal artery orifices are patent as well without any stenosis. These findings confirm that the physician is seeing most of the abdominal aorta (all the way from where the renal arteries connect to the aorta down to the aortic bifurcation) so he has met the definition of an aortogram. When then see findings of the arteries in both of the legs all the way down the legs. The physician is talking about the iliac, femoral, popliteal, tibial, and peroneal arteries (these arteries extend from around the hip area all the way down to the ankle). With these findings from the imaging and confirmation of the fact that the physician first obtained an aortogram from one catheter position up at the top of the aorta and then the lower extremity angiograms of both legs from a second catheter position just above the aortic bifurcation after moving the catheter, we can code CPT codes 75625 and 75716.
Example #2: The left femoral artery was accessed using Seldinger technique. A 6 French sheath was then inserted and advanced to the proximal abdominal aorta where contrast was introduced. An aortogram with iliofemoral runoff was obtained. Findings of angiographic imaging are noted below:
Aorta: The abdominal aorta is patent from the renal arteries to the aortic bifurcation.
Right Lower Extremity: The right common iliac artery has minimal plaque that is non-obstructing. The external iliac, common and superficial femoral, and above the knee popliteal are patent throughout their course.
Left Lower Extremity: The left common iliac artery is patent, but the external iliac artery has a stenosis on the order of 60%. This reconstitutes at the level of the common femoral artery which along with the superficial femoral and above the knee popliteal arteries is patent.
We will discuss the possibility of angioplasty/stenting of the left external iliac artery.
Answer Example #2: We again see the physician entering the femoral artery through Seldinger technique (percutaneous access). He then threads a catheter up into the proximal aorta much like we saw in example #1. He then introduces dye into the aorta and takes images of the abdominal aorta, and “bilateral iliofemoral runoffs” (or images of the iliofemoral arteries on both sides as the dye travels downstream from the aorta and into these arteries). We see no documentation of catheter movement between obtaining images of the aorta and images of the bilateral iliofemoral arteries.
We then need to look at our findings to see what images were obtained and confirm that we have an interpretation of those images. We first see the findings of the aorta. Again the physician has confirmed that the aorta is patent from the renal arteries to the aortic bifurcation, confirming that he is seeing most of the abdominal aorta on these images. He then comments on the bilateral iliac arteries, femoral arteries, and even makes mention of the above the knee popliteal. All of these arteries are patent/normal except for the left external iliac artery where we see a 60% stenosis. Since the physician obtains images of most of the abdominal aorta and the bilateral iliofemoral arteries together from “one catheter position,” this documentation supports CPT 75630. As one final coding tip, the physician may see and comment on arteries below the femoral arteries in a procedure coded with CPT 75630 (as he did in this case where he’s commenting on the above the knee popliteal arteries). This confuses many coders because CPT 75630 states “bilateral iliofemoral arteries” only so often when coders see other arteries mentioned they are tempted to steer away from code 75630. However, if the physician is obtaining the combined abdominal aortic images plus the bilateral lower extremity artery images from a single catheter position, your code is still CPT 75630 even if the physician comments on some additional arteries other than the iliac and femoral arteries that he can see while obtaining his images of the aorta and bilateral iliofemoral arteries.
