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2025 CPT code 36216

Selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch, within a vascular family.

The CPT guidelines for selective vascular catheterizations state that the code includes introduction and all lesser order selective catheterizations used in the approach. Additional catheterizations within the same vascular family are reported separately.

Modifiers may be applicable to this code to indicate specific circumstances, such as increased procedural services (modifier 22), multiple procedures (modifier 51), or reduced services (modifier 52).

Medical necessity for this procedure is established by the presence of signs or symptoms that suggest a vascular abnormality requiring angiographic evaluation. The documentation must support the need for the procedure to diagnose or treat a specific condition.

The physician is responsible for performing the selective catheterization procedure, including gaining access to the blood vessels, inserting and guiding the catheter, injecting contrast material, and interpreting the angiographic images.

In simple words: The doctor inserts a thin tube (catheter) into an artery, usually in the groin or wrist, and guides it to a specific blood vessel in the chest or head area to take X-ray images.

This code describes a procedure where a catheter is selectively placed into a second order thoracic or brachiocephalic branch within a vascular family. This is typically done for angiography. The procedure includes the introduction and placement of the catheter into the artery.

Example 1: A patient presents with symptoms suggestive of a narrowed artery in the chest. A selective catheterization is performed to visualize the thoracic arteries and determine the degree of narrowing., A patient with a known aneurysm in the brachiocephalic artery undergoes selective catheterization for assessment and potential treatment planning., A patient experiences stroke-like symptoms. Selective catheterization is performed to examine the blood vessels in the head and neck to identify any blockages or abnormalities.

Documentation should include details of the access site, the specific artery catheterized, the type of contrast material used, the findings of the angiogram, and any interventions performed. The medical necessity of the procedure must also be documented.

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